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Abbasi-Kangevari M, Arshi S, Hassanian-Moghaddam H, Kolahi AA. Public Opinion on Priorities Toward Fair Allocation of Ventilators During COVID-19 Pandemic: A Nationwide Survey. Front Public Health 2022; 9:753048. [PMID: 34970524 PMCID: PMC8712311 DOI: 10.3389/fpubh.2021.753048] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 11/23/2021] [Indexed: 01/08/2023] Open
Abstract
Background: The rapidly growing imbalance between supply and demand for ventilators during the COVID-19 pandemic has highlighted the principles for fair allocation of scarce resources. Failing to address public views and concerns on the subject could fuel distrust. The objective of this study was to determine the priorities of the Iranian public toward the fair allocation of ventilators during the COVID-19 pandemic. Methods: This anonymous community-based national study was conducted from May 28 to Aug 20, 2020, in Iran. Data were collected via the Google Forms platform, using an online self-administrative questionnaire. The questionnaire assessed participants' assigned prioritization scores for ventilators based on medical and non-medical criteria. To quantify participants' responses on prioritizing ventilator allocation among sub-groups of patients with COVID-19 who need mechanical ventilation scores ranging from -2, very low priority, to +2, very high priority were assigned to each response. Results: Responses of 2,043 participants, 1,189 women, and 1,012 men, were analyzed. The mean (SD) age was 31.1 (9.5), being 32.1 (9.3) among women, and 29.9 (9.6) among men. Among all participants, 274 (13.4%) were healthcare workers. The median of assigned priority score was zero (equal) for gender, age 41-80, nationality, religion, socioeconomic, high-profile governmental position, high-profile occupation, being celebrities, employment status, smoking status, drug abuse, end-stage status, and obesity. The median assigned priority score was +2 (very high priority) for pregnancy, and having <2 years old children. The median assigned priority score was +1 (high priority) for physicians and nurses of patients with COVID-19, patients with nobel research position, those aged <40 years, those with underlying disease, immunocompromise status, and malignancy. Age>80 was the only factor participants assigned -1 (low priority) to. Conclusions: Participants stated that socioeconomic factors, except for age>80, should not be involved in prioritizing mechanical ventilators at the time of resources scarcity. Front-line physicians and nurses of COVID-19 patients, pregnant mothers, mothers who had children under 2 years old were given high priority.
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Affiliation(s)
- Mohsen Abbasi-Kangevari
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shahnam Arshi
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Ali-Asghar Kolahi
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Ghanbari V, Ardalan A, Zareiyan A, Nejati A, Hanfling D, Bagheri A, Rostamnia L. Fair prioritization of casualties in disaster triage: a qualitative study. BMC Emerg Med 2021; 21:119. [PMID: 34645418 PMCID: PMC8513386 DOI: 10.1186/s12873-021-00515-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 10/05/2021] [Indexed: 11/30/2022] Open
Abstract
Background Disasters may result in mass casualties and an imbalance between health care demands and supplies. This imbalance necessitates the prioritization of the victims based on the severity of their condition. Contributing factors and their effect on decision-making is a challenging issue in disaster triage. The present study seeks to address criteria for ethical decision-making in the prioritization of patients in disaster triage. Methods This conventional content analysis study was conducted in 2017. Subjects were selected from among Iranian experts using purposeful and snowball sampling methods. Data were collected using semi-structured interviews and were analyzed by the content analysis. Results Efficient and effective triage and priority-oriented triage were the main categories. These categories summarized a number of medical and nonmedical factors that should be considered in the prioritization of the victims in disaster triage. Conclusion A combination of measures should be considered to maximize the benefits of the prioritization of causalities in disasters. None of these measures alone would suffice to explain all aspects of ethical decision-making in disaster triage. Further investigations are needed to elaborate on these criteria in decision-making. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00515-2.
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Affiliation(s)
- Vahid Ghanbari
- Emergency Nursing Department, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ali Ardalan
- Health in Disaster and Emergencies Department, School of Public Health, Tehran University of Medical Sciences, Avecina Ave, Keshavarz Boulevard, Tehran, Iran
| | - Armin Zareiyan
- Health in Disaster and Emergencies Department, School of Nursing, AJA University of Medical Sciences, Ehtemadzadeh st, West Fatemi St, Tehran, Iran.
| | - Amir Nejati
- Department of Emergency Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Dan Hanfling
- Clinical Professor of Emergency Medicine, George Washington University, Washington, DC, USA
| | - Alireza Bagheri
- Center for Medical Ethics and History of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Leili Rostamnia
- Nursing Department, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Cardona M, Dobler CC, Koreshe E, Heyland DK, Nguyen RH, Sim JPY, Clark J, Psirides A. A catalogue of tools and variables from crisis and routine care to support decision-making about allocation of intensive care beds and ventilator treatment during pandemics: Scoping review. J Crit Care 2021; 66:33-43. [PMID: 34438132 DOI: 10.1016/j.jcrc.2021.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/15/2021] [Accepted: 08/06/2021] [Indexed: 01/16/2023]
Abstract
PURPOSE This scoping review sought to identify objective factors to assist clinicians and policy-makers in making consistent, objective and ethically sound decisions about resource allocation when healthcare rationing is inevitable. MATERIALS AND METHODS Review of guidelines and tools used in ICUs, hospital wards and emergency departments on how to best allocate intensive care beds and ventilators either during routine care or developed during previous epidemics, and association with patient outcomes during and after hospitalisation. RESULTS Eighty publications from 20 countries reporting accuracy or validity of prognostic tools/algorithms, or significant correlation between prognostic variables and clinical outcomes met our eligibility criteria: twelve pandemic guidelines/triage protocols/consensus statements, twenty-two pandemic algorithms, and 46 prognostic tools/variables from non-crisis situations. Prognostic indicators presented here can be combined to create locally-relevant triage algorithms for clinicians and policy makers deciding about allocation of ICU beds and ventilators during a pandemic. No consensus was found on the ethical issues to incorporate in the decision to admit or triage out of intensive care. CONCLUSIONS This review provides a unique reference intended as a discussion starter for clinicians and policy makers to consider formalising an objective a locally-relevant triage consensus document that enhances confidence in decision-making during healthcare rationing of critical care and ventilator resources.
