Intensive Care Role in Disaster Management Critical Care Clinics

In-Hospital Triage

The intensive care unit (ICU) is a finite and expensive resource with demand not infrequently exceeding capacity. Understanding ICU capacity strain is essential to gain situational awareness. Increased capacity strain can influence ICU triage decisions, which rely heavily on clinical judgment. Having an admission and triage protocol with which clinicians are very familiar can mitigate difficult, inappropriate admissions. This article reviews these concepts and methods of in-hospital triage.

Disaster management - preparation and planning for acute care facilities

PURPOSE OF REVIEW

Both human-derived and naturally-occurring disasters stress the surge capacity of health systems and acute care facilities. In this article, we review recent literature related to having a disaster plan, facility planning principles, institutional and team preparedness, the concept of surge capacity, simulation exercises and advantages and disadvantages of each.

RECENT FINDINGS

Evidence suggests that every institution should have a disaster plan and a dedicated team responsible for updating this plan. The disaster plan must be people-oriented and incorporate different perspectives and opinions so that all stakeholders feel included and can contribute to a joint response. Simulation exercises are fundamental for preparation so that the team functions seamlessly in uncommon times when disaster management transitions from a theoretical plan to one that is executed in real time. Notably, however, there are significantly different realities related to disaster management between countries and even within the same country or region. Unfortunately, key stakeholders such as hospital administration, board of directors and investors often do not believe they have any responsibility related to disaster management planning or response. Additionally, while a disaster plan often exists within an institution, it is frequently not well known or understood by many stakeholders. Communication, simple plans and well defined roles are some of the most important characteristics of a successful response. In extreme circumstances, adapting civilian facilities to manage high-volume warfare-related injuries may be adopted, but the consequences of this approach for routine healthcare within a system can be devastating.

SUMMARY

Disaster management requires careful planning with input from multiple stakeholders and a plan that is frequently updated with repeated preparation to ensure the team is ready when a disaster occurs. Close communication as well as clearly defined roles are critical to success when transitioning from preparation to activation and execution of a disaster response.

The Minnesota Medical Operations Coordination Center: A COVID-19 Statewide Response to Ensure Access to Critical Care and Medical-Surgical Beds

BACKGROUND

COVID-19 led to unprecedented inpatient capacity challenges, particularly in ICUs, which spurred development of statewide or regional placement centers for coordinating transfer (load-balancing) of adult patients needing intensive care to hospitals with remaining capacity.

RESEARCH QUESTION

Do Medical Operations Coordination Centers (MOCC) augment patient placement during times of severe capacity challenges?

STUDY DESIGN AND METHODS

The Minnesota MOCC was established with a focus on transfer of adult ICU and medical-surgical patients; trauma, cardiac, stroke, burn, and extracorporeal membrane oxygenation cases were excluded. The center operated within one health care system's bed management center, using a dedicated 24/7 telephone number. Major health care systems statewide and two tertiary centers in a neighboring state participated, sharing information on system status, challenges, and strategies. Patient volumes and transfer data were tracked; client satisfaction was evaluated through an anonymous survey.

RESULTS

From August 1, 2020, through March 31, 2022, a total of 5,307 requests were made, 2,008 beds identified, 1,316 requests canceled, and 1,981 requests were unable to be fulfilled. A total of 1,715 patients had COVID-19 (32.3%), and 2,473 were negative or low risk for COVID-19 (46.6%). COVID-19 status was unknown in 1,119 (21.1%). Overall, 760 were patients on ventilators (49.1% COVID-19 positive). The Minnesota Critical Care Coordination Center placed most patients during the fall 2020 surge with the Minnesota Governor's stay-at-home order during the peak. However, during the fall 2021 surge, only 30% of ICU patients and 39% of medical-surgical patients were placed. Indicators characterizing severe surge include the number of Critical Care Coordination Center requests, decreasing placements, longer placement times, and time series analysis showing significant request-acceptance differences.

INTERPRETATION

Implementation of a large-scale Minnesota MOCC program was effective at placing patients during the first COVID-19 pandemic fall 2020 surge and was well regarded by hospitals and health systems. However, under worsening duress of limited resources during the fall 2021 surge, placement of ICU and medical-surgical patients was greatly decreased.

Mass Critical Care Surge Response During COVID-19: Implementation of Contingency Strategies - A Preliminary Report of Findings From the Task Force for Mass Critical Care

Background

After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of severe ongoing surges throughout the world.

Research Question

A subcommittee from The Task Force for Mass Critical Care (TFMCC) investigated the most recent COVID-19 publications coupled with TFMCC members anecdotal experience in order to formulate operational strategies to optimize contingency level care, and prevent crisis care circumstances associated with increased mortality.

Study Design and Methods

TFMCC adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, “gray” evidence from lay media sources, and anecdotal experiential evidence.

Results

Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs.

Interpretation

A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.

Disaster preparedness: A concept analysis and its application to the intensive care unit

OBJECTIVES

The aim of the study is to understand the concept of disaster preparedness in relation to the intensive care unit through the review and critique of the peer-reviewed literature.

