Pearls
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Emergency mass critical care (EMCC) is limited, essential critical care during disasters when intensive care demands surpass resources.
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Pediatric, neonatal, and cardiac intensivists must be engaged with hospital and regional public health emergency (PHE) planning and preparedness efforts to ensure that they are familiar with strategies and resources to rapidly increase care capacity.
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Pediatric intensive care units (ICUs) should plan to care for three times their usual census for 10 days without outside help during a severe PHE.
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The surge capacity continuum that spans conventional to contingency to crisis capacity should be employed during a PHE in order to extend resources to meet needs.
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All ICU disaster planning efforts should consider protocols for triage teams to support the emergency department, patient tracking and reunification, victim and staff mental health, and the role of medical learners in EMCC efforts.
“Keep your eye on the ball.” Bob Kanter, Trailblazer for Children in the World of Disaster Medicine
During a public health emergency (PHE) such as a natural disaster or pandemic, a large number of infants, children, and young adults may need critical care in order to survive. During such an event, the incident command system (ICS) provides a framework to support decision-making and coordinate efforts across affected sites. Because pediatric critical care is highly specialized and because few nonpediatric providers are comfortable caring for severely ill or injured children, pediatric, neonatal, and cardiac intensive care units (ICUs) represent an essential aspect of patient management during a PHE and should be included within a structured response.
Planning and preparedness for PHEs can save lives. Unfortunately, critical care providers receive little training in disaster medicine and response and are often underinvolved in hospital disaster preparedness efforts. Recent public health emergencies have exposed a lack of PHE awareness, training, and preparation by critical care providers. The goal of this chapter is to educate the pediatric or neonatal ICU provider in the principles and tools of PHE preparedness and emergency mass critical care (EMCC). Learning from smaller or more local PHEs and preparing for critical care during anticipated PHEs may help intensivists better prepare for future catastrophic events that require EMCC. Forward consideration of how to scale up response and conserve, ration, and allocate critical care services can reduce dangerous uncertainty and save time in the event of a larger-scale PHE.
How many pediatric patients could be affected in a public health emergency?
If a PHE affected persons of all ages equally, children aged 0 to 14 years would account for 20% of all patients. However, younger patients may be more vulnerable to infections, dehydration, toxins, and trauma. Therefore, they may be overrepresented in the patient population during a PHE. Events involving a child-specific location, such as school, may result in a patient population predominantly made up of children.
Under usual circumstances, survival rates from high-risk pediatric conditions tend to be higher when children receive care at pediatric hospitals. A national survey estimated a pediatric ICU (PICU) peak capacity of 54 beds per million pediatric population. Typical PICU occupancy in excess of 50% leaves fewer than 30 vacant PICU beds per million age-specific population, with even fewer cardiac ICU (CICU) beds generally available. The younger the patient, the more age-specific and specialized the treatment requirements become, culminating in the extremely preterm neonate who requires equipment unavailable outside of a regional neonatal ICU (NICU). There are approximately 4 million newborns born in the United States annually and 5700 total NICU beds per million age-specific population. In contrast to PICU capacity, occupancy of NICU beds is higher at baseline, with 6% of low-risk term infants and 97% of very-low-birthweight infants requiring NICU care. Because each region may be served by only a few or even a single pediatric-capable hospital, events that disable one hospital may disproportionately degrade regional pediatric and neonatal care.
Quantitative models indicate that survival during a PHE would improve if a pediatric patient surge is distributed to pediatric beds throughout a larger geographic area rather than overwhelming facilities near the epicenter of an emergency. Unfortunately, control of patient distribution may be limited in a severe PHE. As a result, all hospitals must be prepared to care for some children for an extended period of time. Whether or not patients are distributed optimally, outcomes from a large PHE are likely to improve with EMCC approaches. , Additionally, using telemedicine to connect available pediatric critical care and subspecialty physicians to facilities unaccustomed to caring for pediatric patients may significantly extend the reach of pediatric EMCC during a PHE.
What are the most likely public health emergencies?
