Medical Surge Capacity: Workshop Summary

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Few obstetricians are trained in critical care, yet obstetric patients can be affected severely by some infectious disease outbreaks and may require disproportionate critical care resource allocation 7— In many facilities, adult intensive care units are distant from labor and delivery units. Physical separation may pose logistic barriers to the delivery of optimal intensive care for critically ill pregnant women.

These barriers may be exacerbated during times of overwhelming patient volume. These trends warrant thoughtful consideration and extra coordination with critical care clinicians before and during disaster mitigation. These considerations may be true especially when focusing specifically on influenza pandemics. Data from influenza pandemics demonstrate heightened rates of hospitalization and preterm birth associated with maternal influenza infection 8—11, The increased number of newborns born at preterm gestations during an influenza epidemic has clear implications for neonatal intensive care capacity and resource allocation that parallels increased maternal resource needs.

Two special considerations presented by the obstetric population related to infection control practices are 1 the desire for familial involvement in the birthing process, and 2 the importance of lactation and early parental bonding with the neonate. Infectious disease outbreaks often require tight restrictions on visitation procedures while the nature of the epidemic is being investigated. Isolation often is a difficult hospital practice to implement in general and is especially challenging to enforce in the obstetric population given the need women have for support during labor, delivery, and the postpartum period.

Likewise, the importance of lactation and early parent—newborn bonding introduces infection control considerations that are not relevant to other patient populations and, therefore, warrant additional advance planning. Maternity services should coordinate with infectious disease specialists for guidance in this challenging clinical scenario.

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Obstetricians and other obstetric care providers should consider the option of altering obstetric services to function with less resource use. Examples include early hospital discharge after delivery and enhanced use of telephone and telemedicine triage, with attention to documentation requirements.

Surge Capacity

Such alterations often are necessary and beneficial when the volume of patients in a health care facility is unusually high. This concept has received considerable legal and medical attention 20 , The goal of these efforts is to give facilities and health care providers guidance on temporary flexibility in care standards as well as who is permitted to provide care.

Equally important is planning by the hospital leadership for the potential need to rapidly credential temporary obstetric care providers in the face of a health care provider shortage that can occur with a variety of disaster scenarios. Facility preparedness committees are encouraged to consult with their local legal colleagues to assist in interpreting state and federal guidance on this issue. In the case of an environmental disaster, pregnant and postpartum women in need of care may be cut off from a hospital facility, medical records, and health care providers.

The Health and Medicine Division of the National Academy of Sciences, Engineering, and Medicine formerly the Institute of Medicine has recently considered remote and distance care 22 and has reported on one example of the successful use of telephone triage in obstetric care If feasible, creative use of evolving telemedicine capabilities could enable facilities to maintain adequate patient care in the face of increased local resource demands and provide a mechanism for consultation between smaller regional facilities and larger tertiary care facilities.

Some examples may include conducting virtual visits and remote delivery of routine testing, such as antenatal testing Conversely, in emergency scenarios it often is necessary to provide medical care without the benefit of standard technology eg, lack of electronic medical records during a power outage , thus reliance on paper records to facilitate communication during transport may be necessary The use of social media, particularly Twitter, has provided a valuable emergency system to announce safe havens or allow electronic communication from remote areas.

Even during a disaster, documentation of all patient—health care provider interactions in the prenatal record remains important, as is the ability to access those records.

Hospital Disaster Preparedness for Obstetricians and Facilities Providing Maternity Care - ACOG

Communication strategies should include back-up broadcast systems—in the event of loss of telephone communication—that take advantage of new technology, such as telemedicine, that can function over the internet and still may be accessible when other lines of communication have been cut off. Hospitals should prepare for power outages and lack of access to electronic medical records. The possibility that access to the electronic medical record will be limited needs to be considered in advance, and mechanisms for providing patients with copies of their own medical records are recommended.

The disaster recovery phase also should be considered in advance as should the establishment of local mechanisms, or triggers, or both, for transitioning back to the usual standards of care.


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The goal is to enable a smooth recovery that optimizes care and resource use that parallels that of baseline facility function once the acute phase has resolved. The discipline of hospital disaster preparedness has undergone significant advances in recent years, largely driven by the need to respond to an increase in natural and human-influenced crises. Many of the advancements provide new, specific guidance to obstetricians and other obstetric care providers at the individual and institution levels.

Although emergencies may be unexpected, hospitals and obstetric delivery units can prepare to implement plans that will best serve maternal and pediatric care needs when disaster occurs.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Hospital disaster preparedness for obstetricians and facilities provi-ding maternity care. Committee Opinion No. American College of Obstetricians and Gynecologists.

