Mass Critical Care Research Articles

Baseline characteristics, level of disease severity and outcomes of patients with COVID-19 admitted to intensive care unit in COVID-19 dedicated Mugda Medical College and Hospital, Dhaka, Bangladesh

Background: Novel coronavirus disease is associated with highly intensive care unit (ICU) mortality. With the dramatic increase of confirmed cases as well as death toll in Bangladesh, timely and effective management of severely and critically ill patients appears to be particularly important. This includes streamlining workflows for rapid diagnosis and isolation, clinical management, and infection prevention. The main objective of this study was identification of the demographic, clinical characteristics, severity and outcome of patients admitted into ICU. Methods: We aimed to describe the demographic and clinical characteristics, severity of disease, management patterns and outcomes of critically ill patients with coronavirus disease 2019 admitted to ICU in a Bangladeshi setting and for this purpose a retro-prospective study of conveniently selected 63 ICU admitted patients with COVID-19 was conducted from May 1 to June 30, 2020. Data were obtained from patient charts and the hospitals’ records using a structured questionnaire. Results: Most of the ICU patients were older male (30, 65.3%) and most of them were 70 or above years of age group (17, 37.0%). ICU patients more likely suffered from comorbidities like hypertension (938, 60.3%); diabetes (36, 57.1%); chronic kidney disease (21, 33.3%). In most cases treatment in ICU included the administration of antibiotics (100.0%) (Meropenem, 20, 31.7%). Forty-Eight patients died (discharge mortality, 76.2%), and fourteen patients were discharged alive from the ICU with a rate of 22.2%. One patient transferred (Palliative discharge, 1.6%) to other facilities for palliative care purpose.Conclusions: Our findings also highlight the importance of planning for mass critical care along with central oxygen supply system as the need for ICU care and ventilator support to treat patients with COVID-19 grows rapidly in Bangladesh.

Hospital preparedness for mass critical care during SARS-CoV-2 pandemic

Mass critical care caused by the severe acute respiratory syndrome corona virus 2 pandemic poses an extreme challenge to hospitals. The primary goal of hospital disaster preparedness and response is to maintain conventional or contingency care for as long as possible. Crisis care must be delayed as long as possible by appropriate measures. Increasing the intensive care unit (ICU) capacities is essential. In order to adjust surge capacity, the reduction of planned, elective patient care is an adequate response. However, this involves numerous problems that must be solved with a sense of proportion. This paper summarises preparedness and response measures recommended to acute care hospitals.

PC-FACS: COVID-19

PC-FACS (FastArticleCriticalSummaries forClinicians inPalliativeCare) provides hospice and palliative care clinicians with concise summaries of the most important findings from more than 100 medical and scientific journals. If you have colleagues who would benefit from receiving PCFACS, please encourage them to join the AAHPM at aahpm.org. Comments from readers are welcomed at pcfacs@aahpm.org.

Prediction of Pediatric Critical Care Resource Utilization for Disaster Triage.

Pediatric protocols to guide allocation of limited resources during a disaster lack data to validate their use. The 2011 Pediatric Emergency Mass Critical Care Task Force recommended that expected duration of critical care be incorporated into resource allocation algorithms. We aimed to determine whether currently available pediatric illness severity scores can predict duration of critical care resource use. Retrospective cohort study. Seattle Children's Hospital. PICU patients admitted 2016-2018 for greater than or equal to 12 hours (n = 3,206). None. We developed logistic and linear regression models in two-thirds of the cohort to predict need for and duration of PICU resources based on Pediatric Risk of Mortality-III, Pediatric Index of Mortality-3, and serial Pediatric Logistic Organ Dysfunction-2 scores. We tested the predictive accuracy of the models with the highest area under the receiver operating characteristic curve (need for each resource) and R (duration of use) in a validation cohort of the remaining one of three of the sample and among patients admitted during one-third of the sample and among patients admitted during surges of respiratory illness. Pediatric Logistic Organ Dysfunction score calculated 12 hours postadmission had higher predictive accuracy than either Pediatric Risk of Mortality or Pediatric Index of Mortality scores. Models incorporating 12-hour Pediatric Logistic Organ Dysfunction score, age, Pediatric Overall Performance Category, Pediatric Cerebral Performance Category, chronic mechanical ventilation, and postoperative status had an area under the receiver operating characteristic curve = 0.8831 for need for any PICU resource (positive predictive value 80.2%, negative predictive value 85.9%) and area under the receiver operating characteristic curve = 0.9157 for mechanical ventilation (positive predictive value 85.7%, negative predictive value 89.2%) within 7 days of admission. Models accurately predicted greater than or equal to 24 hours of any resource use for 78.9% of patients and greater than or equal to 24 hours of ventilation for 83.1%. Model fit and accuracy improved for prediction of resource use within 3 days of admission, and was lower for noninvasive positive pressure ventilation, vasoactive infusions, continuous renal replacement therapy, extracorporeal membrane oxygenation, and length of stay. A model incorporating 12-hour Pediatric Logistic Organ Dysfunction score performed well in estimating how long patients may require PICU resources, especially mechanical ventilation. A pediatric disaster triage algorithm that includes both likelihood for survival and for requiring critical care resources could minimize subjectivity in resource allocation decision-making.