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Affiliation(s)
- Magnolia Cardona
- Institute for Evidence-Based Healthcare, Bond University Gold Coast, Queensland, Australia; Gold Coast University Hospital Evidence-Based Practice Professorial Unit, Southport, Queensland, Australia.
| | - Claudia C Dobler
- Institute for Evidence-Based Healthcare, Bond University Gold Coast, Queensland, Australia; Evidence-Based Practice Center, Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, MN, USA; The University of New South Wales, South Western Sydney Clinical School, NSW, Australia
| | - Eyza Koreshe
- InsideOut Institute, Central Clinical School, The University of Sydney, NSW, Australia
| | - Daren K Heyland
- Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada
| | - Rebecca H Nguyen
- The University of New South Wales, South Western Sydney Clinical School, NSW, Australia
| | - Joan P Y Sim
- The University of New South Wales, South Western Sydney Clinical School, NSW, Australia
| | - Justin Clark
- Institute for Evidence-Based Healthcare, Bond University Gold Coast, Queensland, Australia
| | - Alex Psirides
- Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand
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Perpetua EM, Guibone KA, Keegan PA, Palmer R, Speight MK, Jagnic K, Michaels J, Nguyen RA, Pickett ES, Ramsey D, Schnell SJ, Wong SC, Reisman M. Best Practice Recommendations for Optimizing Care in Structural Heart Programs: Planning Efficient and Resource Leveraging Systems (PEARLS). STRUCTURAL HEART 2021; 5:168-179. [PMID: 35378800 PMCID: PMC8968322 DOI: 10.1080/24748706.2021.1877858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 01/11/2021] [Accepted: 09/26/2021] [Indexed: 11/24/2022]
Abstract
The COVID19 pandemic brought unprecedented disruption to healthcare. Staggering morbidity, mortality, and economic losses prompted the review and refinement of care for structural heart disease (SHD). To mitigate negative impacts in the face of crisis or capacity constraints, this paper offers best practice recommendations for Planning Efficient and Resource Leveraging Systems (PEARLS) in structural heart programs. A systematic assessment is recommended for hospital capacity, Heart Team roles and functions, and patient and procedural risks associated with increased resource utilization. Strategies, tactics, and pathways are provided for the delivery of patient-centered, efficient and resource-leveraging care from referral to follow-up. Through the optimal use of capacity and resources, paired with dynamic triage, forecasting, and surveillance, Heart Teams may aspire to plan and implement an optimized system of care for SHD. Abbreviations: AS: aortic stenosis; ASD: atrioseptal defect; COVID19: Coronavirus disease 19; LAAO: left atrial appendage occlusion; MI: myocardial infarction; MR: mitral regurgitation; PFO: patent foramen ovale; PVL: paravalvular leak; SHD: structural heart disease; SAVR: surgical aortic valve replacement; SDM: shared decision-making; TAVR: transcatheter aortic valve replacement; TMVr: transcatheter mitral valve repair; TMVR: transcatheter mitral valve replacement; TEE: transesophageal echocardiography; TTE: transthoracic echocardiography.
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Huseynov S, Palma MA, Nayga RM. General Public Preferences for Allocating Scarce Medical Resources During COVID-19. Front Public Health 2020; 8:587423. [PMID: 33363084 PMCID: PMC7759519 DOI: 10.3389/fpubh.2020.587423] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 11/23/2020] [Indexed: 11/13/2022] Open
Abstract
COVID-19 has overwhelmed healthcare systems across the globe with an unprecedented surge in the demand for hospitalizations. Consequently, many hospitals are facing precarious conditions due to limited capacity, especially in the provision of ventilators. The governing ethical principles of medical practice delineated in (1) favor prioritizing younger patients, largely because of their relatively higher expected life years. We conduct a survey of the general public in the United States to elicit their preferences for the allocation of a limited number of ventilators. The results show that the general public views align with the established ethical principles, which favor younger patients. JEL Classification: C91.
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Affiliation(s)
- Samir Huseynov
- Texas A&M University, College Station, TX, United States
| | - Marco A. Palma
- Texas A&M University, College Station, TX, United States
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Marrazzo F, Spina S, Pepe PE, D'Ambrosio A, Bernasconi F, Manzoni P, Graci C, Frigerio C, Sacchi M, Stucchi R, Teruzzi M, Baraldi S, Lovisari F, Langer T, Sforza A, Migliari M, Sechi G, Sangalli F, Fumagalli R. Rapid reorganization of the Milan metropolitan public safety answering point operations during the initial phase of the COVID-19 outbreak in Italy. J Am Coll Emerg Physicians Open 2020; 1:1240-1249. [PMID: 33043317 PMCID: PMC7537156 DOI: 10.1002/emp2.12245] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/03/2020] [Accepted: 08/19/2020] [Indexed: 01/10/2023] Open
Abstract
Objective To quantify how the first public announcement of confirmed coronavirus disease 2019 (COVID-19) in Italy affected a metropolitan region's emergency medical services (EMS) call volume and how rapid introduction of alternative procedures at the public safety answering point (PSAP) managed system resources. Methods PSAP processes were modified over several days including (1) referral of non-ill callers to public health information call centers; (2) algorithms for detection, isolation, or hospitalization of suspected COVID-19 patients; and (3) specialized medical teams sent to the PSAP for triage and case management, including ambulance dispatches or alternative dispositions. Call volumes, ambulance dispatches, and response intervals for the 2 weeks after announcement were compared to 2017-2019 data and the week before. Results For 2 weeks following outbreak announcement, the primary-level PSAP (police/fire/EMS) averaged 56% more daily calls compared to prior years and recorded 9281 (106% increase) on Day 4, averaging ∼400/hour. The secondary-level (EMS) PSAP recorded an analogous 63% increase with 3863 calls (∼161/hour; 264% increase) on Day 3. The COVID-19 response team processed the more complex cases (n = 5361), averaging 432 ± 110 daily (∼one-fifth of EMS calls). Although community COVID-19 cases increased exponentially, ambulance response intervals and dispatches (averaging 1120 ± 46 daily) were successfully contained, particularly compared with the week before (1174 ± 40; P = 0.02). Conclusion With sudden escalating EMS call volumes, rapid reorganization of dispatch operations using tailored algorithms and specially assigned personnel can protect EMS system resources by optimizing patient dispositions, controlling ambulance allocations and mitigating hospital impact. Prudent population-based disaster planning should strongly consider pre-establishing similar highly coordinated medical taskforce contingencies.