Obstet Gynecol ;e—7. Women's Health Care Physicians.

Opinion The American College of Obstetricians and Gynecologists ACOG makes the following recommendations: Hospitals that provide maternity services should implement a standing perinatal subcommittee likely to include obstetrics, pediatrics, and anesthesia in charge of disaster preparedness, which can be mobilized quickly in the event of an emergency.

Hospitals providing care for maternal and neonatal patients should communicate using a common terminology, such as OB-TRAIN Obstetric Triage by Resource Allocation for Inpatient , to facilitate and prioritize transport based on acuity of care. This plan should include an identified alternative site for delivery if the labor and delivery unit is damaged and a system to ensure the necessary equipment can be transported quickly to the alternative site. Background Large-scale catastrophic events and infectious disease outbreaks—including the terrorist attacks of September 11, , the bombing at the Boston Marathon, the — H1N1 influenza pandemic, and the — Ebola outbreak—highlight the need for disaster planning at all community levels.

The Role of Health Care Institutions in Disaster Preparedness Given that health care institutions play an important role in responding to disasters, the discipline of hospital preparedness now occupies a central role in effective disaster mitigation planning 5 , 6. Considerations for Obstetric Care Facilities Features unique to the obstetric population—including antepartum, intrapartum, postpartum and neonatal care—warrant special consideration in the event of a disaster.

Planning for Obstetric Surge Capacity The potential surge in maternal and neonatal patient volume due to mass-casualty events, transfer of high-acuity patients, or redirection of patients because of geographic barriers presents unique challenges for obstetric care facilities. Triage of the Obstetric Patient in Disaster Response Once a hospital has determined its capacity to provide adequate maternity services, the next step is efficient and appropriate triage of obstetric patients.

Special Considerations for Infectious Disease Outbreaks Few obstetricians are trained in critical care, yet obstetric patients can be affected severely by some infectious disease outbreaks and may require disproportionate critical care resource allocation 7— Temporary Modifications in Standard of Care Obstetricians and other obstetric care providers should consider the option of altering obstetric services to function with less resource use.

Remote and Distance Care With Telemedicine In the case of an environmental disaster, pregnant and postpartum women in need of care may be cut off from a hospital facility, medical records, and health care providers. Conclusion The discipline of hospital disaster preparedness has undergone significant advances in recent years, largely driven by the need to respond to an increase in natural and human-influenced crises.

Council on Environmental Health. Pediatrics ;—7. However, the emergence of the next great pandemic will severely affect our ability to care for massive numbers of patients with the traditional approaches with which we have become accustomed. Children often are an overrepresented population during both natural and man-made disasters due to both physiological differences and innate social vulnerabilities.

During influenza pandemics children are often disproportionately represented in the intensive care unit population, tend to require mechanical ventilation more often than adults, and despite this have been shown to have better survival 3 , 4. Unfortunately many governmental and hospital system disaster management plans do not fully incorporate pediatric patients into the overall planning process.

Despite this, some progress has been made over the past several years through the strong advocacy of pediatric providers and pediatric organizations 5 , 6. This chapter provides a brief overview of the history of pandemics as well as the current status of planning for a potential epidemic outbreak. In addition, the US response plans, from the federal to the community health-care level, are reviewed here. The majority of the chapter is devoted to discussing issues specific to hospital planning with a focus on pediatric critical care and strategies to mitigate the potential impact of a future pandemic.

HPP Coalition Surge Test Tool

Next, the chapter reviews proposed triage and surge plans that would be required under both pandemic conditions as well as unique situations such as an Ebola epidemic and the unique limitations faced by pediatric critical care in both scenarios. Finally, we will introduce the ethical challenges that will arise as a result.

The H1N1 influenza virus produced the first pandemic to test the limits of modern medical care of this era. The United States alone saw roughly Children saw a significantly higher impact from H1N1 with an attack rate nearly 7 times higher than seasonal influenza outbreaks in years past 8. Although the H1N1 pandemic swept the globe with significant morbidity and mortality, this does not seem to compare with the severity of the influenza pandemic Table 1.

Children five years of age and less had the highest mortality rate, most resulting from secondary bacterial infections for which there were not yet antimicrobial treatments The most recent emerging infection to cause scientists, medical providers and policymakers to reassess current pandemic planning has been the Ebola outbreak of — While it was nearly completely limited to the population of Guinea, Liberia and Sierra Leone in West Africa, this virus infected 28, people with 11, deaths Previous Ebola outbreaks had occurred in Africa but this outbreak resulted in 36 cases and 15 deaths outside of West Africa with 11 people treated in the United States, 4 of whom contracted the virus outside of West Africa This has prompted local, state, and national agencies to make huge investments into the preparation for pandemics in the future.