Planning for the next influenza pandemic: Using the science and art of logistics.

The complexities and challenges for healthcare providers and their efforts to provide fundamental basic items to meet the logistical demands of an influenza pandemic are discussed in this article. The supply chain, planning, and alternatives for inevitable shortages are some of the considerations associated with this emergency mass critical care situation. The planning process and support for such events are discussed in detail with several recommendations obtained from the literature and the experience from recent mass casualty incidents (MCIs). The first step in this planning process is the development of specific triage requirements during an influenza pandemic. The second step is identification of logistical resources required during such a pandemic, which are then analyzed within the proposed logistics science and art model for planning purposes. Resources highlighted within the model include allocation and use of work force, bed space, intensive care unit assets, ventilators, personal protective equipment, and oxygen. The third step is using the model to discuss in detail possible workarounds, suitable substitutes, and resource allocation. An examination is also made of the ethics surrounding palliative care within the construction of an MCI and the factors that will inevitably determine rationing and prioritizing of these critical assets to palliative care patients.

Pediatric Mass Casualty Incident: A Real Crisis Mandating Inter-Disciplinary Coordination, Considering Ethical Issues

Interdisciplinary coordination of the director of crisis committee with emergency and other department's staff, financial support team, public relations, rehabilitation team,and police are required to successfully manage mass casualty incidents (MCIs). Prevention, staff training, equipment availability, clear-cut responsibilities and predicting all requirements are crucial aspects to be prepared (1). The task force for Mass Critical Care published guidance for adult MCI in 2008; For children, 17 experts of the Oak Ridge Institute for Science and Education developed recommendations for pediatric MCI (2). Certain guidelines have been suggested by the Centers for Disease Control and Prevention (CDC) and subsequently published in Pediatric Critical Care Medicine as a supplement as well as the more recent supplement in CHEST that updates the previous works (3, 4). Although the literature has provided sufficient evidence managing the situation, some major difficulties still exist in the stage of response to the crisis. Lack of equipment especially in international crises may lead to neglect moribund patients. This problem is more prominent for pediatric patients (5, 6). Personnel shortage mandates to accept the less-qualified staff contribution for pediatric care

The Ethical Allocation of Resources During a Pediatric Emergency Mass Critical Care Event

Emergency mass critical care events have affected children during the H1N1 influenza breakout, the natural disaster in Haiti, and during other disasters in the USA and abroad. Such an event is likely to happen again which has prompted state and federal government and various societies including the American Academy of Pediatrics to develop emergency preparedness plans. The main purpose of these plans is to maximize the survival of pediatric patients affected by such an event. Advance planning which includes surveillance, management of resources, involvement of family members, the use of triage standards of care, and ongoing research shows promise in maximizing the survival of pediatric patients if an event were to occur. In the USA, reports from the H1N1 event and the natural disaster in Haiti have shown that these strategies have the potential to save many lives. The inclusion of these methods in advance planning for an emergency mass critical care event may improve the overall survival rate of pediatric patients.

Disaster Preparedness in Neonatal Intensive Care Units.

Disasters disproportionally affect vulnerable, technology-dependent people, including preterm and critically ill newborn infants. It is important for health care providers to be aware of and prepared for the potential consequences of disasters for the NICU. Neonatal intensive care personnel can provide specialized expertise for their hospital, community, and regional emergency preparedness plans and can help develop institutional surge capacity for mass critical care, including equipment, medications, personnel, and facility resources.