Public health emergency risks vary depending on hospital location, population demographics, and local resources. Each hospital is tasked with maintaining emergency plans for its most likely PHEs. This list is usually generated via a hazards vulnerability analysis (HVA), which leverages local expertise in medical management and infrastructure risks, and combines this with frequency and severity data on past and potential events. Events such as information technology (IT) and electronic medical record (EMR) outages are experienced nearly universally in healthcare settings and are included in HVAs. Primary planning for IT/EMR outages should include protocols for downtime procedures, paper charting, and nonelectronic communication. Hospitals should engage in drills, tabletop exercises, and simulations targeted to address issues identified by their HVA. Smaller and less severe events, such as planned EMR downtimes and routine adverse weather should be used as opportunities to clarify and test protocols for larger PHEs.
Who will make decisions during an emergency?
Responses to major public health emergencies are organized within a National Response Framework, as outlined by the federal US Department of Homeland Security. Emergency responses are coordinated at the most local jurisdiction possible, usually at the city or county level, until those resources are outpaced. The hospital ICS further provides a leadership framework within and among organizations responding to an emergency, representing a simplified and clear chain of command in order to speed decision-making. A hospital ICS includes clinical and nonclinical representation, provides flexible logistical support, and helps to prioritize key functions. Disaster plans at every hospital should incorporate ICS principles, regardless of the size of the hospital; ICS planning guides are widely available to aid in plan development. Identifying the ICU role within the local ICS framework is an essential part of PHE preparedness ( Fig. 9.1 ).
What is the expected timeline of a public health emergency?
When a sudden-impact PHE occurs, the hospital’s ICS is activated. The initial priority is to perform an assessment of the current state of the hospital; units rapidly assess their bed capacity, including potential beds that could be mobilized. Patients potentially no longer requiring ICU care should be identified for rapid transfer or discharge, and on-site staff able to be redirected to patient care should be tallied. If the PHE directly affects the structure or function of the hospital building, the initial assessment should also include numbers of newly injured staff, visitors, and patients, as well as any damage to the unit. These initial assessment numbers are collected from each unit, and a rough estimate of potential incoming patients is, in turn, shared with area leaders.
Based on initial assessment and estimates, the incident commander will direct the response to ensure adequate staff supplies, equipment, and clinical space, and will communicate decisions regarding whether to mobilize potential bed capacity identified in the initial assessment. Information from the ICS should be communicated to front-line staff early on to reduce uncertainty and ensure a clear and united message to patients and families. ICS-directed response may include assigning and sometimes reassigning current staff, calling in additional staff, ordering and distributing additional supplies, and identifying when standards of care should change. Area leaders should be called in as soon as possible to aid in coordinating the response and offload clinical staff of administrative duties. As information about the event becomes available, ICU leaders and educators may need to provide incident-specific just-in-time teaching to staff.
What is a surge and what can be done to meet surge needs?
Critical care responses to PHEs are scaled according to the size and severity of the emergency ( Fig. 9.2 ). , Emergency surges are categorized as minor, moderate, or major. A minor event would require up to 20% increase above usual peak hospital capacity; conventional surge methods would likely suffice to provide normal standards of critical care to all who need it in this scenario. Conventional critical care surge needs can be met by canceling elective admissions, quickly discharging all patients who can safely leave the ICU, mobilizing staff, and adding bed space ( Fig. 9.3 ).
Moderate emergency surges result in an increased patient population of between 20% and 100% of usual capacity, necessitating a contingency response to most effectively use limited resources. Contingency surge methods include all elements of the conventional response with additional strategies to expand coverage. Non-ICU patient care areas may be repurposed for ICU-level care. Staff are leveraged by changing provider-to-patient ratios or by using non-ICU staff in a tiered approach whereby non-ICU providers provide care and are, in turn, supervised by ICU providers. Supplies and equipment are conserved when possible; some substitutions, adaptations, and reuse may be necessary when safe. The goal of the contingency surge response is to significantly increase capacity while minimally affecting patient care practices.
EMCC and crisis standards of care (CSC) are required when a large PHE threatens to overwhelm critical care resources despite fully deployed conventional and contingency surge responses. Following a sudden-impact PHE, there may be an initial emergency department (ED) surge lasting a few hours and a subsequent ICU phase of weeks, while prolonged events such as pandemics could require both EDs and ICUs to sustain contingency or crisis strategies for months. It is recommended that hospitals with PICUs be able to care for up to three times the usual number of critically ill pediatric patients for up to 10 days without outside help. In these circumstances, population-based goals will attempt to maximize the number of survivors by reallocating lifesaving interventions to persons who are more likely to benefit from them. This represents an escalation from usual standards of care to CSC. PHE powers are defined on a state-by-state basis; thus, ICU leaders must be familiar with their own state and hospital incident command process for determining when CSC should be activated.
