Transcript Influenza: The Good, The Bad, and the Ugly*

Crisis Care Update
John L. Hick, MD
Hennepin County Medical Center
April 28, 2016
Hospital Resources –
MSP Metro Area
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Total beds (medical) ~5000
Calculated overall surge capacity 2500-3500
Stepdown beds 501 (surge 190 additional)
ICU beds 416 (surge 192 additional)
PICU beds 64 (surge 20-39 additional)
OR suites 295
Ventilators 533
ECMO – About 12 facilities, 1-2 patients per
facility
Pandemic modeling
Assume
50% of cases present during weeks 4-7 of
pandemic, Flu Surge 2.0 numbers for moderate
Weeks 4-7 new cases presenting requiring ventilator
at HCMC every 1.4 days
Per day hospital visits for HCMC (22%) – 209 (if can
limit to 10x actual hospitalizations with clinics, media
campaign, etc.) – Average ED volume about 320/d
thus 529 visits / day
2006
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Hick, et. al. - Academic Emerg. Med.
Christian et. al. – CMAJ
AHRQ – Mass Medical Care
2007
2009
2012 - IOM
Duty to Plan
“Note that in an important ethical sense,
entering a crisis standard of care mode is
not optional – it is a forced choice, based on
the emerging situation. Under such
circumstances, failing to make substantive
adjustments to care operations – i.e., not to
adopt crisis standards of care – is very
likely to result in greater death, injury or
illness.”
Crisis Standards of Care
A substantial change in usual
healthcare operations and the
level of care it is possible to
deliver, which is made necessary
by a pervasive (e.g., pandemic
influenza) or catastrophic (e.g.,
earthquake, hurricane) disaster.
Crisis Standards of Care
The formal declaration that crisis
standards of care are in
operation enables specific
legal/regulatory powers and
protections for healthcare
providers in the necessary tasks
of allocating and using scarce
medical resources and
implementing alternate care
facility operations.
Overarching Goal
Do the greatest good for the
greatest number of persons
you can based upon the
resources available…
How to do the greatest good…
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Implement incident management and surge
capacity plans
Anticipate resource shortfalls
Solve the imbalance:
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Bring in resources
Transfer patients
Triage resources
Get help…
COALITIONS /
COMMUNITY
FEMA Liz Roll
Triage
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Type
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Primary
Secondary
Tertiary
Goal
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Access / priority (ER)
Maintain health
Return to duty
Survival
Functional recovery
Longevity
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Treatment Factors
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Time
Treater
Treatment
Host factors
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Severity of disease
process
Underlying organ
function
Social factors?
Incident Triage
Reactive
Proactive
Incident Type
Early no-notice
Later, or biologic
Situational awareness
Poor
Good
Resources
Highly Dynamic
Relatively static
Shortfalls
Stabilization care
Definitive care
Triage
Primary, Secondary
Tertiary
Decision basis
Clinical assessment
Decision tools
Decision-making
Ad hoc
Structured
Declarations and
protections
No
Yes
Regional assistance
Resources
Decisions, resources
BOOM – S/M/L
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Bus bombing
London, England – Tom Diaz
Reactive Triage – 10 patients
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32 yom
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Shrapnel injury
Penetrating abdominal
trauma L upper abd
80/60 BP despite IV
fluids
Pale and diaphoretic
Otherwise normal
exam
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35 yof
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Thrown by blast
Comatose (GCS 4)
BP 80/60 despite fluids
Pneumothorax – BP
same after chest tube
FAST Abd US – free
fluid
Reactive Triage – 100 patients
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32 yom
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Shrapnel injury
Penetrating abdominal
trauma L upper abd
80/60 BP despite IV
fluids
Pale and diaphoretic
Otherwise normal
exam
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35 yof
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Thrown by blast
Comatose (GCS 4)
BP 80/60 despite fluids
Pneumothorax – BP
same after chest tube
FAST Abd US – free
fluid
nuclear
World in Conflict – Gamespot.com
Reactive Triage – 1000 patients
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32 yom
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Shrapnel injury
Penetrating abdominal
trauma L upper abd
80/60 BP despite IV
fluids
Pale and diaphoretic
Otherwise normal
exam
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35 yof
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Thrown by blast
Comatose (GCS 4)
BP 80/60 despite fluids
Pneumothorax – BP
same after chest tube
FAST Abd US – free
fluid
Proactive Triage
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Patient 1 – on ECMO
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6 year old
Respiratory failure
from influenza
SOFA 8
Day 4 on ventilator
Underlying health is
good
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Patient 2 – in ICU
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15 year old
Respiratory failure
from influenza
Failing maximal vent
therapy
SOFA 7
Underlying health is
good
Proactive Triage
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Patient 1 – on ECMO
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60 year old
Respiratory failure
from influenza
SOFA 8
Day 4 on ventilator
Underlying health is
good
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Patient 2 – in ICU
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15 year old
Respiratory failure
from influenza
Failing maximal vent
therapy
SOFA 7
Underlying health is
good
Proactive Triage
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Patient 1 – on ECMO
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6 year old
Respiratory failure
from influenza
SOFA 8
Day 4 on ventilator
Underlying health –
advanced CF
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Patient 2 – in ICU
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15 year old
Respiratory failure
from influenza
Failing maximal vent
therapy
SOFA 7
Underlying health is
good
Proactive Triage
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Patient 1 – on ECMO
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6 year old
Respiratory failure
from influenza
SOFA 13
Day 4 on ventilator
Underlying health is
good
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Patient 2 – in ICU
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15 year old
Respiratory failure
from influenza
Failing maximal vent
therapy
SOFA 7
Underlying health is
good
Foundations
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Common Ethical Framework
Legal / Liability protection
Define
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Planning framework
Operational framework
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State roles
Platform and mechanism for regional coordination
Hospital roles
Regional / state
Institutional
Implementation / Decision Support Tools
Strategies
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Prepare
Substitute
Adapt
Conserve
Re-use
Re-allocate
Supply Strategies
Conventional Contingency
Stockpiled supplies
used
Substitute Equivalent
medications used
Conserve Oxygen flow rates Oxygen only for
titrated
saturations < 90%
Adapt
Anesthesia machine for
mechanical ventilation
Re-Use
Re-use NG tubes and
ventilator circuits
ReRe-allocate oxygen
Allocate
saturation monitors,
cardiac monitors from lowrisk patients
Crisis
Prepare
Oxygen only for
respiratory failure
Bag-valve manual
ventilation
Re-use invasive
lines
Re-allocate
ventilators
HCMC Shortage Grid
Priority
Medication
Avg.
