EMERGENCY MASS CRITICAL CARE

1. EMERGENCY MASS CRITICAL CARE Lewis Rubinson MD, PhD County Health Officer Deschutes County Health Department Bend, OR Medical Officer OR-2 DMAT

2. HUMAN CASES H5N12004-2006 Case fatality rate ~ 50% Most deaths from refractory respiratory failure Most people are critically ill Respiratory failure > 70% Shock Acute renal failure 10-29% In US, pts with similar severity of illness are managed in ICUs

3. CRITICAL CARE DEMAND Number of critically ill patients ?? availability and effectiveness of countermeasures Uncertain virulence of strain if human-to-human transmission Rate of development of critical illness Time from hosp to resp failure: < 2 days Duration of critical illness Time from hosp to death: 4-30 days (most cohorts median > 1 week)

4. LIMITED ICU SURGE CAPACITY 87,400 ICU beds in non-federal US hospitals ICU occupancy 65-80 % Breadth of ICU meds and equipment create financial barriers to building reserve ICUs Logistical difficulties of using reserve ICU and need for equipment maintenance further barriers Shortages of critical care nurses, pharmacists, respiratory therapists and intensivists in most communities > 10% of ICUs have beds closed due to nursing shortage

5. ADDITIONAL PANDEMIC CRITICAL CARE CHALLENGES Concurrent impact on many hospitals Limited evacuation Limited deployment of stuff and staff Infection control measures increase critical care challenges Prolonged response Fatigue How long can cancel elective surgeries, use anesthesia machines, repurpose staff ?

6. MOST CRITICALLY ILL PEOPLE SURVIVE Disaster Situation Patients unable to receive mechanical ventilation and/or hemodynamic support are likely to die.

7. What to do when the number of critically ill patients far exceeds traditional hospital critical care capacity and evacuation is not immediately available?

8. OPTIONS Provide usual ICU services on a first-come first-served basis. Stop providing critical care services. Plan and prepare for usual ICU services for all additional patients. Modify standards of critical care to provide limited but high-yield critical care interventions and processes for many additional patients.

9. EMERGENCY MASS CRITICAL CARE Emergency changes in: Spectrum of critical care interventions Triage Staffing Medical equipment Clinical trials Provide circumscribed set of key critical care interventions to many patients rather than maximal critical care to far fewer Derived from recommendations of a working group of 33 North American experts

10. WORKING GROUP ON EMERGENCY MASS CRITICAL CARE

11. Which critical care interventions should be provided if resources are limited and usual critical care cannot be provided to all in need?

12. FREQUENTLY USED  ICU INTERVENTIONS Intra-aortic counter-pulsation device Continuous renal replacement therapy ICP monitoring High-frequency oscillatory ventilation Activated protein C infusion Conventional mechanical ventilation Vasopressor infusion Large volume blood product transfusions Intra-arterial blood pressure monitoring

13. PRIORITIZING CRITICAL CARE INTERVENTIONS Supports the organ systems most likely to cause death Demonstrated effectiveness or best professional judgment to improve survival in similar clinical conditions Do not require prohibitively expensive equipment Not staff or resource intensive

14. EMERGENCY MASS CRITICAL CARE INTERVENTIONS Mechanical ventilation Basic mode(s) Hemodynamic support IV fluids, vasopressor(s) Set of prophylactic interventions Thromboembolism prophylaxis, elevation of head of bed and ? GI prophylaxis

15. AUGMENTING POSITIVE PRESSURE VENTILATION (PPV) Reserve sophisticated full-feature ventilators Vendor rental supply Limited data regarding quantities available, especially during large event with many requesting hospitals Anesthesia machines Adequate short-term option, but limited quantities and cannot be repurposed for long response Alternative ventilation options

16. STRATEGIC NATIONAL STOCKPILE VENTILATORS Thousands of ventilators Not enough for serious pandemic Prioritization for distribution to many hospitals in need remains uncertain NO OXYGEN !

