The new proposal suggests legally protecting clinicians who follow accepted protocols for the allocation of scarce resources when providing care during mass critical care events.
In plan English, the new proposal suggests denying treatment to some victims of disaster, so that resources can be concentrated on those with the most likelihood of surviving.
“Most countries, including the United States, have insufficient critical care resources to provide timely, usual care for a surge of critically ill and injured victims,” said Asha Devereaux, MD, FCCP, Task Force for Mass Critical Care. “If a mass casualty critical care event occurred tomorrow, many people with clinical conditions that are survivable under usual health-care system circumstances may have to forgo life-sustaining interventions due to deficiencies in supply, staffing, or space.”
As a result, the Task Force for Mass Critical Care developed an emergency mass critical care (EMCC) framework for hospitals and public health authorities aimed to maximize effective critical care surge capacity. According to those who developed it, the framework represents a major step forward to uniformly deliver sufficient critical care during catastrophes and maximize the number of victims who have access to potential life-saving interventions.
Published as a supplement to the May issue of CHEST, the peer-reviewed journal of the American College of Chest Physicians (ACCP), “Definitive Care for the Critically Ill During a Disaster” offers guidance for hospitals, medical professionals and public health authorities on how to prepare for and provide essential critical care when the need for critical care resources far exceeds availability.
Expanding Critical Care Resources for a Disaster
To prepare for a mass critical care event, the task force proposes that hospitals with ICUs aim to meet several standards, including the ability to provide sufficient critical care for at least triple their usual ICU capacity and sustain this surge for up to 10 days without external assistance. Suggested surge capacity requirements include stockpiling medical equipment, including mechanical ventilators; optimizing medication; designating auxiliary critical care areas; and augmenting critical care staff.
Prior to the rationing of critical care resources, hospitals and surrounding areas must first experience a “trigger” event that includes a declared state of emergency and lack of critical equipment or infrastructure. The decision to initiate EMCC must occur in conjunction with local and regional medical emergency operations command authority and not by individual hospitals.
The task force advises rationing scarce critical care resources only after surge capacity has been exceeded and all attempts to use outside resources have been made. Under these circumstances, the task force proposes a formal EMCC triage and resource allocation protocol. Examples of the protocol include:
- The hospital triage officer/team will assess and prioritize all patients for receipt of scarce interventions using objective medical criteria.
- Palliative care for all patients will be a priority. However, patients will be ineligible for scarce critical care interventions if they have extreme organ failure and/or severe chronic illness with a short life expectancy.
- Critical care resources will not be preferentially distributed to any specific population group.
- Decisions regarding resource allocation will be documented, remain transparent, occur uniformly across all affected regions, and subject to rigorous quality assurance.
“Ideally, having an emergency mass critical care plan in place would prevent hospitals from needing to ration critical care resources,” said Lewis Rubinson, MD, PhD, Task Force for Mass Critical Care. “However, if the surge capacity is exceeded, the use of emergency mass critical care triage and rationing will help local health-care facilities minimize mortality and optimize survival.”
Critics Say ‘Plan Better’
Dr. Maurice Ramirez, founding chair of the American Board of Disaster Medicine, is not a fan of the proposals published in CHEST.
“It is necessary to prepare for times of a pandemic, however, this preparedness plan is not the right one,” says Ramirez, DO, BCDM, BCEM, CNS, CMRO. “The proposed system suggests the total removal of care from the Baby Boomers. Historical data and recent research show that up to 80 percent of the youngest, healthiest and strongest will fall ill in a pandemic. Evidence from the 1918 Spanish Flu Pandemic extrapolates to 40 percent of the workforce was affected that time around.”
Ramirez says scientists currently project 6 percent of those who contract the flu will die, meaning 2 percent of the world’s workforce will disappear, “leaving Baby Boomers and Generation Y to run the world.”
According to him, “the current avian influenza strains under surveillance for pandemic spread are characterized by a sparing for those under age 18 and over age 55, while holding a fatality rate of 57 percent among those age 20 to 55 who succumb to infection.”
The EMCC protocol allows the triage officer and supporting triage team to make decisions that benefit the greatest number of patients with potentially limited resources. Consequently, lifesaving care may be withheld from one patient and given to another, prompting ethical and legal implications.
To reassure critical care providers and ensure consistent allocation of critical care resources, the task force advocates for legal protection of healthcare professionals and institutions that follow accepted EMCC protocols while providing care during times that require critical care resource rationing. Government endorsement of a protocol for EMCC triage and resource allocation ideally would shield practitioners and institutions acting in good faith from liability.
Triage in a resource-limited environment, such as a hospital laboring under a pandemic, demands the application of resources in such a way as to serve the most people possible, says Ramirez, who adds, “It is not ethical to provide care to a 30-year-old just because they are 30 years young if providing that care will deny life-saving care to two or more other people, regardless of the age of these other two. It is equally unethical to withhold care from a 65-year-old when providing that care will not deny life-sustaining care to two or more other people.”
He calls the ACCP recommendations “a reasonable, if limited, guideline,” adding current recommendations are meant for those difficult situations when there are resources for one patient and two people who require that care. Ramirez says a better solution is to promote preparedness to expand healthcare surge capacity in addition to integrated triage and resource allocation.
“The new EMCC framework provides a much needed foundation for disaster preparedness in the critical care setting. Suggestions proposed by the task force will facilitate ongoing discussions and allow for further input from the disaster planning community,” says Alvin V. Thomas, Jr., MD, FCCP, president of the ACCP. “Hospitals, communities and government agencies must take the next steps to modify framework principles and implement them in critical care environments.”
For more information about the EMCC supplement or to download a complimentary copy, visit http://ww.chestjournal.org.