Surge capacity logistics: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

Barriers and facilitators to provide continuity of care to dischargeable patients in disasters: A qualitative study

OBJECTIVE

Early discharge of some in-patients is the effective measure to create hospital surge capacity in disasters. However, some of these patients may need to post-discharge continuity of care. The aim of the current study then is to explore the barriers of continuity of care, and to provide suitable solutions for potentially dischargeable patients during disasters.

METHODS

This qualitative study was conducted in Iran in 2017. The data was collected via unstructured interviews with 24 disaster professionals; and analyzed by content analysis method.

RESULTS

Identified barriers to the continuity of care were classified into seven categories, 'lack of disaster paradigm'; 'challenges of pre-hospital system'; 'insufficient coordination and cooperation'; 'inadequate hospital preparedness'; 'lack of using available resources and capacities'; 'poor patients' knowledge' and 'poor planning'. The suggested solutions for post-discharge continuity of care were: creation of registry and follow-up system; removing pre-hospital challenges; including disaster management courses in medical school curriculum; promoting hospital preparedness by All-Hazard Approach; and effective use of available resources.

CONCLUSION

Understanding the barriers to continuity of care for discharged patients for adopting policies based on experiences of health care providers can help planners to design and implement effective programs, which will enhance patients' access to necessary care.

The Imbalance in Medical Demand and Supply for Pediatric Victims in an Earthquake

OBJECTIVES

We quantified an absolute imbalance of the medical risks and the support needs for children at each disaster-based hospital in Kanagawa immediately following the occurrence of a large earthquake by using the risk resource ratio (RRR) and need for medical resources (NMR).

METHODS

The RRR and NMR of 33 disaster-based hospitals were estimated through dividing the estimated number of pediatric victims by the number of critically patients. We calculated the ratio of the NMR of each hospital.

RESULTS

The total number of pediatric victims in Kanagawa was estimated at 8,391. The total number of vacant beds for pediatric victims was 352. The median RRR and NMR of the total number of pediatric victims were 27 and 224. The median RRR and NMR of the number of critically ill pediatric patients were 27 and 12.

CONCLUSIONS

The absolute imbalance of the RRR and NMR for children in Kanagawa was quantified. This suggests that we might embark on preparedness strategies for children in advance. (Disaster Med Public Health Preparedness. 2018;13:672-676).

Always ready, always prepared-preparing for the next pandemic

A future global pandemic is likely to occur and planning for the care of critically ill children is less robust than that for adults. This review covers the current state of federal and regional resources for pediatric care in pandemics, a strategy for pandemic preparation in pediatric intensive care units and regions focusing on stuff, space, staff and systems, considerations in developing surge capacity and triage protocols, special circumstances such as highly infectious and highly lethal pandemics, and a discussion of ethics in the setting of pediatric critical care in a pandemic.

Findings from an Assessment and Inventory of a Regional, Decentralized Stockpile

Stockpiles can aid with healthcare surge that occurs after a disaster, and experts recommend that these caches be assessed at least annually to ensure supply integrity. The purpose of this study was to assess a regional stockpile to determine its viability and readiness. An assessment was performed in the summer and fall of 2016 on a regionally funded stockpile that was decentralized through a regional network of 15 local hospitals. Each supply was assessed to determine whether the correct amount was present, if it was in a safe and usable condition (ie, deployable), and whether it had expired. Stockpiled materials were categorized by the type of supply or equipment for analysis. The percent of deployable materials was calculated for each item, each category of supplies, and for the entire cache. Almost all sites (93.3%, n = 14) reported that they inventory their cache at least once a year. On average, 60.1% of each site's cache materials were present and deployable (range: 22.1%-87.5%). The best-maintained supplies included personal protective equipment (79.4% deployable) and general medical supplies (73.5% deployable). Decontamination equipment and pediatric supplies had the lowest percentages of deployability (29.0% and 37.7%, respectively). Although almost all sites claimed to assess the stockpile annually, results from this study indicate that almost half of the supplies are either missing or in an unusable condition. This not only represents wasted resources, but it could also hinder disaster response, leading to increased morbidity and mortality. Facilities may need to invest in infrastructure to maintain stockpiled materials after purchase to ensure viability.

Reverse Triage to Increase the Hospital Surge Capacity in Disaster Response

Introduction

Successful and effective management of large-scale disasters and epidemics requires pre-established systematic plans to minimize the damage and control the situation. With an increasing number of people in need of urgent medical care, hospitals must improve their response capacity, being at the forefront of responding to disasters and incidents. One way to develop the hospital capacity in disaster response is by reverse triage (RT).