Units
Month(s)
Purchased Units on
Supply on Units on
per
Hand as
Hand
Hand
Month
of:
Exp Release
Date
Strategy
High
Amikacin 250mg/ml 2ml vial
0.00
0
20
8/28/13 No release date
High
Droperidol 2.5mg/ml 2ml vial
0.00
0
900
8/28/13 No release date
High
Glycopyrrolate 0.2mg/ml 1ml vial
3.80
95
25
8/28/13 Early September Switch NBICU to 1 ml vials
high
Glycopyrrolate 0.2mg/ml 5ml vial
0.00
0
375
8/28/13 Late September Alert in Epic
High
Hydroxyzine 50mg/ml 1ml vial
0.00
0
50
Alert to use oral if possible,
Keep vials in PACU rest
8/28/13 No release date return to main pharmacy;
all other doses from main
pharmacy multidose vial
High
Sodium Phosphate 3mm/ml all size vials
0.00
0
75
8/28/13 Late September
High
Heparin 25,000U/250ML (D5 or NS)
0.87
155
178
8/28/13 Early September
Intermediate Mannitol 25% 50ml vial
2.60
78
30
8/28/13 Early September
Intermediate Atropine 1mg/ml 1ml vial
0.87
13
15
8/28/13 No release date
Intermediate Bupivacaine 0.5% + EPI 1:200K 30ml vial
2.13
170
80
8/28/13 Early September OR use w/o Epi
Intermediate Calcium Chloride 10% 10ml vial
0.00
0
10
8/28/13 No release date Use syringes internally
Intermediate Fentanyl 50mcg/ml 2ml syringe
1.97
4,920
2,500
8/28/13 No release date
Ordering 10,000 unit vials
to make own bags
0.4mg/1ml vials available alternative alert in place
Place Fentanyl 5ml vials for
high users
Impact of Drug Shortages
Delays in treatment
 82% of hospitals had delayed treatment; > 50% not always
able to provide patients with recommended treatment
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Ethical dilemmas (oncology Rx – leucovorin, cytarabine)
Less effective therapy
 69% of hospital reported patients got a less effective Rx
because the most effective drug unavailable
ISMP survey 2010
Capstick Int J Tuberculosis & lung disease 2011;15(6)
Continuum of Disaster Care
Crisis Care
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Indicators and Triggers
Incident management
Clinical input
Communications
‘Triage’ decisions (restrictions, etc.) and
processes
Quality assurance and reporting
Coalition and other actions to return to
conventional status
Space
Hospital C
Hospital B
Clinic coord
Hospital A
Healthsystem
Regional Healthcare
Resource Center
Multi-Agency Coordination
Center
EM
A
EMS
PH
A
B
Jurisdiction
Emergency
Management
B
C
C
A
B
EMS Agencies
C
Public Health
Agencies
EMS crisis care plan
Metro Compact Scarce
Resources
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Foundational elements – ethical, policy,
existing conditions that may trigger
Definitions
Situations and concept of operations
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Isolated
Continuing
Communications
System monitoring
Metro
Compact
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Isolated?
RHRC
RMAT / SAT
MDH requests
Triage teams
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Regional teams
Regional Triage
Factors to consider…and not
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YES
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Likelihood of benefit
Change in quality of
life
Duration of benefit
Urgency of need
Amount of resources
required
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NO
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Gender
Race
Ability to pay
Social worth
Perceived obstacles to
treatment
Patient contribution to
illness
Past resource use
Other considerations…
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Age
Cultural
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Hmong
Native American
‘Essential personnel’
Hospital Plans
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Trigger(s)
Notifications
ICS
Participants
Tools
Process
Communication
Other considerations
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Behavioral health and security responses
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Public information / managing expectations
Triage decision documentation
Triage decision review
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Internal audit
Appeal
Palliative care
Recovery
What are some new issues?
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Experience in Haiti
SOFA scores have limited value in
respiratory failure cases (e.g. pandemic flu)
Systems that proactively exclude patients
from resources are not advisable –
comparative systems are preferred
Must involve coalitions/state in proactive
triage processes and resource allocation
Crisis care must take into account a broader
spectrum than triage of life-saving resources
Implementation issues
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Legal protections
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Community acceptance
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Emergency powers
‘Standard of care’ issues
Lack of precedent
Equal protection for equal roles (state vs. private
employee)
WA, MD, MN, TX, other projects
‘Difference’ between initiation and withdrawal of
resources
Provider acceptance
The road ahead
Refinement
of prediction tools
Integration of crisis care decision processes
into drug shortages and other ‘daily’ disasters
Critical care surge planning for ACCP targets
involves ‘crisis’ planning
Community engagement
Provider engagement
Closing Thoughts
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‘The best defense is a good offense’
Focus
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Legal/regulatory support for CSC
Local / agency operational plans for surge –
including crisis care
Process
Consistency
Importance of the healthcare system /
regional systems
Questions?