REVIEW METHOD USED

Rodgers' method of evolutionary concept analysis was used in the study.

DATA SOURCES

Healthcare databases included in the review were Cumulative Index to Nursing and Allied Health Literature, Public MEDLINE, Scopus, and ProQuest.

REVIEW METHODS

Electronic data bases were searched using terms such as "intensive care unit" OR "critical care" AND prep∗ OR readiness OR plan∗ AND disaster∗ OR "mass casualty incidents" OR "natural disaster" OR "disaster planning" NOT paed∗ OR ped∗ OR neonat∗. Peer-reviewed articles published in English between January 2000 and April 2020 that focused on intensive care unit disaster preparedness or included intensive care unit disaster preparedness as part of a facility-wide strategy were included in the analysis.

RESULTS

Eighteen articles were included in the concept analysis. Fourteen different terms were used to describe disaster preparedness in intensive care. Space, physical resources, and human resources were attributes that relied on each other and were required in sufficient quantities to generate an adequate response to patient surges from disasters. When one attribute is extended beyond normal operational capacities, the effectiveness and capacity of the other attributes will likely be limited.

CONCLUSION

This concept analysis has shown the varied language used when referring to disaster preparedness relating to the intensive care unit within the research literature. Attributes including space, physical resources, and human resources were all found to be integral to a disaster response. Future research into what is required of these attributes to generate an all-hazards approach in disaster preparedness in intensive care units will contribute to optimising standards of care.

A Spatiotemporal Tool to Project Hospital Critical Care Capacity and Mortality From COVID-19 in US Counties

Objectives. To create a tool to rapidly determine where pandemic demand for critical care overwhelms county-level surge capacity and to compare public health and medical responses.Methods. In March 2020, COVID-19 cases requiring critical care were estimated using an adaptive metapopulation SEIR (susceptible‒exposed‒infectious‒recovered) model for all 3142 US counties for future 21-day and 42-day periods from April 2, 2020, to May 13, 2020, in 4 reactive patterns of contact reduction-0%, 20%, 30%, and 40%-and 4 surge response scenarios-very low, low, medium, and high.Results. In areas with increased demand, surge response measures could avert 104 120 additional deaths-55% through high clearance of critical care beds and 45% through measures such as greater ventilator access. The percentages of lives saved from high levels of contact reduction were 1.9 to 4.2 times greater than high levels of hospital surge response. Differences in projected versus actual COVID-19 demands were reasonably small over time.Conclusions. Nonpharmaceutical public health interventions had greater impact in minimizing preventable deaths during the pandemic than did hospital critical care surge response. Ready-to-go spatiotemporal supply and demand data visualization and analytics tools should be advanced for future preparedness and all-hazards disaster response.

Mass Casualties and Disaster Implications for the Critical Care Team

Preparing for disasters both natural and anthropogenic requires assessment of risk through hazard vulnerability analysis and formulation of facility and critical care-specific disaster plans. Disaster surge conditions often require movement from conventional to contingency or crisis-level operations to meet the needs of the many under our care. Predisaster planning for modification of critical care space, staffing, and supplies is essential to successful execution of operations during a surge. Expansion of intensive care unit beds to nonconventional units such as perioperative areas, general care units, and even external temporary units may be necessary. Creative, tiered staffing models as well as just-in-time education of noncritical care clinicians and support staff are important to multiply capable personnel under surge conditions. Finally, anticipation of demand for key equipment and supplies is essential to maintain stockpiles, establish supply chains, and sustain operations under prolonged disaster scenarios.

All for One and One for All: Voluntary Physicians in the Intensive Medicine Units During the COVID-19 Outbreak in Spain

OBJECTIVES

Our purpose was to determine the intensive care units' (ICU's) medical staff surge capacity during the coronavirus disease 2019 (COVID-19) outbreak in Spring 2020 in Spain.

METHODS

A multicenter retrospective survey was performed addressing the medical specialties present in the ICUs and the increase in bed capacity during this period.

RESULTS

Sixty-seven centers (62.04%) answered the questionnaire. The ICU bed capacity during the pandemic outbreak increased by 160% (95% confidence interval [CI], 128.97-191.03%). The average number of beds per intensive care medicine (ICM) specialist was 1.5 ± 0.60 and 3.71 ± 2.44 beds/specialist before and during the COVID-19 outbreak, respectively. Non-ICM specialists and residents were present in 50 (74.63%) and 23 (34.3%) ICUs during the outbreak, respectively. The number of physicians (ICM and non-ICM residents and specialists) in the ICU increased by 89.40% (95% CI, 64.26114.53%). The increase in ICM specialists was, however, 4.94% (95% CI, -1.35-11.23%). Most non-ICM physicians were anesthetists, followed by pediatricians and cardiologists.

CONCLUSIONS

The majority of ICUs in our study were able to rapidly expand critical care capacity by adapting areas outside of the normal ICU to manage critically ill patients, and by extending the critical care staff with noncritical care physicians working as force multipliers.