Application AMA/CDC Congress on Health Systems Readiness ...


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Application AMA/CDC Congress on Health Systems Readiness ...

  1. 1. Application AMA/CDC Congress on Health Systems Readiness, July 18-20, 2007, Washington D.C. 1.) CATEGORY Medical Surge Capacity Critical Care Services Delivery Workforce Education Legal & Regulatory Policy 2.) COMMUNITY DESCRIPTION At most hospitals, critical care is provided in intensive care units (ICU) by a multi-professional team including nurses, pharmacists, respiratory care professionals and intensivists. In addition, many additional healthcare professionals may interface with critically ill and injured people including emergency medical services professionals, emergency department personnel, anesthesiologists, surgeons, other surgery personnel. Many of these personnel are in short supply during everyday hospital operations, and reserve ICU equipment and space is limited. In spite of the limited capacity, these health professionals may be involved in the response to disasters such as a severe influenza pandemic, which cause mass casualty critical care needs. This project is intended to provide consensus recommendations regarding critical care surge capacity and management of scarce critical care resources during such events. The intended audience includes1) frontline healthcare professionals who may care for critically ill and injured victims of disasters; 2) emergency planners who are responsible for regional or statewide clinical surge capacity planning and preparedness, and 3) federal medical planners who have responsibility for mass casualty care. 3.) PLANNING PROCESS Limitations in critical care surge capability had been previously recognized and recommendations for augmenting critical care during disasters, termed Emergency Mass Critical Care, had been issued by a previous working group. The initial recommendations for Emergency Mass Critical Care were an important initial effort. However, the recommendations lacked sufficient detail for frontline critical care health professionals to translate into potential for patient care. This current project initiated from a grass roots effort of critical care healthcare professionals that have current medical responsibility for critically ill and injured people and who were concerned that there remained insufficient guidance to expand critical care capability for disasters. These efforts were considered time-sensitive and bolstered by the increasing concern for a severe influenza pandemic. To develop recommendations which could standardize planning and preparing for mass casualty critical care, the group set out to develop a broad-based task force to tackle critical care surge capacity as well as allocation of scarce critical care
  2. 2. resources. Initially a steering committee with experts in fields including bioethics, critical care medicine, disaster medicine, emergency medicine, federal government medical response, and local public health was assembled. This group developed draft recommendations for review and discussion by the larger task force. To best influence mass casualty critical care at the local, regional and national level, the Task Force of Mass Casualty Critical Care includes almost all of the national critical care relevant professional societies which together reflect a base of 200,000+ healthcare professionals and who represent respiratory care professionals, nurses, pharmacists, and intensivists. In addition, senior officials from Department of Homeland Security, Department of Defense, Department of Health and Human Services and the Centers for Disease Control and Prevention are on the task force. Nationally recognized experts from emergency medicine, emergency medical services, bioethics, and palliative care are also members of the task force. The Task Force on Mass Casualty Critical Care was convened in Chicago on January 26 and 27, 2007. The two days brought intensive review of the initial draft recommendations. Each of the recommendations was discussed and after the in- person meeting the recommendations were revised to reflect the comments and to achieve consensus on all recommendations. Revisions of the documents continue and the recommendations will be finalized by the end of Spring 2007. The task force has been very successful in terms of process. All Task Force members were chosen based on their previous experiences and work. While members were senior and seasoned, no specific member monopolized or diverted the process. We suspect one of the major reasons for our success is that we selected people who are known to work well in groups. The second reason is that for months prior to convening the task force, the steering committee developed mature draft documents to guide the task force deliberations. All elements of these documents were fair game for discussion and revision, but the document structure provided the skeleton for the agenda. This kept the discussions on topic and assured that much got accomplished during the meeting. Key gaps that continue are the engagement of community members, clinicians, and policy makers regarding modification of processes of critical care and imitation, withdrawal and withholding of critical care services during overwhelming disasters. A multi-pronged approach to active engagement and dissemination is anticipated. Furthermore, many of the recommendations are based on best professional judgment due to the paucity of data. We intend to recommend validation evaluations of several of the major recommendations. 4.) NARRATIVE The severe acute respiratory syndrome (SARS) epidemic of 2002-2003, recent natural disasters, concern for intentional catastrophes, and the looming threat of an influenza pandemic have stimulated much recent debate about how to plan for and implement large-scale critical care disaster response . In 2004 the Working Group on Emergency Mass Critical Care, a North American expert panel, developed consensus recommendations for augmenting critical care during an epidemic. They conceived
  3. 3. Emergency Mass Critical Care (EMCC), a circumscribed set of key of critical care elements to meet the medical need for a catastrophic number of additional critically ill and injured patients. These recommendations provided a solid, conceptual framework for mass casualty critical care response; however there are insufficient details for hospitals to translate into patient care capability. Consequently, the Task Force on Mass Casualty Critical Care, comprised of 37 senior-level participants with broad-based expertise relevant to mass casualty critical care, convened to issue specific, clinical-focused recommendations for providing adequate, sustained critical care outside of traditional intensive care units (ICU) during catastrophes. In addition, the task force provides recommendations on allocating scarce critical care resources, such as mechanical ventilators, when need far outweighs availability. The task force addressed goal critical care surge capacity to guide pre-event planning, situational triggers to initiate or terminate Emergency Mass Critical Care, crucial critical care delivery services, respiratory equipment characteristics and quantities to sufficiently manage patients with respiratory failure who require sustained surge care, non-respiratory equipment quantities to adequately provide the crucial critical care services, treatment space requirements, and staffing suggestions to strategically augment critical care. The task force also addressed means to most objectively prioritize critically ill and injured patients who need services that are in short supply, who should be responsible for critical care triage, the federal, state, intra-state regional, and facilities responsibilities for ensuring that a standard approach to triage with minimization of bias can be implemented during disasters if needed. The critical care delivery teams and the institutions that they work within are set up to deliver a well established level of care for their patients. Mass casualty events such as a severe influenza pandemic will stress the existing infrastructure and force caregivers into situations for which little if any precedent has been established. Our goal was to offer some practical guidance for those who will face the dire circumstances surrounding a mass casualty event. This guidance was extrapolated from critical care practice, military medicine experience, disaster epidemiology, and reflects the current best professional judgments for mass casualty critical care. While not a substitute for effective antivirals or vaccine, Emergency Mass Critical Care will likely optimize critical care surge capacity to increase community member’s likelihood that if they have respiratory failure during a pandemic they can receive possibly life-sustaining supportive critical care. 5.) CONTACT INFORMATION Task Force on Mass Casualty Critical Care representatives: Lewis Rubinson, MD, PhD Disaster Medicine Director Public Health Seattle King County Seattle, Washington
  4. 4. Asha Devereaux, MD, FCCP Chair, Disaster Response NW-ACCP Lead Physician-Medical Reserve Corps, San Diego Division of Pulmonary and Critical Care Medicine Sharp Coronado Hospital Coronado, CA Jeff Dichter, MD Director of the Critical Care Service Presbyterian Hospital Albuquerque, New Mexico James Geiling, MD, FCCP Chief, Medical Service Veterans Affairs Medical Center White River Junction, VT Associate Professor of Medicine Dartmouth Medical School Hanover, NH Michael Bourisaw Director, ACCP Critical Care Institute 3300 Dundee Road Northbrook, IL 60062 (847) 498-8123