Dan Hanfling

Health care facility and community strategies for patient care surge capacity

Abstract Recent terrorist and epidemic events have underscored the potential for disasters to generate large numbers of casualties. Few surplus resources to accommodate these casualties exist in our current health care system. Plans for “surge capacity” must thus be made to accommodate a large number of patients. Surge planning should allow activation of multiple levels of capacity from the health care facility level to the federal level. Plans should be scalable and flexible to cope with the many types and varied timelines of disasters. Incident management systems and cooperative planning processes will facilitate maximal use of available resources. However, resource limitations may require implementation of triage strategies. Facility-based or “surge in place” solutions maximize health care facility capacity for patients during a disaster. When these resources are exceeded, community-based solutions, including the establishment of off-site hospital facilities, may be implemented. Selection criteria, logistics, and staffing of off-site care facilities is complex, and sample solutions from the United States, including use of local convention centers, prepackaged trailers, and state mental health and detention facilities, are reviewed. Proper pre-event planning and mechanisms for resource coordination are critical to the success of a response.

Radiation injury after a nuclear detonation: medical consequences and the need for scarce resources allocation.

A 10-kiloton (kT) nuclear detonation within a US city could expose hundreds of thousands of people to radiation. The Scarce Resources for a Nuclear Detonation Project was undertaken to guide community planning and response in the aftermath of a nuclear detonation, when demand will greatly exceed available resources. This article reviews the pertinent literature on radiation injuries from human exposures and animal models to provide a foundation for the triage and management approaches outlined in this special issue. Whole-body doses >2 Gy can produce clinically significant acute radiation syndrome (ARS), which classically involves the hematologic, gastrointestinal, cutaneous, and cardiovascular/central nervous systems. The severity and presentation of ARS are affected by several factors, including radiation dose and dose rate, interindividual variability in radiation response, type of radiation (eg, gamma alone, gamma plus neutrons), partial-body shielding, and possibly age, sex, and certain preexisting medical conditions. The combination of radiation with trauma, burns, or both (ie, combined injury) confers a worse prognosis than the same dose of radiation alone. Supportive care measures, including fluid support, antibiotics, and possibly myeloid cytokines (eg, granulocyte colony-stimulating factor), can improve the prognosis for some irradiated casualties. Finally, expert guidance and surge capacity for casualties with ARS are available from the Radiation Emergency Medical Management Web site and the Radiation Injury Treatment Network.

Protective equipment for health care facility decontamination personnel: regulations, risks, and recommendations.

After recent terrorist attacks, new attention has been focused on health care facility decontamination practices. This article reviews core issues related to the selection of appropriate personal protective equipment for health care facility decontamination personnel, with an emphasis on respiratory protection. Existing federal regulations focus primarily on scene response and not on issues specific to health care facility decontamination practices. Review of existing databases, relevant published literature, and individual case reports reveal some provider health risks, especially when the exposure involves organophosphate agents. However, reported risks from secondary exposure to contaminated patients at health care facilities are low. These risks should be adequately addressed with Level C personal protective equipment, including air-purifying respirator technologies, unless the facility determines that specific local threats require increased levels of protection.

Establishing and training health care facility decontamination teams

Recent terrorist events, changes in Joint Commission on Accreditation of Healthcare Organizations requirements, and availability of grant funding have focused health care facility attention on emergency preparedness. Health care facilities have historically been underprepared for contaminated patients presenting to their facilities. These incidents must be properly managed to reduce the health risks to the victims, providers, and facility. A properly equipped and well-trained health care facility team is a prerequisite for rapid and effective decontamination response. This article reviews Occupational Safety and Health Administration (OSHA) training requirements for personnel involved with decontamination responses, as well as issues of team selection and training. Sample OSHA operations-level training curricula tailored to the health care environment are outlined. Initial and ongoing didactic and practical training can be implemented by the health care facility to ensure effective response when contaminated patients arrive seeking emergency medical care.

Definitive Care for the Critically III During a Disaster : A Framework for Optimizing Critical Care Surge Capacity

Background Plausible disasters may yield hundreds or thousands of critically ill victims. However, most countries, including those with widely available critical care services, lack sufficient specialized staff, medical equipment, and ICU space to provide timely, usual critical care for a large influx of additional patients. Shifting critical care disaster preparedness efforts to augment limited, essential critical care (emergency mass critical care [EMCC]), rather than to marginally increase unrestricted, individual-focused critical care may provide many additional people with access to life-sustaining interventions. In 2007, in response to the increasing concern over a severe influenza pandemic, the Task Force on Mass Critical Care (hereafter called the Task Force) convened to suggest the essential critical care therapeutics and interventions for EMCC. Task Force suggestions EMCC should include the following: (1) mechanical ventilation, (2) IV fluid resuscitation, (3) vasopressor administration, (4) medication administration for specific disease states (eg, antimicrobials and antidotes), (5) sedation and analgesia, and (6) select practices to reduce adverse consequences of critical illness and critical care delivery. Also, all hospitals with ICUs should prepare to deliver EMCC for a daily critical care census at three times their usual ICU capacity for up to 10 days. Discussion By using the Task Force suggestions for EMCC, communities may better prepare to deliver augmented critical care in response to disasters. In light of current mass critical care data limitations, the Task Force suggestions were developed to guide preparedness but are not intended as strict policy mandates. Additional research is required to evaluate EMCC and revise the strategy as warranted.