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Affiliation(s)
- Francesco Marrazzo
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Stefano Spina
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Paul E. Pepe
- Metropolitan Emergency Medical Services Medical Directors Global CoalitionDallasTexasUSA
| | | | - Filippo Bernasconi
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Paola Manzoni
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Carmela Graci
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Cristina Frigerio
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Marco Sacchi
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Riccardo Stucchi
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Mario Teruzzi
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Sara Baraldi
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Federica Lovisari
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Thomas Langer
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
- School of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
| | | | - Maurizio Migliari
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Giuseppe Sechi
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
| | - Fabio Sangalli
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
| | - Roberto Fumagalli
- Azienda Regionale Emergenza Urgenza (AREU)MilanLombardyItaly
- Department of Anesthesia and Critical Care MedicineNiguarda HospitalMilanItaly
- School of Medicine and SurgeryUniversity of Milano‐BicoccaMilanItaly
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Henriksen J, Kolognizak T, Houghton T, Cherne S, Zhen D, Cimino PJ, Latimer CS, Scherpelz KP, Yoda RA, Alpers CE, Chhieng DF, Keene CD, Gonzalez-Cuyar LF. Rapid Validation of Telepathology by an Academic Neuropathology Practice During the COVID-19 Pandemic. Arch Pathol Lab Med 2020; 144:1311-1320. [PMID: 32551815 PMCID: PMC10777891 DOI: 10.5858/arpa.2020-0372-sa] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— The coronavirus disease 19 (COVID-19) pandemic is placing unparalleled burdens on regional and institutional resources in medical facilities across the globe. This disruption is causing unprecedented downstream effects to traditionally established channels of patient care delivery, including those of essential anatomic pathology services. With Washington state being the initial North American COVID-19 epicenter, the University of Washington in Seattle has been at the forefront of conceptualizing and implementing innovative solutions in order to provide uninterrupted quality patient care amidst this growing crisis. OBJECTIVE.— To conduct a rapid validation study assessing our ability to reliably provide diagnostic neuropathology services via a whole slide imaging (WSI) platform as part of our departmental COVID-19 planning response. DESIGN.— This retrospective study assessed diagnostic concordance of neuropathologic diagnoses rendered via WSI as compared to those originally established via traditional histopathology in a cohort of 30 cases encompassing a broad range of neurosurgical and neuromuscular entities. This study included the digitalization of 93 slide preparations, which were independently examined by groups of board-certified neuropathologists and neuropathology fellows. RESULTS.— There were no major or minor diagnostic discrepancies identified in either the attending neuropathologist or neuropathology trainee groups for either the neurosurgical or neuromuscular case cohorts. CONCLUSIONS.— Our study demonstrates that accuracy of neuropathologic diagnoses and interpretation of ancillary preparations via WSI are not inferior to those generated via traditional microscopy. This study provides a framework for rapid subspecialty validation and deployment of WSI for diagnostic purposes during a pandemic event.
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Affiliation(s)
| | | | - Tracy Houghton
- From the Department of Pathology, University of Washington, Seattle
| | - Steve Cherne
- From the Department of Pathology, University of Washington, Seattle
| | - Daisy Zhen
- From the Department of Pathology, University of Washington, Seattle
| | - Patrick J Cimino
- From the Department of Pathology, University of Washington, Seattle
| | | | | | - Rebecca A Yoda
- From the Department of Pathology, University of Washington, Seattle
| | - Charles E Alpers
- From the Department of Pathology, University of Washington, Seattle
| | - David F Chhieng
- From the Department of Pathology, University of Washington, Seattle
| | - C Dirk Keene
- From the Department of Pathology, University of Washington, Seattle
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Abstract
This paper applies a scenario planning approach, to outline some current uncertainties related to COVID-19 and what they might mean for plausible futures for which we should prepare, and to identify factors that we as individual faculty members and university institutions should be considering now, when planning for the future under COVID-19. Although the contextual focus of this paper is Canada, the content is likely applicable to other places where the COVID-19 epidemic curve is in its initial rising stage, and where universities are predominantly publicly funded institutions.
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Ethical prioritization of patients during disaster triage: A systematic review of current evidence. Int Emerg Nurs 2019; 43:126-132. [PMID: 30612846 DOI: 10.1016/j.ienj.2018.10.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 08/17/2018] [Accepted: 10/21/2018] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Triage is a dynamic and complex decision-making process in order to determine priority of access to medical care in a disaster situation. The elements which should govern an ethical decision-making in prioritizing of victims have been debated for a long time. This paper aims to identify ethical principles guiding patient prioritization during disaster triage. METHOD Electronic databases were searched via structured search strategy from 1990 until July 2017. The studies investigating patients' prioritization in disaster situation were eligible for inclusion. All types of articles and guidelines were included. RESULT Of 7167 titles identified in the search, 35 studies were included. The important factors identified in patient prioritization were grouped into two categories: medical measures (medical need, likelihood of benefit and survivability) and Nonmedical measures (saving the most lives, youngest first, preserving function of society, protecting vulnerable groups, required resources and unbiased selection). Demographic characteristics, health status of patients, social value of patient, and unbiased selection are discriminatory factors in disaster triage. CONCLUSION Various factors have been introduced to consider ethical patient prioritization in disaster triage. Providers' engagement, public education, and ongoing training are required to reach a fair decision.