Objective

The current study was conducted to investigate the role of RT to create additional hospital surge capacity in one of the major referral academic hospitals of Isfahan, Iran.

Method

This cross-sectional study was conducted in 2015 at Al-Zahra Subspecialty Hospital, Isfahan, Iran. The ten most common diseases leading to hospitalization in each ward of the hospital in 2014 were reviewed and, based on the prevalence, sorted and listed. Academic instructions for making a decision and possibility of early discharge was written and approved by an expert panel. On a day that was not set previously, the pre-selected in-charge person of each department was asked to run the RT following the instructions, and the number and percentage of those who were eligible for discharge via RT were determined.

Results

The total BOR in Al-Zahra Hospital in 2014 was about 80%, so it was estimated that almost 140 out of 700 beds are vacant. The results showed that by using RT, 108 (20%) hospitalized cases could be discharged, and considering the bed occupancy rate of about 80% and 140 vacant beds, a total of 248 beds could be provided following RT.

Conclusion

Running RT in 41 wards and units of Isfahan Al-Zahra Hospital, on average, added 108 beds to the hospital capacity. This increment is not the same in all wards, as the role of intensive care units in RT for surge capacity is insignificant.

Hospital Surge Capacity: A Web-Based Simulation Tool for Emergency Planners

The National Center for the Study of Preparedness and Catastrophic Event Response (PACER) has created a publicly available simulation tool called Surge (accessible at http://www.pacerapps.org) to estimate surge capacity for user-defined hospitals. Based on user input, a Monte Carlo simulation algorithm forecasts available hospital bed capacity over a 7-day period and iteratively assesses the ability to accommodate disaster patients. Currently, the tool can simulate bed capacity for acute mass casualty events (such as explosions) only and does not specifically simulate staff and supply inventory. Strategies to expand hospital capacity, such as (1) opening unlicensed beds, (2) canceling elective admissions, and (3) implementing reverse triage, can be interactively evaluated. In the present application of the tool, various response strategies were systematically investigated for 3 nationally representative hospital settings (large urban, midsize community, small rural). The simulation experiments estimated baseline surge capacity between 7% (large hospitals) and 22% (small hospitals) of staffed beds. Combining all response strategies simulated surge capacity between 30% and 40% of staffed beds. Response strategies were more impactful in the large urban hospital simulation owing to higher baseline occupancy and greater proportion of elective admissions. The publicly available Surge tool enables proactive assessment of hospital surge capacity to support improved decision-making for disaster response. (Disaster Med Public Health Preparedness. 2018;12:513–522)

Best Practices for Healthcare Facility and Regional Stockpile Maintenance and Sustainment: A Literature Review

Preparing for mass casualty incidents is essential to maximizing community resilience. Many US-based organizations and regions have developed stockpiles of medications, supplies, and equipment for mass casualty incident preparedness. The Centers for Disease Control and Prevention (CDC) assess and manage federally stockpiled materials, but hospitals, healthcare systems, and regional organizations are responsible for maintaining locally owned caches. The CDC has protocols for assessing and managing the Strategic National Stockpile, but no such guidance exists for local or geographical/regional stockpiles. This article outlines best practices and recommendations identified in the literature related to maintaining and sustaining a local or regional stockpile. Recommendations are provided on the timing and procedures for assessing, inventorying, storing, managing, tracking, and deploying materials stockpiled on site, in a trailer, or in a warehouse. In addition, alternative approaches for maintaining a local or regional cache, such as vendor- or user-managed inventory methods, are addressed. Management of local or regional caches requires an investment in infrastructure and training but is necessary to ensure the integrity of stockpiled medication and supplies and to enable rapid and appropriate activation during a mass casualty incident. Hospitals, healthcare systems, businesses, academic institutions, public health agencies, organizations, and regions can use the recommendations here to develop protocols or policies to properly manage their existing stockpiles, which should minimize costs related to damaged supplies.

Healthcare Provider Perceptions of Causes and Consequences of ICU Capacity Strain in a Large Publicly Funded Integrated Health Region: A Qualitative Study

OBJECTIVES

Discrepancy in the supply-demand relationship for critical care services precipitates a strain on ICU capacity. Strain can lead to suboptimal quality of care and burnout among providers and contribute to inefficient health resource utilization. We engaged interprofessional healthcare providers to explore their perceptions of the sources, impact, and strategies to manage capacity strain.

DESIGN

Qualitative study using a conventional thematic analysis.

SETTING

Nine ICUs across Alberta, Canada.

