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HUMAN CASES H5N1 2004-2006. Case fatality rate ~ 50%Most deaths from refractory respiratory failureMost people are critically illRespiratory failure > 70%ShockAcute renal failure 10-29%In US, pts with similar severity of illness are managed in ICUs. CRITICAL CARE DEMAND. Number of critically ill patients?? availability and effectiveness of countermeasures Uncertain virulence of strain if human-to-human transmissionRate of development of critical illnessTime from hosp to resp failure9458
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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