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Identifying Factors That May Influence Decision-Making Related to the Distribution of Patients During a Mass Casualty Incident. Disaster Med Public Health Prep 2017; 12:101-108. [PMID: 28918763 DOI: 10.1017/dmp.2017.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to identify and seek agreement on factors that may influence decision-making related to the distribution of patients during a mass casualty incident. METHODS A qualitative thematic analysis of a literature review identified 56 unique factors related to the distribution of patients in a mass casualty incident. A modified Delphi study was conducted and used purposive sampling to identify peer reviewers that had either (1) a peer-reviewed publication within the area of disaster management or (2) disaster management experience. In round one, peer reviewers ranked the 56 factors and identified an additional 8 factors that resulted in 64 factors being ranked during the two-round Delphi study. The criteria for agreement were defined as a median score greater than or equal to 7 (on a 9-point Likert scale) and a percentage distribution of 75% or greater of ratings being in the highest tertile. RESULTS Fifty-four disaster management peer reviewers, with hospital and prehospital practice settings most represented, assessed a total of 64 factors, of which 29 factors (45%) met the criteria for agreement. CONCLUSIONS Agreement from this formative study suggests that certain factors are influential to decision-making related to the distribution of patients during a mass casualty incident. (Disaster Med Public Health Preparedness. 2018;12:101-108).
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Implementing a negative-pressure isolation ward for a surge in airborne infectious patients. Am J Infect Control 2017; 45:652-659. [PMID: 28330710 PMCID: PMC7115276 DOI: 10.1016/j.ajic.2017.01.029] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 01/26/2017] [Accepted: 01/26/2017] [Indexed: 11/23/2022]
Abstract
A 30-bed negative-pressure isolation ward was established on a functioning hospital. The pressure relative to the main hospital was −29 Pa by adjusting the ventilation. No occurrences of pressure reversal occurred at ward entrance. Pressures on the ward changed to slightly positive. Health care personnel should wear personal protective equipment on the ward.
Background During a large-scale airborne infectious disease outbreak, the number of patients needing hospital-based health care services may exceed available negative-pressure isolation room capacity. Methods To test one method of increasing hospital surge capacity, a temporary negative-pressure isolation ward was established at a fully functioning hospital. Negative pressure was achieved in a 30-bed hospital ward by adjusting the ventilation system. Differential pressure was continuously measured at 22 locations, and ventilation airflow was characterized throughout the ward. Results The pressure on the test ward relative to the main hospital hallway was −29 Pa on average, approximately 10 times higher than the Centers for Disease Control and Prevention guidance for airborne infection control. No occurrences of pressure reversal occurred at the entrances to the ward, even when staff entered the ward. Pressures within the ward changed, with some rooms becoming neutrally or slightly positively pressurized. Conclusions This study showed that establishing a temporary negative-pressure isolation ward is an effective method to increase surge capacity in a hospital.
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12
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Migrant crisis in Europe: implications for intensive care specialists. Intensive Care Med 2016; 42:249-51. [PMID: 26489927 DOI: 10.1007/s00134-015-4104-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
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Venkatesan S, Myles PR, McCann G, Kousoulis AA, Hashmi M, Belatri R, Boyle E, Barcroft A, van Staa TP, Kirkham JJ, Nguyen Van Tam JS, Williams TJ, Semple MG. Development of processes allowing near real-time refinement and validation of triage tools during the early stage of an outbreak in readiness for surge: the FLU-CATs Study. Health Technol Assess 2016; 19:1-132. [PMID: 26514069 DOI: 10.3310/hta19890] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND During pandemics of novel influenza and outbreaks of emerging infections, surge in health-care demand can exceed capacity to provide normal standards of care. In such exceptional circumstances, triage tools may aid decisions in identifying people who are most likely to benefit from higher levels of care. Rapid research during the early phase of an outbreak should allow refinement and validation of triage tools so that in the event of surge a valid tool is available. The overarching study aim is to conduct a prospective near real-time analysis of structured clinical assessments of influenza-like illness (ILI) using primary care electronic health records (EHRs) during a pandemic. This abstract summarises the preparatory work, infrastructure development, user testing and proof-of-concept study. OBJECTIVES (1) In preparation for conducting rapid research in the early phase of a future outbreak, to develop processes that allow near real-time analysis of general practitioner (GP) assessments of people presenting with ILI, management decisions and patient outcomes. (2) As proof of concept: conduct a pilot study evaluating the performance of the triage tools 'Community Assessment Tools' and 'Pandemic Medical Early Warning Score' to predict hospital admission and death in patients presenting with ILI to GPs during inter-pandemic winter seasons. DESIGN Prospective near real-time analysis of structured clinical assessments and anonymised linkage to data from EHRs. User experience was evaluated by semistructured interviews with participating GPs. SETTING Thirty GPs in England, Wales and Scotland, participating in the Clinical Practice Research Datalink. PARTICIPANTS All people presenting with ILI. INTERVENTIONS None. MAIN OUTCOME MEASURES Study outcome is proof of concept through demonstration of data capture and near real-time analysis. Primary patient outcomes were hospital admission within 24 hours and death (all causes) within 30 days of GP assessment. Secondary patient outcomes included GP decision to prescribe antibiotics and/or influenza-specific antiviral drugs and/or refer to hospital - if admitted, the need for higher levels of care and length of hospital stay. DATA SOURCES Linked anonymised data from a web-based structured clinical assessment and primary care EHRs. RESULTS In the 24 months to April 2015, data from 704 adult and 159 child consultations by 30 GPs were captured. GPs referred 11 (1.6%) adults and six (3.8%) children to hospital. There were 13 (1.8%) deaths of adults and two (1.3%) of children. There were too few outcome events to draw any conclusions regarding the performance of the triage tools. GP interviews showed that although there were some difficulties with installation, the web-based data collection tool was quick and easy to use. Some GPs felt that a minimal monetary incentive would promote participation. CONCLUSIONS We have developed processes that allow capture and near real-time automated analysis of GP's clinical assessments and management decisions of people presenting with ILI. FUTURE WORK We will develop processes to include other EHR systems, attempt linkage to data on influenza surveillance and maintain processes in readiness for a future outbreak. STUDY REGISTRATION This study is registered as ISRCTN87130712 and UK Clinical Research Network 12827. FUNDING The National Institute for Health Research Health Technology Assessment programme. MGS is supported by the UK NIHR Health Protection Research Unit in Emerging and Zoonotic Infections.
