Chest
Volume 146, Issue 4, Supplement, October 2014, Pages e17S-e43S
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Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement Online Only Articles
Surge Capacity Logistics: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

https://doi.org/10.1378/chest.14-0734Get rights and content

BACKGROUND

Successful management of a pandemic or disaster requires implementation of preexisting plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective and includes focused intensive care abilities and requirements as well as all individuals and organizations involved in hospital and regional planning. The suggestions in this article are important for all involved in a large-scale disaster or pandemic, including front-line clinicians, hospital administrators, and public health or government officials. Specifically, this article focuses on surge logistics—those elements that provide the capability to deliver mass critical care.

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 studies upon which evidence-based recommendations could be made. The results were reviewed for relevance to the topic, and the articles were screened by two topic editors for placement within one of the surge domains noted previously. 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. The Surge Capacity topic panel subsequently followed the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestion based on expert opinion using a modified Delphi process.

RESULTS

This article presents 22 suggestions pertaining to surge capacity mass critical care, including requirements for equipment, supplies, and pharmaceuticals; staff preparation and organization; methods of mitigating overwhelming patient loads; the role of deployable critical care services; and the use of transportation assets to support the surge response.

CONCLUSIONS

Critical care response to a disaster relies on careful planning for staff and resource augmentation and involves many agencies. Maximizing the use of regional resources, including staff, equipment, and supplies, extends critical care capabilities. Regional coalitions should be established to facilitate agreements, outline operational plans, and coordinate hospital efforts to achieve predetermined goals. Specialized physician oversight is necessary and if not available on site, may be provided through remote consultation. Triage by experienced providers, reverse triage, and service deescalation may be used to minimize ICU resource consumption. During a temporary loss of infrastructure or overwhelmed hospital resources, deployable critical care services should be considered.

Section snippets

Stockpiling of Equipment, Supplies, and Pharmaceuticals

1. We suggest hospital support services, including pharmacy, laboratory, radiology, respiratory therapy, and nutrition services, also be included in the planning of critical care surge.

2. We suggest equipment, supplies, and pharmaceutical stockpiles specific to the delivery of mass critical care (MCC) be interoperable and compatible at the regional level and ideally at the state/provincial level, so as to ensure uniformity of response capabilities, coordinated training, and a mechanism for

Materials and Methods

The Surge Capacity topic group met in June 2012 and developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Four literature searches were conducted to identify studies upon which evidence-based recommendations could be made. Searches were limited to between January 1995 and October 2012; English-language articles were included and non-English-language articles excluded (e-Appendix 1). A total of 1,440

Stockpiling of Equipment, Supplies, and Pharmaceuticals

1. We suggest hospital support services, including pharmacy, laboratory, radiology, respiratory therapy, and nutrition services, also be included in the planning of critical care surge.

2. We suggest equipment, supplies, and pharmaceutical stockpiles specific to the delivery of MCC be interoperable and compatible at the regional level, and ideally at the state/provincial level, so as to ensure uniformity of response capabilities, coordinated training, and a mechanism for exchange of material

Areas for Research

Demographic data of critical care requirements based on the overall population served, specific caseloads, and ICU cases and needs over time is an area that needs to be explored. Methodological assessment of achieved vs required surge would rely on standard ICU management report forms and data forms per patient. At the ICU management and institutional levels, forms based on the framework proposed for critical incident reporting could be used to study the events post hoc.108 For the individual

Conclusions

The critical care response to a disaster is more prolonged than the response in other sections of the hospital, which necessitates preplanning and training for staff augmentation and redistribution of resources. The limits of effective nurse-to-critical patient ratios in a disaster setting have yet to be elucidated, but lower ratios are clearly beneficial. Critical care physician oversight is crucial whether through direct or long-distance consult (eg, telemetry, telephone), particularly, but

Acknowledgments

Author contributions: S. E. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S. E., J. L. H., D. H., B. L. E., E. S. T., R. D. B., R. K. K., N. K., J. R. D., A. V. D. and M. D. C. contributed to the development of PICO questions; S. E., J. L. H., D. H., B. L. E., E. S. T., R. D. B., and R. K. K. conducted the literature review; S. E., J. L. H., D. H., B. L. E., E. S. T., R. D. B., R. K. K., N. K., J. R.

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    FUNDING/SUPPORT: This publication was supported by the Cooperative Agreement Number 1U90TP00591-01 from the Centers of Disease Control and Prevention, and through a research sub award agreement through the Department of Health and Human Services [Grant 1 - HFPEP070013-01-00] from the Office of Preparedness of Emergency Operations. In addition, this publication was supported by a grant from the University of California–Davis.

    COI grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.

    DISCLAIMER: American College of Chest Physicians guidelines and consensus statements are intended for general information only, are not medical advice, and do not replace professional care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this consensus statement can be accessed at http://dx.doi.org/10.1378/chest.1464S1.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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