Developments in Surge Research Priorities: A Systematic Review of the Literature Following the Academic Emergency Medicine Consensus Conference, 2007–2015

In 2006, Academic Emergency Medicine (AEM) published a special issue summarizing the proceedings of the AEM consensus conference on the "Science of Surge." One major goal of the conference was to establish research priorities in the field of "disasters" surge. For this review, we wished to determine the progress toward the conference's identified research priorities: 1) defining criteria and methods for allocation of scarce resources, 2) identifying effective triage protocols, 3) determining decision-makers and means to evaluate response efficacy, 4) developing communication and information sharing strategies, and 5) identifying methods for evaluating workforce needs. Specific criteria were developed in conjunction with library search experts. PubMed, Embase, Web of Science, Scopus, and the Cochrane Library databases were queried for peer-reviewed articles from 2007 to 2015 addressing scientific advances related to the above five research priorities identified by AEM consensus conference. Abstracts and foreign language articles were excluded. Only articles with quantitative data on predefined outcomes were included; consensus panel recommendations on the above priorities were also included for the purposes of this review. Included study designs were randomized controlled trials, prospective, retrospective, qualitative (consensus panel), observational, cohort, case-control, or controlled before-and-after studies. Quality assessment was performed using a standardized tool for quantitative studies. Of the 2,484 unique articles identified by the search strategy, 313 articles appeared to be related to disaster surge. Following detailed text review, 50 articles with quantitative data and 11 concept papers (consensus conference recommendations) addressed at least one AEM consensus conference surge research priority. Outcomes included validation of the benchmark of 500 beds/million of population for disaster surge capacity, effectiveness of simulation- and Internet-based tools for forecasting of hospital and regional demand during disasters, effectiveness of reverse triage approaches, development of new disaster surge metrics, validation of mass critical care approaches (altered standards of care), use of telemedicine, and predictions of optimal hospital staffing levels for disaster surge events. Simulation tools appeared to provide some of the highest quality research. Disaster simulation studies have arguably revolutionized the study of disaster surge in the intervening years since the 2006 AEM Science of Surge conference, helping to validate some previously known disaster surge benchmarks and to generate new surge metrics. Use of reverse triage approaches and altered standards of care, as well as Internet-based tools such as Google Flu Trends, have also proven effective. However, there remains significant work to be done toward standardizing research methodologies and outcomes, as well as validating disaster surge metrics.

Legal Preparedness: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

Significant legal challenges arise when health-care resources become scarce and population-based approaches to care are implemented during severe disasters and pandemics. Recent emergencies highlight the serious legal, economic, and health impacts that can be associated with responding in austere conditions and the critical importance of comprehensive, collaborative health response system planning. This article discusses legal suggestions developed by the American College of Chest Physicians (CHEST) Task Force for Mass Critical Care to support planning and response efforts for mass casualty incidents involving critically ill or injured patients. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. Following the CHEST Guidelines Oversight Committee's methodology, the Legal Panel developed 35 key questions for which specific literature searches were then conducted. The literature in this field is not suitable to provide support for evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process resulting in seven final suggestions. Acceptance is widespread for the health-care community's duty to appropriately plan for and respond to severe disasters and pandemics. Hospitals, public health entities, and clinicians have an obligation to develop comprehensive, vetted plans for mass casualty incidents involving critically ill or injured patients. Such plans should address processes for evacuation and limited appeals and reviews of care decisions. To legitimize responses, deter independent actions, and trigger liability protections, mass critical care (MCC) plans should be formally activated when facilities and practitioners shift to providing MCC. Adherence to official MCC plans should contribute to protecting hospitals and practitioners who act in good faith from liability. Finally, to address anticipated staffing shortages during severe and prolonged disasters and pandemics, governments should develop approaches to formally expand the availability of qualified health-care workers, such as through using official foreign medical teams. As a fundamental element of health-care and public health emergency planning and preparedness, the law underlies critical aspects of disaster and pandemic responses. Effective responses require comprehensive advance planning efforts that include assessments of complex legal issues and authorities. Recent disasters have shown that although law is a critical response tool, it can also be used to hold health-care stakeholders who fail to appropriately plan for or respond to disasters and pandemics accountable for resulting patient or staff harm. Claims of liability from harms allegedly suffered during disasters and pandemics cannot be avoided altogether. However, appropriate planning and legal protections can help facilitate sound, consistent decision-making and support response participation among health-care entities and practitioners.