The overarching federal pandemic response plan for the United States was released by the Homeland Security Council in November and was based on three pillars: preparedness and communication, surveillance and detection, and response and containment Included in the reauthorization was important language ensuring that both critical care and pediatric planning were included in national planning and response efforts.

The Assistant Secretary for Preparedness and Response is the federal agency responsible for coordinating national efforts in this area. A variety of federal, state, and local response plans have been created along with various international plans. Unfortunately, several of the plans being generated use slightly different terminology and triggers for responses, which can lead to confusion.

As of June , all 50 US states have completed pandemic influenza plans. The plans of the 5 most populous states were reviewed closely. Urban and rural community plans from each of those states were reviewed as well Facilitation of medical surge adequate treatment of vastly increased numbers of patients under mass-casualty or pandemic conditions and fatality management were among the major gaps identified in the majority of plans.

Mass vaccination, distribution of antiviral agents, public health continuity-of-operation plans, and community health-care coalitions were among the major gaps less commonly identified. Medical surge, fatality management, and community containment measures were 3 of the major areas in which state and local officials desired additional federal guidance. Unfortunately, although progress in pediatric specific planning has been made as mentioned in the introduction, important gaps remain. In , the National Commission on Children and Disasters delivered a comprehensive report with specific recommendations to the United States Congress that examined and assessed the needs of children for preparedness, response, and recovery from all hazards, including major disasters and emergencies Improvements in funding for pediatric disaster planning is critical in light of the relative lack of day to day pediatric readiness, again improved from earlier studies, that many emergency departments in the United States currently demonstrate The ability to respond to an increase in demand, which exceeds the normal, is referred to as surge capacity.

This includes things such as push-packs pre-packed supplies held in reserve to meet increased demand , overflow of patients outside of typical care areas such as mechanically-ventilated patients in the post-anesthesia care unit PACU in addition to the intensive care unit ICU , use of personnel typically assigned to other areas transferred to the ICU, and triage of both patient disposition and allocation of resources such as ventilators and neuraminidase inhibitors Integration of other areas of the hospital beyond the emergency department and the pediatric intensive care unit PICU into surge planning is vital and should include the neonatal intensive care unit NICU as well as other areas Rapid acquisition of local clinical and epidemiologic data during an influenza pandemic may help establish reliable early estimates of critical care resource utilization and guide whether contingency measures will be needed to accommodate the influx of patients An important development in pediatric disaster planning has been the creation of voluntary regional coalitions designed to help healthcare systems prepare and respond using coordinated medical resources during emergencies and disasters.

Examples include coalitions that are pediatric focused Mountain States Pediatric Disaster Coalition or those where pediatrics is well integrated into the greater coalition Northwest Healthcare Response Network Table 2. There are a wide variety of helpful planning, pediatric specific, guidelines and tools to assist local and regional planning with several useful resources summarized in Table 2.

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Four tenants of disaster planning have been described as stuff, space, staff and systems Table 3 22 , Stuff is the supply needed to provide care. Space is the appropriate physical space to provide critical care as well as sufficient space to provide other services such as triage, temporary housing, storage and tracking of patient remains, and waste disposal. Staff refers not just to providers and nurses but all support services needed to care for patients, families, and staff. Systems are the coordinated command and control centers and supporting services that provide efficient, coordinated flow of resources, patients, and information.

This section will focus on these 4 areas as well as considerations for direct patient care in the management of critically ill children in pandemics. Prior to discussion of the medical care of pediatric patients in a pandemic it is important to consider crisis standards of care CSC. Their recommendation is that this declaration come from a state or federal agency under emergency circumstances. This declaration should enable specific legal and regulatory protections for health care providers when having to operate under conditions of limited medical resources and alternate models of care.

It is reasonable to incorporate this concept into local facility plans as well to provide similar guidance and protections for staff in the absence of a formal declaration. Examples of medical operations under these standards are discussed below but design and implementation of these standards for each agency should be planned prior to a crisis and remain flexible based on each situation. When considering stuff it is important to remember under most circumstances that hospitals will retain only enough supplies for 3—5 days of normal operations. In the ICU this pace is likely to be sustained for weeks to months 26 - Those items that require special attention are non-substitutable items such as ventilators and their circuits, N95 masks, and certain medications.

In addition to local facility stockpiling with a 5—10 day supply of these items, dual sourcing of the same items should also be considered Both the Chest Consensus Statement and European Society of Intensive Care statement on pandemics recommend a regional approach to the management of critical supplies 31 , A regional approach requires interoperable and compatible critical care supplies for hospitals in a given region This approach requires that planning involve coordination within local hospital systems as well as government agencies to be effective.

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