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Affiliation(s)
- Sudhir Venkatesan
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Puja R Myles
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, UK
| | - Gerard McCann
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Antonis A Kousoulis
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Maimoona Hashmi
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Rabah Belatri
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Emma Boyle
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Alan Barcroft
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | | | - Jamie J Kirkham
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | | | - Timothy J Williams
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Malcolm G Semple
- Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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Goodacre S, Irving A, Wilson R, Beever D, Challen K. The PAndemic INfluenza Triage in the Emergency Department (PAINTED) pilot cohort study. Health Technol Assess 2015; 19:v-xxi, 1-69. [PMID: 25587699 DOI: 10.3310/hta19030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Research needs to be undertaken rapidly in the event of an influenza pandemic to develop and evaluate triage methods for people presenting to the emergency department with suspected pandemic influenza. OBJECTIVES We aimed to pilot a research study to be undertaken in a pandemic to identify the most accurate triage method for patients presenting to the emergency department with suspected pandemic influenza. The objectives of the pilot study were to develop a standardised clinical assessment form and secure online database; test both using data from patients with seasonal influenza; seek clinician views on the usability of the form; and obtain all regulatory approvals required for the main study. DESIGN Study methods were piloted using an observational cohort study and clinician views were sought using qualitative, semistructured interviews. SETTING Six acute hospital emergency departments. PARTICIPANTS Patients attending the emergency department with suspected seasonal influenza during winter 2012-13 and clinicians working in the emergency departments. MAIN OUTCOME MEASURES Adverse events up to 30 days were identified, but analysis of the pilot data was limited to descriptive reporting of patient flow, data completeness and patient characteristics. RESULTS Some 165 patients were identified, of whom 10 withdrew their data, leaving 155 (94%) for analysis. Follow-up data were available for 129 of 155 (83%), with 50 of 129 (39%) being admitted to hospital. Three cases (2%) were recorded as having suffered an adverse outcome. There appeared to be variation between the hospitals, allowing for small numbers. Three of the hospitals identified 150 of 165 (91%) of the patients, and all 10 withdrawing patients were at the same hospital. The proportion with missing follow-up data varied from 8% to 31%, and the proportion admitted varied from 4% to 85% across the three hospitals with meaningful numbers of cases. All of the deaths were at one hospital. There was less variation between hospitals in rates of missing data, and for most key variables missing rates were between 5% and 30%. Higher missing rates were recorded for blood pressure (39%), inspired oxygen (43%), capillary refill (36%) and Glasgow Coma Scale score (43%). Chest radiography was performed in 51 of 118 cases, and electrocardiography in 40 of 111 cases with details recorded. Blood test results were available for 32 of 155 cases. The qualitative interviews revealed generally positive views towards the standardised assessment form. Concerns about lack of space for free text were raised but counterbalanced by appreciation that it fitted on to one A4 page. A number of amendments were suggested but only three of these were suggested by more than one participant, and no suggestions were made by more than two participants. CONCLUSIONS A standardised assessment form is acceptable to clinicians and could be used to collect research data in an influenza pandemic, but analysis may be limited by missing data. FUTURE WORK An observational cohort study to identify the most accurate triage method for predicting severe illness in emergency department attendees with suspected pandemic influenza is set up and ready to activate if, or when, a pandemic occurs. TRIAL REGISTRATION Current Controlled Trials ISRCTN56149622. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 3. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andy Irving
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Richard Wilson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Beever
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Kirsty Challen
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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15
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Wilkinson AM, Matzo M. Nursing Education for Disaster Preparedness and Response. J Contin Educ Nurs 2015; 46:1-9. [PMID: 25646952 DOI: 10.3928/00220124-20150126-01] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2014] [Accepted: 09/21/2014] [Indexed: 02/28/2024]
Abstract
Catastrophic mass casualty events (MCEs), such as pandemic influenza outbreaks, earthquakes, or large-scale terrorism-related events, quickly and suddenly yield thousands of victims whose needs overwhelm local and regional health care systems, personnel, and resources. Such conditions require deploying scarce resources in a manner that is different from the more common multiple casualty event. This article presents issues associated with providing nursing care under MCE circumstances of scarce resources and the educational needs of nurses to prepare them to effectively respond in these emergencies. J Contin Educ Nurs. 2015;46(x):xxx-xxx.
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16
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Zhong S, Clark M, Hou XY, Zang Y, FitzGerald G. Progress and challenges of disaster health management in China: a scoping review. Glob Health Action 2014; 7:24986. [PMID: 25215910 PMCID: PMC4161949 DOI: 10.3402/gha.v7.24986] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 07/31/2014] [Accepted: 08/13/2014] [Indexed: 11/16/2022] Open
Abstract
Background Despite the importance of an effective health system response to various disasters, relevant research is still in its infancy, especially in middle- and low-income countries. Objective This paper provides an overview of the status of disaster health management in China, with its aim to promote the effectiveness of the health response for reducing disaster-related mortality and morbidity. Design A scoping review method was used to address the recent progress of and challenges to disaster health management in China. Major health electronic databases were searched to identify English and Chinese literature that were relevant to the research aims. Results The review found that since 2003 considerable progress has been achieved in the health disaster response system in China. However, there remain challenges that hinder effective health disaster responses, including low standards of disaster-resistant infrastructure safety, the lack of specific disaster plans, poor emergency coordination between hospitals, lack of portable diagnostic equipment and underdeveloped triage skills, surge capacity, and psychological interventions. Additional challenges include the fragmentation of the emergency health service system, a lack of specific legislation for emergencies, disparities in the distribution of funding, and inadequate cost-effective considerations for disaster rescue. Conclusions One solution identified to address these challenges appears to be through corresponding policy strategies at multiple levels (e.g. community, hospital, and healthcare system level).