Surge Capacity Logistics: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

Successful management of a pandemic or disaster requires implementation of preexisting plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective and includes focused intensive care abilities and requirements as well as all individuals and organizations involved in hospital and regional planning. The suggestions in this article are important for all involved in a large-scale disaster or pandemic, including front-line clinicians, hospital administrators, and public health or government officials. Specifically, this article focuses on surge logistics-those elements that provide the capability to deliver mass critical care. The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify studies upon which evidence-based recommendations could be made. The results were reviewed for relevance to the topic, and the articles were screened by two topic editors for placement within one of the surge domains noted previously. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. The Surge Capacity topic panel subsequently followed the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestion based on expert opinion using a modified Delphi process. This article presents 22 suggestions pertaining to surge capacity mass critical care, including requirements for equipment, supplies, and pharmaceuticals; staff preparation and organization; methods of mitigating overwhelming patient loads; the role of deployable critical care services; and the use of transportation assets to support the surge response. Critical care response to a disaster relies on careful planning for staff and resource augmentation and involves many agencies. Maximizing the use of regional resources, including staff, equipment, and supplies, extends critical care capabilities. Regional coalitions should be established to facilitate agreements, outline operational plans, and coordinate hospital efforts to achieve predetermined goals. Specialized physician oversight is necessary and if not available on site, may be provided through remote consultation. Triage by experienced providers, reverse triage, and service deescalation may be used to minimize ICU resource consumption. During a temporary loss of infrastructure or overwhelmed hospital resources, deployable critical care services should be considered.

Surge Capacity Principles: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

This article provides consensus suggestions for expanding critical care surge capacity and extension of critical care service capabilities in disasters or pandemics. It focuses on the principles and frameworks for expansion of intensive care services in hospitals in the developed world. A companion article addresses surge logistics, those elements that provide the capability to deliver mass critical care in disaster events. The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with injured or critically ill multiple patients, including front-line clinicians, hospital administrators, and public health or government officials. The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify evidence on which to base key suggestions. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force were also included for validation by the expert panel. This article presents 10 suggestions pertaining to the principles that should guide surge capacity and capability planning for mass critical care, including the role of critical care in disaster planning; the surge continuum; targets of surge response; situational awareness and information sharing; mitigating the impact on critical care; planning for the care of special populations; and service deescalation/cessation (also considered as engineered failure). Future reports on critical care surge should emphasize population-based outcomes as well as logistical details. Planning should be based on the projected number of critically ill or injured patients resulting from specific scenarios. This should include a consideration of ICU patient care requirements over time and must factor in resource constraints that may limit the ability to provide care. Standard ICU management forms and patient data forms to assess ICU surge capacity impacts should be created and used in disaster events.

Special Populations: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

Past disasters have highlighted the need to prepare for subsets of critically ill, medically fragile patients. These special patient populations require focused disaster planning that will address their medical needs throughout the event to prevent clinical deterioration. The suggestions in this article are important for all who are involved in large-scale disasters or pandemics with multiple critically ill or injured patients, including frontline clinicians, hospital administrators, and public health or government officials. Key questions regarding the care of critically ill or injured special populations during disasters or pandemics were identified, and a systematic literature review (1985-2013) was performed. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. The panel did not include pediatrics as a separate special population because pediatrics issues are embedded in each consensus document. Fourteen suggestions were formulated regarding the care of critically ill and injured patients from special populations during pandemics and disasters. The suggestions cover the following areas: defining special populations for mass critical care, special population planning, planning for access to regionalized service for special populations, triage and resource allocation of special populations, therapeutic considerations, and crisis standards of care for special populations. Chronically ill, technologically dependent, and complex critically ill patients present a unique challenge to preparing and implementing mass critical care. There are, however, unique opportunities to engage patients, primary physicians, advocacy groups, and professional organizations to lessen the impact of disaster on these special populations.