Hemodynamic Effects of Calcium Chloride in a Canine Model of Acute Propranolol Intoxication

STUDY OBJECTIVE To evaluate the hemodynamic effects of calcium chloride in a canine model of acute propranolol toxicity. METHODS Two minutes after the completion of a propranolol infusion (10 mg/kg), a bolus of .125 mL/kg 10% CaCl solution followed by an infusion of .375 mL/kg over the next 30 minutes or a bolus and subsequent infusion of an equivalent volume of normal saline solution was administered to each dog. RESULTS CaCl yielded significant improvements in propranolol-induced decreases in cardiac index and stroke volume compared with saline solution-treated control animals (overall alpha = .05). Furthermore, CaCl administration resulted in earlier improvement in propranolol-induced alterations in mean arterial pressure, maximal left ventricular pressure change over time, and peripheral vascular resistance compared with saline solution (overall alpha = .05). We observed no difference between treatment groups in response to propranolol-induced bradycardia or QRS-interval prolongation. CONCLUSION In this model of acute propranolol toxicity, CaCl therapy improved depressed hemodynamic status, mainly by a positive inotropic action.

National preparedness for a catastrophic emergency: crisis standards of care.

PUBLIC HEALTH EMERGENCIES UNDERSCORE THE IMMEdiate and crucial need to plan for a mass disaster in which tens or even hundreds of thousands of individuals suddenly require medical care. On October 24, 2009, President Obama declared a public health emergency in response to influenza A(H1N1), but natural disasters (eg, hurricanes, floods, or earthquakes) and terrorism acts (eg, anthrax or a nuclear detonation) similarly demonstrate the critical need for national preparedness. Public health emergencies evoke troubling questions with life-or-death consequences. Which patients should receive limited resources and who decides? Should professional standards of care change and if so, what are the catalysts? Should the law grant civil or criminal immunity to professionals acting in good faith? Hurricane Katrina is a galvanizing point for answering such difficult questions, so gaining the public’s trust is vital.

Definitive Care for the Critically Ill During a Disaster: A Framework for Optimizing Critical Care Surge Capacity From a Task Force for Mass Critical Care Summit Meeting, January 26-27, 2007, Chicago, IL

Background Plausible disasters may yield hundreds or thousands of critically ill victims. However, most countries, including those with widely available critical care services, lack sufficient specialized staff, medical equipment, and ICU space to provide timely, usual critical care for a large influx of additional patients. Shifting critical care disaster preparedness efforts to augment limited, essential critical care (emergency mass critical care [EMCC]), rather than to marginally increase unrestricted, individual-focused critical care may provide many additional people with access to life-sustaining interventions. In 2007, in response to the increasing concern over a severe influenza pandemic, the Task Force on Mass Critical Care (hereafter called the Task Force) convened to suggest the essential critical care therapeutics and interventions for EMCC. Task Force suggestions EMCC should include the following: (1) mechanical ventilation, (2) IV fluid resuscitation, (3) vasopressor administration, (4) medication administration for specific disease states (eg, antimicrobials and antidotes), (5) sedation and analgesia, and (6) select practices to reduce adverse consequences of critical illness and critical care delivery. Also, all hospitals with ICUs should prepare to deliver EMCC for a daily critical care census at three times their usual ICU capacity for up to 10 days. Discussion By using the Task Force suggestions for EMCC, communities may better prepare to deliver augmented critical care in response to disasters. In light of current mass critical care data limitations, the Task Force suggestions were developed to guide preparedness but are not intended as strict policy mandates. Additional research is required to evaluate EMCC and revise the strategy as warranted.

Inhalational Anthrax Due to Bioterrorism: Would Current Centers for Disease Control and Prevention Guidelines Have Identified the 11 Patients with Inhalational Anthrax from October through November 2001?

A panel of 10 physicians used the nominal group technique to assess the ability of the Centers for Disease Control and Prevention (CDC) interim guidelines for clinical evaluation of persons with possible inhalational anthrax (IA) to retrospectively identify the 11 patients with IA seen during the October 2001 bioterrorism outbreak. The guidelines would not have identified 10 of 11 of these patients, primarily because the guidelines were designed to address only those patients with a known history of exposure or clearly identified environmental or occupational risk. The panel suggested revisions to the guidelines, primarily consisting of broadening the criteria for evaluation to include either known exposure or environmental occupational risk, or to include clinical symptoms consistent with IA. These extensions of the guidelines retrospectively identified 8 of 11 of the patients with IA from October 2001.

A Framework for Catastrophic Disaster Response

THE JAPANESE TSUNAMI,HAITIAN EARTHQUAKE, AND GULF Coast hurricane offered stark reminders of how vulnerable organized societies are to catastrophic events. They also show how public health emergencies— whether naturally occurring (eg, a pandemic outbreak of novel influenza) or deliberate (eg, a terrorist attack using an improvised nuclear device)—will stress the health system beyond its current capacity. This will require a health and medical response that is fundamentally different from the status quo. Health systems are designed and organized to provide optimal care for ill or injured patients as well as to provide care to additional patients following a large-scale incident. Most health systems have enough surge capacity to respond effectively to conventional disasters such as a plane crash or building collapse. However, health care delivery systems and public health lack the infrastructure, resources, and capability to effectively respond to a catastrophic event. The 3 critical components of catastrophic disaster preparedness are development of crisis standards of care, development of a “systems” approach that ensures integration among key stakeholders, and meaningful engagement with health professionals and the public.