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Affiliation(s)
- Shuang Zhong
- Center for Emergency and Disaster Management, School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia; Center for Health Management and Policy, Shandong University, Jinan, China;
| | - Michele Clark
- Center for Emergency and Disaster Management, School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia; School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Xiang-Yu Hou
- Center for Emergency and Disaster Management, School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Yuli Zang
- School of Nursing, Shandong University, Jinan, China
| | - Gerard FitzGerald
- Center for Emergency and Disaster Management, School of Public Health and Social Work, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia;
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17
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Myles PR, Nguyen-Van-Tam JS, Lim WS, Nicholson KG, Brett SJ, Enstone JE, McMenamin J, Openshaw PJM, Read RC, Taylor BL, Bannister B, Semple MG. Comparison of CATs, CURB-65 and PMEWS as triage tools in pandemic influenza admissions to UK hospitals: case control analysis using retrospective data. PLoS One 2012; 7:e34428. [PMID: 22509303 PMCID: PMC3317953 DOI: 10.1371/journal.pone.0034428] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 02/28/2012] [Indexed: 12/04/2022] Open
Abstract
Triage tools have an important role in pandemics to identify those most likely to benefit from higher levels of care. We compared Community Assessment Tools (CATs), the CURB-65 score, and the Pandemic Medical Early Warning Score (PMEWS); to predict higher levels of care (high dependency - Level 2 or intensive care - Level 3) and/or death in patients at or shortly after admission to hospital with A/H1N1 2009 pandemic influenza. This was a case-control analysis using retrospectively collected data from the FLU-CIN cohort (1040 adults, 480 children) with PCR-confirmed A/H1N1 2009 influenza. Area under receiver operator curves (AUROC), sensitivity, specificity, positive predictive values and negative predictive values were calculated. CATs best predicted Level 2/3 admissions in both adults [AUROC (95% CI): CATs 0.77 (0.73, 0.80); CURB-65 0.68 (0.64, 0.72); PMEWS 0.68 (0.64, 0.73), p<0.001] and children [AUROC: CATs 0.74 (0.68, 0.80); CURB-65 0.52 (0.46, 0.59); PMEWS 0.69 (0.62, 0.75), p<0.001]. CURB-65 and CATs were similar in predicting death in adults with both performing better than PMEWS; and CATs best predicted death in children. CATs were the best predictor of Level 2/3 care and/or death for both adults and children. CATs are potentially useful triage tools for predicting need for higher levels of care and/or mortality in patients of all ages.
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Affiliation(s)
- Puja R. Myles
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
| | | | - Wei Shen Lim
- Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Karl G. Nicholson
- Infectious Diseases Unit, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Stephen J. Brett
- Centre for Peri-operative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Joanne E. Enstone
- Division of Epidemiology and Public Health, University of Nottingham, Nottingham, United Kingdom
| | - James McMenamin
- Health Protection Scotland, NHS National Services Scotland, Glasgow, United Kingdom
| | - Peter J. M. Openshaw
- Centre for Respiratory Infections, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Robert C. Read
- Department of Infection & Immunity, University of Sheffield, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Bruce L. Taylor
- Department of Critical Care, Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | - Barbara Bannister
- Infectious Diseases Department, Royal Free Hampstead NHS Trust, London, United Kingdom
| | - Malcolm G. Semple
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
- * E-mail:
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18
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Koenig KL, Lim HCS, Tsai SH. Crisis Standard of Care: Refocusing Health Care Goals During Catastrophic Disasters and Emergencies. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.jecm.2011.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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19
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Ashton-Cleary DT, Tillyard ARJ, Freeman NVE. Intensive Care Admission Triage during a Pandemic: A Survey of the Acceptability of Triage Tools. J Intensive Care Soc 2011. [DOI: 10.1177/175114371101200303] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We conducted a survey of the UK Intensive Care Society regarding physician opinion of national guidance on ICU triage during a viral pandemic. Respondents graded agreement for seventeen triage criteria, ten from the Department of Health. We determined whether respondents accepted the whole tool on the basis of proportion of criteria agreed with. A modified tool was devised and acceptability compared. Five hundred and fifty questionnaires were returned (33.1% from senior physicians). Approximately half of senior physicians (49.5%) and 44.4% of other respondents found the tool acceptable. This improved to 68.7% and 59.2% for the modified tool. Chi-square analysis revealed no statistically significant difference between the opinions of senior physicians and other respondents (p=0.850 for the original tool, p=0.593 for the modified tool). A small change to the government guidelines produced a tool with improved acceptability among ICU physicians.
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Affiliation(s)
- David T Ashton-Cleary
- Speciality Registrar in Anaesthesia and Intensive Care, Derriford Hospital, Plymouth
| | | | - Nicola VE Freeman
- Speciality Registrar in Anaesthesia and Intensive Care, Torbay Hospital
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20
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Adeniji KA, Cusack R. The Simple Triage Scoring System (STSS) successfully predicts mortality and critical care resource utilization in H1N1 pandemic flu: a retrospective analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R39. [PMID: 21269458 PMCID: PMC3221968 DOI: 10.1186/cc10001] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2010] [Revised: 11/26/2010] [Accepted: 01/26/2011] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Triage protocols are only initiated when it is apparent that resource deficits will occur across a broad geographical area despite efforts to expand or acquire additional capacity. Prior to the pandemic the UK Department of Health (DOH) recommended the use of a staged triage plan incorporating Sepsis-related Organ Failure Assessment (SOFA) developed by the Ontario Ministry of Health to assist in the triage of critical care admissions and discharges during an influenza outbreak in the UK. There are data to suggest that had it been used in the recent H1N1 pandemic it may have led to inappropriate limitation of therapy if surge capacity had been overwhelmed. METHODS We retrospectively reviewed the performance of the Simple Triage Scoring System (STSS) as an indicator of the utilization of hospital resources in adult patients with confirmed H1N1 admitted to a university teaching hospital. Our aim was to compare it against the staged initial SOFA score process with regards to mortality, need for intensive care admission and requirement for mechanical ventilation and assess its validity. RESULTS Over an 8 month period, 62 patients with confirmed H1N1 were admitted. Forty (65%) had documented comorbidities and 27 (44%) had pneumonic changes on their admission CXR. Nineteen (31%) were admitted to the intensive care unit where 5 (26%) required mechanical ventilation (MV). There were 3 deaths. The STSS group categorization demonstrated a better discriminating accuracy in predicting critical care resource usage with a receiver operating characteristic area under the curve (95% confidence interval) for ICU admission of 0.88 (0.78-0.98) and need for MV of 0.91 (0.83-0.99). This compared to the staged SOFA score of 0.77 (0.65-0.89) and 0.87 (0.72-1.00) respectively. Low mortality rates limited analysis on survival predictions. CONCLUSIONS The STSS accurately risk stratified patients in this cohort according to their risk of death and predicted the likelihood of admission to critical care and the requirement for MV. Its single point in time, accuracy and easily collected component variables commend it as an alternative reproducible system to facilitate the triage and treatment of patients in any future influenza pandemic.