Resource-Poor Settings: Infrastructure and Capacity Building

Planning for mass critical care (MCC) in resource-poor or constrained settings has been largely ignored, despite their large populations that are prone to suffer disproportionately from natural disasters. Addressing MCC in these settings has the potential to help vast numbers of people and also to inform planning for better-resourced areas. The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of disaster (mitigation/preparedness/response/recovery), literature searches were conducted to identify evidence on which to answer the key questions in these areas. Given a lack of data upon which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process. The five key questions were then separated as follows: definition, infrastructure and capacity building, resources, response, and reconstitution/recovery of host nation critical care capabilities and research. Addressing these questions led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part 1, Infrastructure/Capacity in this article, and part 2, Response/Recovery/Research in the accompanying article. Lack of, or presence of, rudimentary ICU resources and limited capacity to enhance services further challenge resource-poor and constrained settings. Hence, capacity building entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is needed to mount a surge response. Moreover, planning should include when to disengage and how the host nation can provide capacity beyond the mass casualty care event.

Triage: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

Pandemics and disasters can result in large numbers of critically ill or injured patients who may overwhelm available resources despite implementing surge-response strategies. If this occurs, critical care triage, which includes both prioritizing patients for care and rationing scarce resources, will be required. The suggestions in this chapter are important for all who are involved in large-scale pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. The Triage topic panel reviewed previous task force suggestions and the literature to identify 17 key questions for which specific literature searches were then conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force that were not being updated were also included for validation by the expert panel. The suggestions from the task force outline the key principles upon which critical care triage should be based as well as a path for the development of the plans, processes, and infrastructure required. This article provides 11 suggestions regarding the principles upon which critical care triage should be based and policies to guide critical care triage. Ethical and efficient critical care triage is a complex process that requires significant planning and preparation. At present, the prognostic tools required to produce an effective decision support system (triage protocol) as well as the infrastructure, processes, legal protections, and training are largely lacking in most jurisdictions. Therefore, critical care triage should be a last resort after mass critical care surge strategies.

System-Level Planning, Coordination, and Communication: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

System-level planning involves uniting hospitals and health systems, local/regional government agencies, emergency medical services, and other health-care entities involved in coordinating and enabling care in a major disaster. We reviewed the literature and sought expert opinions concerning system-level planning and engagement for mass critical care due to disasters or pandemics and offer suggestions for system-planning, coordination, communication, and response. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. The American College of Chest Physicians (CHEST) consensus statement development process was followed in developing suggestions. Task Force members met in person to develop nine key questions believed to be most relevant for system-planning, coordination, and communication. A systematic literature review was then performed for relevant articles and documents, reports, and other publications reported since 1993. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions were developed and grouped according to the following thematic elements: (1) national government support of health-care coalitions/regional health authorities (HC/RHAs), (2) teamwork within HC/RHAs, (3) system-level communication, (4) system-level surge capacity and capability, (5) pediatric patients and special populations, (6) HC/RHAs and networks, (7) models of advanced regional care systems, and (8) the use of simulation for preparedness and planning. System-level planning is essential to provide care for large numbers of critically ill patients because of disaster or pandemic. It also entails a departure from the routine, independent system and involves all levels from health-care institutions to regional health authorities. National government support is critical, as are robust communication systems and advanced planning supported by realistic exercises.

Introduction and Executive Summary: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

Natural disasters, industrial accidents, terrorism attacks, and pandemics all have the capacity to result in large numbers of critically ill or injured patients. This supplement provides suggestions for all of those involved in a disaster or pandemic with multiple critically ill patients, including front-line clinicians, hospital administrators, professional societies, and public health or government officials. The current Task Force included a total of 100 participants from nine countries, comprised of clinicians and experts from a wide variety of disciplines. Comprehensive literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert-opinion-based suggestions that are presented in this supplement using a modified Delphi process. The ultimate aim of the supplement is to expand the focus beyond the walls of ICUs to provide recommendations for the management of all critically ill or injured adults and children resulting from a pandemic or disaster wherever that care may be provided. Considerations for the management of critically ill patients include clinical priorities and logistics (supplies, evacuation, and triage) as well as the key enablers (systems planning, business continuity, legal framework, and ethical considerations) that facilitate the provision of this care. The supplement also aims to illustrate how the concepts of mass critical care are integrated across the spectrum of surge events from conventional through contingency to crisis standards of care.