SUBJECTS

Nineteen focus groups (n = 122 participants).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Participants' perspectives on strain on ICU capacity and its perceived impact on providers, families, and patient care were explored. Participants defined "capacity strain" as a discrepancy between the availability of ICU beds, providers, and ICU resources (supply) and the need to admit and provide care for critically ill patients (demand). Four interrelated themes of contributors to strain were characterized (each with subthemes): patient/family related, provider related, resource related, and health system related. Patient/family-related subthemes were "increasing patient complexity/acuity," along with patient-provider communication issues ("paucity of advance care planning and goals-of-care designation," "mismatches between patient/family and provider expectations," and "timeliness of end-of-life care planning"). Provider-related factor subthemes were nursing workforce related ("nurse attrition," "inexperienced workforce," "limited mentoring opportunities," and "high patient-to-nurse ratios") and physician related ("frequent turnover/handover" and "variations in care plan"). Resource-related subthemes were "reduced service capability after hours" and "physical bed shortages." Health system-related subthemes were "variable ICU utilization," "preferential "bed" priority for other services," and "high ward bed occupancy." Participants perceived that strain had negative implications for patients ("reduced quality and safety of care" and "disrupted opportunities for patient- and family-centered care"), providers ("increased workload," "moral distress," and "burnout"), and the health system ("unnecessary, excessive, and inefficient resource utilization").

CONCLUSIONS

Engagement with frontline critical care providers is essential for understanding their experiences and perspectives regarding strained capacity and for the development of sustainable strategies for improvement.

Pulmonary ultrasound and pulse oximetry versus chest radiography and arterial blood gas analysis for the diagnosis of acute respiratory distress syndrome: a pilot study

Introduction

In low-resource settings it is not always possible to acquire the information required to diagnose acute respiratory distress syndrome (ARDS). Ultrasound and pulse oximetry, however, may be available in these settings. This study was designed to test whether pulmonary ultrasound and pulse oximetry could be used in place of traditional radiographic and oxygenation evaluation for ARDS.

Methods

This study was a prospective, single-center study in the ICU of Harborview Medical Center, a referral hospital in Seattle, Washington, USA. Bedside pulmonary ultrasound was performed on ICU patients receiving invasive mechanical ventilation. Pulse oximetric oxygen saturation (SpO₂), partial pressure of oxygen (PaO₂), fraction of inspired oxygen (FiO₂), provider diagnoses, and chest radiograph closest to time of ultrasound were recorded or interpreted.

Results

One hundred and twenty three ultrasound assessments were performed on 77 consecutively enrolled patients with respiratory failure. Oxygenation and radiographic criteria for ARDS were met in 35 assessments. Where SpO₂ ≤ 97 %, the Spearman rank correlation coefficient between SpO₂/FiO₂ and PaO₂/FiO₂ was 0.83, p < 0.0001. The sensitivity and specificity of the previously reported threshold of SpO₂/FiO₂ ≤ 315 for PaO₂/FiO₂ ≤ 300 was 83 % (95 % confidence interval (CI) 68–93), and 50 % (95 % CI 1–99), respectively. Sensitivity and specificity of SpO₂/FiO₂ ≤ 235 for PaO₂/FiO₂ ≤ 200 was 70 % (95 % CI 47–87), and 90 % (95 % CI 68–99), respectively. For pulmonary ultrasound assessments interpreted by the study physician, the sensitivity and specificity of ultrasound interstitial syndrome bilaterally and involving at least three lung fields were 80 % (95 % CI 63–92) and 62 % (95 % CI 49–74) for radiographic criteria for ARDS. Combining SpO₂/FiO₂ with ultrasound to determine oxygenation and radiographic criteria for ARDS, the sensitivity was 83 % (95 % CI 52–98) and specificity was 62 % (95 % CI 38–82). For moderate–severe ARDS criteria (PaO₂/FiO₂ ≤ 200), sensitivity was 64 % (95 % CI 31–89) and specificity was 86 % (95 % CI 65–97). Excluding repeat assessments and independent interpretation of ultrasound images did not significantly alter the sensitivity measures.

Conclusions

Pulse oximetry and pulmonary ultrasound may be useful tools to screen for, or rule out, impaired oxygenation or lung abnormalities consistent with ARDS in under-resourced settings where arterial blood gas testing and chest radiography are not readily available.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0995-5) contains supplementary material, which is available to authorized users.

ICU Telemedicine Solutions

During the last 15 years, critical care services provided via telemedicine have expanded to now be incorporated into the care of 13% of patients in intensive care units (ICUs) in the United States. A response to shortfalls in the availability of critical care-trained providers has evolved into integrated programs of ICU care with contributions to improved outcomes through proactive management, population oversight, and standardization of care processes. The most impactful characteristics of successful ICU telemedicine programs are now better understood with more than a decade of national experience and the accrued benefits to health care systems.