17. PPV OPTIONS

19. PPV MAY STILL BE LIMITED Non-federal PPV caches will increase equipment capacity BUT� for severe pandemic capacity is still likely to be exceeded by demand. ? Attack rate ? Virulence ? Concurrent PPV demand ? Geographical impact

20. Who should provide Emergency Mass Critical Care?

21. USUAL ICU STAFFING Ideal ICU staffing Critical care pharmacists, respiratory therapists, nurses, registered dietitians and intensivists Low Nurse:Patient ratios associated with worse outcomes Pharmacists� participation on daily rounds reduce adverse drug events Respiratory therapists are invaluable for maintenance and operation of airway and ventilation equipment

22. STAFFING FOR EMERGENCY MASS CRITICAL CARE May have a number of non-critical care staff available Surgeons, anesthesiologists if elective surgeries cancelled Non-critical care allied health professionals --HOWEVER-- Complexities of critical care may limit effectiveness of non-critical care staff working independently.

23. TIERED STAFFING:Critical care staff collaborating with non-critical care staff on all patients

24. TIERED NURSING Non-critical care nurses assigned primary responsibility for patient assessment Documentation Administration of medications Bedside care (maintaining head of bed at 45�, moving pts to prevent pressure ulcers) Real-time patient assessment

25. TIERED NURSING Critical care nurses can supervise and advise non-critical care nurses on critical care-specific issues Vasopressor and sedation titration Suggested ratio (depending on situation): 1 non-critical care nurse to 2 pts; 3 non-critical care nurses collaborating with 1 critical care nurse

26. TIERED NPs, PAs,MDs,DOs Non-intensivists responsible for general care of patients. Initial response to changes in patients� condition Documentation of care and care plan Most non-critical care medical issues Critical care issues after consultation with intensivist or implementing standardized order sets Intensivists manage acute emergencies, ventilator-patient interaction (together with RTs), and consult on general critical care issues

27. TIERED NPs, PAs,MDs,DOs 1 non-intensivist to 6 patients; 4 non-intensivists to 1 intensivist Non-intensivists should receive basic critical care training as part of disaster preparedness (e.g. HDM) Standardized order sets Reduce variability and errors of omission Modify for specific disease (e.g. pandemic influenza, inhalational anthrax)

28. STAFFING COMPARISON

29. Triage and Rationing: Who should receive Emergency Mass Critical Care?

30. TRIAGE OPTIONS DURING OUTBREAKS �First-come, first-served� Current critical care triage Prioritization based on likelihood to benefit Utilitarian �the greatest good for the greatest number� Prioritization based on social worth

31. Where should Emergency Mass Critical Care be delivered when all usual critical care options are full?

32. EMERGENCY MASS CRITICAL CARE IN HOSPITALS PACU, ED provide only a handful of additional beds Equipment, medical gases, isolation, and using tiered staff most safely and efficiently provided on concentrated hospital wards Step-down units first, then general hospital wards If prolonged disaster repurposing endoscopy, cath labs, and ORs less optimal Non-hospital alternate care sites should be used for non-critically ill patients

33. EMERGENCY MASS CRITICAL CARE BEDS ICUs usually 5-15% of total inpatient beds In past, hospitals have made approximately 20% inpatient beds available within 24 hours by recalling staff, canceling surgeries, expedited discharges Can increase hospital total critical care capacity by 2-4 fold if critically ill patients given admission priority As outbreak unfolds, can likely increase critical care capacity 5-10 fold over existing ICU capacity.

34. EQUIPMENT FOR EMERGENCY MASS CRITICAL CARE Portable ventilators, anesthesia machines and/or full-feature ventilators Medical gas, suction Pulse oximeter Non-invasive blood pressure cuffs Urine quantification device IV administration equipment (hospitals may choose to have central venous catheters)

35. EMERGENCY MASS CRITICAL CARE Emergency Changes Scope of critical care Critical care triage Staffing Equipment Clinical Trials Assumptions: Some critical care is better than no critical care Knowledge about usual critical care interventions can guide prioritization of high yield interventions

36. AVIAN INFLUENZA HITS FLORIDA