Resource-Poor Settings: Response, Recovery, and Research: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

Planning for mass critical care in resource-poor and constrained settings has been largely ignored, despite large, densely crowded populations who are prone to suffer disproportionately from natural disasters. As a result, disaster response has been suboptimal and in many instances hampered by lack of planning, education and training, information, and communication. The Resource-Poor Settings panel developed five key question domains; defining the term resource poor and using the traditional phases of the disaster cycle (mitigation/preparedness/response/recovery). Literature searches were conducted to identify evidence to answer the key questions in these areas. Given a lack of data on which to develop evidence-based recommendations, expert-opinion suggestions were developed, and consensus was achieved using a modified Delphi process. The five key questions were as follows: definition, capacity building and mitigation, what resources can we bring to bear to assist/surge, response, and reconstitution and recovery of host nation critical care capabilities. Addressing these led the panel to offer 33 suggestions. Because of the large number of suggestions, the results have been separated into two sections: part I, Infrastructure/Capacity in the accompanying article, and part II, Response/Recovery/Research in this article. A lack of rudimentary ICU resources and capacity to enhance services plagues resource-poor or constrained settings. Capacity building therefore entails preventative strategies and strengthening of primary health services. Assistance from other countries and organizations is often needed to mount a surge response. Moreover, the disengagement of these responding groups and host country recovery require active planning. Future improvements in all phases require active research activities.

Ethical Considerations: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

Mass critical care entails time-sensitive decisions and changes in the standard of care that it is possible to deliver. These circumstances increase provider uncertainty as well as patients' vulnerability and may, therefore, jeopardize disciplined, ethical decision-making. Planning for pandemics and disasters should incorporate ethics guidance to support providers who may otherwise make ad hoc patient care decisions that overstep ethical boundaries. This article provides consensus-developed suggestions about ethical challenges in caring for the critically ill or injured during pandemics or disasters. The suggestions in this article are important for all of those involved in any pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. We adapted the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestions. Twenty-four key questions were developed, and literature searches were conducted to identify evidence for suggestions. The detailed literature reviews produced 144 articles. Based on their expertise within this domain, panel members also supplemented the literature search with governmental publications, interdisciplinary workgroup consensus documents, and other information not retrieved through PubMed. The literature in this field is not suitable to support evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. We report the suggestions that focus on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns. Ethics issues permeate virtually all aspects of pandemic and disaster response. We have addressed some of the most pressing issues, focusing on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns. Our suggestions reflect the consensus of the Task Force. We recognize, however, that some suggestions, including those related to end-of-life care, may be controversial. We highlight the need for additional research and dialogue in articulating values to guide health-care decisions during disasters.

881

Introduction: Following Hurricane Katrina and the 2009 H1N1 epidemic, pediatric critical care clinicians recognized the urgent need for a standardized pediatric triage system. The 2010 Pediatric Emergency Mass Critical Care (PEMCC) Taskforce could not recommend any current triage model but advised further research towards this goal. Hypothesis: Providers will prefer an objective pediatric triage system for PEMCC as compared to one that includes factors such as subjective evaluation, neuro-cognitive outcome or patient age. Methods: This cross-sectional survey used an audience response system with US healthcare providers who attended a regional pediatric disaster preparation symposium in 2012 to answer ethical and logistical questions about triage. Differences in opinions between respondents’ professions and hospital type were evaluated using a Student’s t-test. Results: 112 attendees responded (89% response rate); 55% were nurses, 26% physicians and 19% other providers. Work locations included pediatric hospitals (51%) vs. clinics, non-pediatric hospitals or other areas (49%). 59% of respondents agreed that a pediatric triage system should include both objective and subjective components. 59% prioritized children predicted to have a good neuro-cognitive outcome. 70% agreed that no pediatric age group should be prioritized. When considering the effect of workplace, 63% of non-neutral responding pediatric hospital providers preferred a pediatric triage system combining both a subjective evaluation by a care provider and an objective score compared with 37% from care settings other than a non-pediatric care settings (p= 0.04). Conclusions: In this regional survey of providers, the majority of respondents agree that a pediatric triage system should: 1) include both an objective score and a subjective evaluation, 2) prioritize predicted neuro-cognitive outcome but 3) should not include patient age. However, the majority of responders from settings other than pediatric hospitals prefer a triage system that excludes subjective evaluation. Further evaluation of community and provider opinion in other regions is clearly necessary to further the development of a nationally standardized pediatric triage system.