Surge capacity principles: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

This article provides consensus suggestions for expanding critical care surge capacity and extension of critical care service capabilities in disasters or pandemics. It focuses on the principles and frameworks for expansion of intensive care services in hospitals in the developed world. A companion article addresses surge logistics, those elements that provide the capability to deliver mass critical care in disaster events. The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with injured or critically ill multiple patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify evidence on which to base key suggestions. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force were also included for validation by the expert panel.

RESULTS

This article presents 10 suggestions pertaining to the principles that should guide surge capacity and capability planning for mass critical care, including the role of critical care in disaster planning; the surge continuum; targets of surge response; situational awareness and information sharing; mitigating the impact on critical care; planning for the care of special populations; and service deescalation/cessation (also considered as engineered failure).

CONCLUSIONS

Future reports on critical care surge should emphasize population-based outcomes as well as logistical details. Planning should be based on the projected number of critically ill or injured patients resulting from specific scenarios. This should include a consideration of ICU patient care requirements over time and must factor in resource constraints that may limit the ability to provide care. Standard ICU management forms and patient data forms to assess ICU surge capacity impacts should be created and used in disaster events.

Business and continuity of operations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

During disasters, supply chain vulnerabilities, such as power, transportation, and communication, may affect the delivery of medications and medical supplies and hamper the ability to deliver critical care services. Disasters also have the potential to disrupt information technology (IT) in health-care systems, resulting in interruptions in patient care, particularly critical care, and other health-care business functions. The suggestions in this article are important for all of those involved in a large-scale pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The Business and Continuity of Operations Panel followed the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology in developing key questions regarding medication and supply shortages and the impact disasters may have on healthcare IT. Task force members met in person to develop the 13 key questions believed to be most relevant for Business and Continuity of Operations. A systematic literature review was then performed for relevant articles and documents, reports, and gray literature reported since 2007. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.

RESULTS

Eighteen suggestions addressing mitigation strategies for supply chain vulnerabilities including medications and IT were generated. Suggestions offered to hospitals and health system leadership regarding medication and supply shortages include: (1) purchase key medications and supplies from more than one supplier, (2) substituted medications or supplies should ideally be similar to those already used by an institution's providers, (3) inventories should be tracked electronically to monitor medication/supply levels, (4) consider higher inventories of medications and supplies known or projected to be in short supply, (5) institute alternate use protocols when a (potential) shortage is identified, and 6) support government and nongovernmental organizations in efforts to address supply chain vulnerability. Health-care IT can be damaged in a disaster, and hospitals and health system leadership should have plans for urgently reestablishing local area networks. Planning should include using portable technology, plans for providing power, maintenance of a patient database that can accompany each patient, and protection of patient privacy. Additionally, long-term planning should include prioritizing servers and memory disk drives and possibly increasing inventory of critical IT supplies in preparedness planning.

CONCLUSIONS

The provision of care to the critically ill or injured during a pandemic or disaster is dependent on key processes, such as the supply chain, and infrastructure, such as IT systems. Hospitals and health systems will help minimize the impact of medication and supply shortages with a focused strategy using the steps suggested. IT preparedness for maintaining local area networks, functioning clinical information systems, and adequate server and memory storage capacity will greatly enhance preparedness for hospital and health system clinical and business operations.

System-level planning, coordination, and communication: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

System-level planning involves uniting hospitals and health systems, local/regional government agencies, emergency medical services, and other health-care entities involved in coordinating and enabling care in a major disaster. We reviewed the literature and sought expert opinions concerning system-level planning and engagement for mass critical care due to disasters or pandemics and offer suggestions for system-planning, coordination, communication, and response. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The American College of Chest Physicians (CHEST) consensus statement development process was followed in developing suggestions. Task Force members met in person to develop nine key questions believed to be most relevant for system-planning, coordination, and communication. A systematic literature review was then performed for relevant articles and documents, reports, and other publications reported since 1993. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.

RESULTS

Suggestions were developed and grouped according to the following thematic elements: (1) national government support of health-care coalitions/regional health authorities (HC/RHAs), (2) teamwork within HC/RHAs, (3) system-level communication, (4) system-level surge capacity and capability, (5) pediatric patients and special populations, (6) HC/RHAs and networks, (7) models of advanced regional care systems, and (8) the use of simulation for preparedness and planning.

CONCLUSIONS

System-level planning is essential to provide care for large numbers of critically ill patients because of disaster or pandemic. It also entails a departure from the routine, independent system and involves all levels from health-care institutions to regional health authorities. National government support is critical, as are robust communication systems and advanced planning supported by realistic exercises.