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Augmentation of Hospital Critical Care Capacity After Bioterrorist Attacks

By Jennifer Nuzzo, S.M. and Richard Waldhorn, M.D., August 24, 2005

Some estimates of the results of biological attacks or large epidemics indicate that hundreds, or possibly thousands of victims would become critically ill and in need of intensive medical care. Given the slim chance that hospitals would have advance warning of the character, timing, size or geographical distribution of such an attack, advance planning is essential. Hospitals should give specific consideration to critical care surge capacity as they plan their response to biological attacks, because in many medical centers, critical care units and emergency rooms routinely operate with staff and resources already limited to such an extent that rapid expansion of capacity would be exceedingly difficult.

Hospitals have means of coping with routine surges of critically-ill patients (such as diverting incoming EMS or transferring patients to alternate institutions). However, such actions will not be sufficient during a crisis in which the number of critically ill patients is beyond an entire metropolitan area's usual ICU capacity. Furthermore, under such conditions, hospitals will likely have, at best, limited support from the federal government’s deployable medical teams and limited ability to divert or transfer patients to other hospitals, which means they will have to plan for operating without outside support. Hospitals will also have to protect their staff members. This challenge was clearly demonstrated during the SARS epidemics, during which hospitals and critical care units were key areas for dissemination of infection. If healthcare workers are not adequately protected, not only will staffing be jeopardized, but an epidemic may be prolonged. Therefore, all planning will have to account for protection of healthcare providers and other hospital staff.

It is, therefore, important that hospitals develop a set of emergency mass critical care practices that could be implemented in the event that their critical care capacity is exceeded. To address this need, the Center for Biosecurity of UPMC and the Society for Critical Care Medicine convened the Working Group on Emergency Mass Critical Care in June 2004. Charged with the task of developing recommendations for delivery of critical care services in the event of a bioterrorist attack or an epidemic resulting in mass casualties, the group acknowledged that in these conditions, traditional clinical care standards in general, and critical care standards in particular, would be difficult for hospitals to maintain. Acknowledging that hospitals currently face staffing, space, and budgetary constraints in their day-to-day operations, the working group developed recommendations for efficient augmentation of hospital surge capacity that would not require unreasonable expenditures.

Central to the group’s recommendations is the assumption that in an emergency, more lives could be saved by offering a set of key critical care interventions to a larger number of patients as opposed to attempting to offer maximal critical care interventions that would require all available human and material resources to just a small number of victims. Based on this premise, the working group identified the essential elements of critical care practice that would constitute the minimal acceptable critical care standards in these conditions. Those standards include basic modes of mechanical ventilation, hemodynamic support, and a small set of prophylactic interventions that are recognized to reduce morbidity and mortality in critical illness.

The working group also provided advice for hospitals in planning to manage patient triage, make the best use of skilled medical staff (including non-intensivists), locate the delivery of critical care, prioritize infection control procedures, and determine the medical equipment and classes of medications that should be held in reserve for use during crises.

The working group’s recommendations represent an important interim step toward hospital preparedness, and articulate a set of actions that hospitals may take in advance of a crisis to improve continuity of care delivery during a mass casualty biological emergency. Although it would be ideal for hospitals to plan regionally to respond to bioterrorist attacks, the working group also acknowledged that the current status of multi-institutional planning is limited. Moreover, hospitals may not be able to depend on federal assistance in the immediate time of crisis. Consequently, these recommendations are based on the further assumption that for at least 48 hours following a sudden, unexpected surge of patients from a bioterrorist attack or a natural epidemic, individual institutions will bear the burden of finding ways to provide adequate space, materials, and staffing resources to treat incoming patients.

The group’s consensus opinion is that an individual hospital that plans its response following this set of recommendations will likely double or triple its overall critical care capacity. Moreover, were all hospitals in a region positioned to augment critical care in the manner delineated in these recommendations, that region would substantially increase the number of patients who would likely receive life-saving medical attention. Expanding capacity in this way is important because it may prevent serious degradation of care in the face of a large-scale event involving critically ill patients.

An electronic version of the working group’s consensus article on augmenting hospital critical care capacity following a bioterrorist attack is currently available ahead of print publication and free of charge on the website of the Society of Critical Care Medicine; the article is scheduled to be published in the journal Critical Care Medicine in October 2005.

Editors’ Note: In the event of a large epidemic, hospitals may be stretched beyond their normal limits to deliver care to critically ill patients. Health care providers and administrators may be called upon to ration both care and resources. And in such conditions, adherence to current high standards of critical care will likely be difficult, if not impossible to maintain, even while there may be great pressure to provide levels and types of care not feasible during a time of emergency rapid surge. Therefore, if faced with large numbers of people with a sudden need for specialized care and equipment, hospital leaders and front line care providers will have to be able to adapt existing standards of care in a manner appropriate to the crisis at hand. The time to devise guidelines for those adaptations is not during a crisis, but well in advance.

Given the complicated demands of planning for a rapid surge in critical care, advance planning is essential, and will require new ideas, including criteria and guidelines to govern emergency standards of care and the rationing of treatment and equipment. These are all decisions better made in advance, when they can be guided to the greatest extent possible by sound reason and evidence. Acceptance of alterations in standards of care requires consensus in the medical community, which takes considerable time and effort to develop. The recommendations made by the Working Group on Emergency Mass Critical Care are an important step in the right direction.