Sudden-impact events that stress the resources of a community may require the implementation of temporary reactive mass critical care. However, no historical precedents exist for sustained mass critical care such as might occur with major regional damage or severe pandemic. During the initial wave of COVID-19 in New York City, temporary mass critical care via rapid expansion of COVID-19 units and staff was utilized as a means to address the overwhelming care needs of patients. EMCC, whether temporary or sustained, should attempt to provide these five priority lifesaving interventions: (1) respiratory support, (2) fluid resuscitation, (3) vasopressors, (4) antidotes and antibiotics, and (5) analgesia and sedation. In order to provide adequate essential care to a greater number of patients, some more resource-intensive interventions may need to be delayed or foregone in EMCC settings. Examples include strict monitoring and frequent recording of vital signs and fluid balance, parenteral nutrition, invasive hemodynamic monitoring, intracranial pressure monitoring, renal replacement therapy, and extracorporeal life support. , Similarly, lifesaving EMCC interventions can be extended to much larger than usual numbers of patients by conservation of resources, substitution, adapting personnel, supplies, and spaces, reusing selected items, and reallocation of resource-intense interventions from patients not expected to survive to patients with a higher likelihood of quick recovery and survival. Patient care plans may need to be based more on physical examination findings than on ancillary studies; relying less on laboratory and imaging studies may represent a fundamental shift in patient management paradigms. The degree of deviation from usual practices should be proportional to the gap between patient needs and existing resources, and EMCC should be implemented in an organized way by each hospital’s ICS with the input of public health experts.
How can the intensive care unit support the emergency department during a public health emergency?
To provide continuity of patient care and maintain situational awareness, ICU teams must interact closely with the ED. Rapidly accommodating patients from the ED or operating room will be essential to allow those areas to continue receiving new patients. Triage of patients to match needs with available resources evolves as the PHE unfolds, according to shifting needs and available resources. Initial triage categories are assigned in the ED by an experienced clinician whose sole role is to act as triage officer and should be based on existing triage algorithms. In some cases, ICU staff may be temporarily reassigned to work in the ED as a triage team to speed this process and ensure appropriate patient allocation.
Physiologic triage identifies patients needing immediate lifesaving interventions. Physiologic triage tools identify patients in five categories: (1) those needing immediate lifesaving interventions; (2) those who need significant intervention that can be delayed; (3) those needing little or no treatment; (4) those who are so severely ill or injured that survival is unlikely despite major interventions; and (5) those who have already died. Care of patients triaged to group 4, often referred to as “expectant,” will deviate most significantly from usual approaches to intensive care. Because of overall demands on the system, scarce resources must be allocated to other patients who are more likely to survive, and expectant patients should receive appropriate palliative care.
While no single triage tool is always rapid, completely accurate, appropriate for all ages and disorders, and already familiar to all providers, triage and ED staff should be familiar with the physiologic triage tools in use locally. The local chosen tools should be made available online and in printed form to all relevant areas so that patients are triaged and treated in a standardized manner. Pediatric experts should partner with regional healthcare coalitions to provide standardized pediatric healthcare education, such as pediatric triage and other specialized pediatric topics, prior to a PHE.
When decontamination or infection control are central to the PHE at hand, these should be incorporated into the ED and triage response. Decontamination reduces toxic effects for the victim and mitigates contamination of providers, staff, and the hospital facility. Antidotes are given after cleaning an area of the body for administration. Consideration should be given to risks of hypothermia by using warm water preferentially for those at highest risk of thermal instability. Respiratory support during decontamination may be necessary and should be planned for. For PHEs with highly virulent transmissible infections, infection control must begin outside the ED entrance and continue without interruption in the hospital while the patient is infectious. ,
How can all intensive care units work together?
Pediatric hospitals often have more than one ICU with at least some patient flux between the NICU, PICU, and CICU depending on census. There may be flux between the PICU and adult ICUs depending on patient age, size, underlying conditions, and disease process. During a PHE, usual boundaries for these areas should be evaluated and stretched to accommodate the greatest number of critically ill patients ( Fig. 9.4 ). Critical care may be represented by a single ICU leader within the ICS in order to facilitate awareness of the global pool of ICU beds, staff, equipment, and supplies.