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Affiliation(s)
- Kayode A Adeniji
- Critical Care Research Unit, SUHT, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK.
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21
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Corcoran SP, Niven AS, Reese JM. Critical care management of major disasters: a practical guide to disaster preparation in the intensive care unit. J Intensive Care Med 2011; 27:3-10. [PMID: 21220272 DOI: 10.1177/0885066610393639] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Recent events and regulatory mandates have underlined the importance of medical planning and preparedness for catastrophic events. The purpose of this review is to provide a brief summary of current commonly identified threats, an overview of mass critical care management, and a discussion of resource allocation to provide the intensive care unit (ICU) director with a practical guide to help prepare and coordinate the activities of the multidisciplinary critical care team in the event of a disaster.
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Affiliation(s)
- Shawn P Corcoran
- Department of Medicine, Madigan Army Medical Center, Tacoma, WA 98431, USA.
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22
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23
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Pandemic influenza and the critically ill pediatric patient: addressing the right issues for the "worst case" scenario. Pediatr Crit Care Med 2010; 11:436-8. [PMID: 20453622 DOI: 10.1097/pcc.0b013e3181dab208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Altered standards of care during an influenza pandemic: identifying ethical, legal, and practical principles to guide decision making. Disaster Med Public Health Prep 2010; 3 Suppl 2:S132-40. [PMID: 19755912 DOI: 10.1097/dmp.0b013e3181ac3dd2] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although widespread support favors prospective planning for altered standards of care during mass casualty events, the literature includes few, if any, accounts of groups that have formally addressed the overarching policy considerations at the state level. We describe the planning process undertaken by public health officials in the Commonwealth of Massachusetts, along with community and academic partners, to explore the issues surrounding altered standards of care in the event of pandemic influenza. Throughout 2006, the Massachusetts Department of Public Health and the Harvard School of Public Health Center for Public Health Preparedness jointly convened a working group comprising ethicists, lawyers, clinicians, and local and state public health officials to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. Community stakeholders were also engaged in the process through facilitated discussion of case scenarios focused on these and other issues. The objective of this initiative was to establish a framework and some fundamental principles that would subsequently guide the process of establishing specific altered standards of care protocols. The group collectively identified 4 goals and 7 principles to guide the equitable allocation of limited resources and establishment of altered standards of care protocols. Reviewing and analyzing this process to date may serve as a resource for other states.
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25
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Christian MD, Hamielec C, Lazar NM, Wax RS, Griffith L, Herridge MS, Lee D, Cook DJ. A retrospective cohort pilot study to evaluate a triage tool for use in a pandemic. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R170. [PMID: 19874595 PMCID: PMC2784402 DOI: 10.1186/cc8146] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 10/14/2009] [Accepted: 10/29/2009] [Indexed: 01/26/2023]
Abstract
Introduction The objective of this pilot study was to assess the usability of the draft Ontario triage protocol, to estimate its potential impact on patient outcomes, and ability to increase resource availability based on a retrospective cohort of critically ill patients cared for during a non-pandemic period. Methods Triage officers applied the protocol prospectively to 2 retrospective cohorts of patients admitted to 2 academic medical/surgical ICUs during an 8 week period of peak occupancy. Each patient was assigned a treatment priority (red -- 'highest', yellow -- 'intermediate', green -- 'discharge to ward', or blue/black -- 'expectant') by the triage officers at 3 separate time points (at the time of admission to the ICU, 48, and 120 hours post admission). Results Overall, triage officers were either confident or very confident in 68.4% of their scores; arbitration was required in 54.9% of cases. Application of the triage protocol would potentially decrease the number of required ventilator days by 49.3% (568 days) and decrease the total ICU days by 52.6% (895 days). On the triage protocol at ICU admission the survival rate in the red (93.7%) and yellow (62.5%) categories were significantly higher then that of the blue category (24.6%) with associated P values of < 0.0001 and 0.0003 respectively. Further, the survival rate of the red group was significantly higher than the overall survival rate of 70.9% observed in the cohort (P < 0.0001). At 48 and 120 hours, survival rates in the blue group increased but remained lower then the red or yellow groups. Conclusions Refinement of the triage protocol and implementation is required prior to future study, including improved training of triage officers, and protocol modification to minimize the exclusion from critical care of patients who may in fact benefit. However, our results suggest that the triage protocol can help to direct resources to patients who are most likely to benefit, and help to decrease the demands on critical care resources, thereby making available more resources to treat other critically ill patients.
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Affiliation(s)
- Michael D Christian
- Department of National Defence, Canadian Forces, Mount Sinai Hospital Toronto/University Health Network, University of Toronto, 600 University Avenue, Toronto, ON, Canada.
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26
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Vaughan E, Tinker T. Effective health risk communication about pandemic influenza for vulnerable populations. Am J Public Health 2009; 99 Suppl 2:S324-32. [PMID: 19797744 DOI: 10.2105/ajph.2009.162537] [Citation(s) in RCA: 248] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The consequences of pandemic influenza for vulnerable populations will depend partly on the effectiveness of health risk communications. Strategic planning should fully consider how life circumstances, cultural values, and perspectives on risk influence behavior during a pandemic. We summarize recent scientific evidence on communication challenges and examine how sociocultural, economic, psychological, and health factors can jeopardize or facilitate public health interventions that require a cooperative public. If ignored, current communication gaps for vulnerable populations could result in unequal protection across society during an influenza pandemic. We offer insights on communication preparedness gleaned from scientific studies and the deliberations of public health experts at a meeting convened by the Centers for Disease Control and Prevention, May 1 and 2, 2008.
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Affiliation(s)
- Elaine Vaughan
- Department of Psychology and Social Behavior, University of California, 3340 Social Ecology 2, Irvine, CA 92697, USA.
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27
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Moreno RP, Rhodes A, Chiche JD. The ongoing H1N1 flu pandemic and the intensive care community: challenges, opportunities, and the duties of scientific societies and intensivists. Intensive Care Med 2009; 35:2005-8. [PMID: 19841893 PMCID: PMC2779348 DOI: 10.1007/s00134-009-1706-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Accepted: 10/06/2009] [Indexed: 01/21/2023]
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Abstract
Disasters come in all shapes and forms, and in varying magnitudes and intensities. Nevertheless, they offer many of the same lessons for critical care practitioners and responders. Among these, the most important is that well thought out risk assessment and focused planning are vital. Such assessment and planning require proper training for providers to recognize and treat injury from disaster, while maintaining safety for themselves and others. This article discusses risk assessment and planning in the context of disasters. The article also elaborates on the progress toward the creation of portable, credible, sustainable, and sophisticated critical care outside the walls of an intensive care unit. Finally, the article summarizes yields from military-civilian collaboration in disaster planning and response.
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Affiliation(s)
- Saqib I Dara
- Critical Care Medicine, Al Rahba Hospital-Johns Hopkins International, Abu Dhabi, United Arab Emirates
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Williams L, Gannon J. Use of the SOFA Score in Pandemic Influenza — A Prospective Study. J Intensive Care Soc 2009. [DOI: 10.1177/175114370901000305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
It has been predicted that in the event of an influenza pandemic in the UK, there could be up to ten times the number of patients requiring critical care support than there are beds available. To aid rational, objective and ethical clinical decision making, the Department of Health recommends using the Sequential Organ Failure Assessment (SOFA) score as a tool for triaging admissions to the critical care unit. This study assessed what effect using the SOFA score would have on capacity. Daily SOFA scores were calculated for all patients on the critical care unit over a one month period. Twenty-four per cent of patients did not meet the criteria for admission to the unit, which would have freed up 36% of bed days in the event of a pandemic. Using this scoring system in conjunction with other measures recommended by the national framework may help the hospital cope with the high demand for critical care beds in the event of an influenza pandemic.
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Affiliation(s)
- Louise Williams
- Foundation Year 2, Wirral University Teaching Hospital NHS Foundation Trust
| | - John Gannon
- Consultant in Critical Care and Anaesthesia, Wirral University Teaching Hospital NHS Foundation Trust
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The Needs of Children in Natural or Manmade Disasters. INTENSIVE AND CRITICAL CARE MEDICINE 2009. [PMCID: PMC7120869 DOI: 10.1007/978-88-470-1436-7_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Disasters have been described as “events of sufficient scale, asset depletion, or numbers of victims to overwhelm medical resources” [1] or as “a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses that exceed the ability of the affected community or society to cope using its own resources” [2]. Importantly, that definition goes on to state: “A disaster is a function of the risk process. It results from the combination of hazards, conditions of vulnerability and insufficient capacity or measures to reduce the potential negative consequences of risk.”
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[Organization of intensive care in situation of avian flu pandemic]. Arch Pediatr 2008; 15:1781-93. [PMID: 18995996 PMCID: PMC7127334 DOI: 10.1016/j.arcped.2008.09.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Revised: 07/22/2008] [Accepted: 09/05/2008] [Indexed: 11/20/2022]
Abstract
The influenza pandemic will create a major increase in demand for hospital admissions, particularly for critical care services. The recommendations detailed herein have been elaborated by experts from medical societies potentially involved in this situation and focus on general hospital organization. Intensive care units will initially face high demand for admission; the Healthcare Authorities must therefore study how ICU capacity can be expanded. Pediatric intensive care units will be particularly affected by this situation of relative bed shortage, since young children, particularly infants, are expected to be affected by severe clinical forms of avian flu. Therefore, the weight threshold for admission to the adult ICU was lowered to 20 kg. Neonatal intensive care units (NICU) should remain, if possible, low viral density areas. Mixed (neonatal and pediatric) intensive care units could be dedicated to infants and children only. NICU admission of extreme premature babies should be limited in this difficult situation. Pediatric intensive care units (PICU) admission capacity could be doubled by using intermediate care and postoperative care units. The staff could be increased by doctors and nurses involved in canceled programmed activities. Healthcare workers transferred to PICU should be given special training.
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Ehrenstein BP. Pandemic influenza: are we prepared to face our obligations? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:165. [PMID: 18638362 PMCID: PMC2575555 DOI: 10.1186/cc6938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
After decades of low personal risk for contracting lethal diseases, physicians are suddenly facing the possibility of a substantial increase in occupational risk during an influenza pandemic. If they are not confronted before the onset of an influenza pandemic, feelings of unease and fear or ignorance about physicians' professional obligations could profoundly hinder individual physicians in fulfilling their professional duties. Such feelings could therefore undermine institutional and societal preparations. In their review published in Critical Care, Anantham and coworkers outline the ethical framework that forms the basis of the professional obligations of physicians who respond to health care emergencies, such as an influenza pandemic.
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Abstract
The development of an epidemic of avian influenza will have a major impact on the organisation and structure of the facilities for treatment. This paper, the product of collaboration between the six learned societies concerned, analyses the impact of a possible pandemic on the various aspects of management of patients requiring intensive care. It describes the organisation of hospital pathways for flu and non-flu patients with, in particular, the necessary actions in terms of separation of care facilities, the triage of patients and the cancellation of non-urgent activities. It analyses the preconditions necessary for the efficient functioning of intensive care and the predictable limiting factors. It underlines the importance of training of medical and paramedical personnel. Finally, it tackles the specific problems of paediatric intensive care: organisation, capacity for admissions and training.
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