9) Principles for staffing models should include the following:
- Strategies to achieve and maintain adequate staffing levels should be developed.
- Patient care assignments for units should be managed by the most experienced clinician available.
- Assignments should be based on staff abilities and experience.
- Delegation of duties that usually lie within the scope of some workers' practice to different healthcare workers may be necessary and appropriate under surge conditions.
- Systematic efforts to reduce care variability, procedure complications, and errors of omission must be used when possible.
To expand critical care capacity during PEMCC, the model of care provision must be modified (3, 8). Because critical care human resources are limited (33–35), it will be necessary to employ staff who typically work outside of critical care in the provision of PEMCC. The fundamental principle underlying this recommendation is that it is important to focus on skills rather than job titles. By focusing on the skills that are required to perform PEMCC and matching that with the skills various healthcare workers possess, it is much easier to identify which staff can be redeployed to assist with PEMCC.
One approach to maintain safe practice yet still allow staff expansion through the integration of noncritical care workers is the use of care teams. In the care team model, experienced critical care providers work in partnership with providers who possess certain skills to perform aspects of PEMCC but who do not routinely work in PICUs. For example, instead of the typical 2:1 or 1:1 critical care nurse-to-patient ratio, in PEMCC two critical care nurses may work with three nurses from other areas, such as postanesthesia care or step-down units, for a total of six or seven patient coverage by a care team. The critical care nurses can supervise the noncritical care patients and perform tasks that lie outside the skill set of the other nurses. This model is not all that dissimilar from how residents, fellows, and staff work in teaching hospitals. Project XTREME (Cross-Training Respiratory Extenders for Medical Emergencies) provides an example of how this type of approach can be applied to respiratory therapy needs in disaster response by training healthcare providers to function as “respiratory therapy extenders” capable of managing mechanical ventilators under supervision (36).
PEMCC in nonpediatric hospitals
1) All hospitals must plan for the care of some children:
- Hospitals with neonatal ICUs will need to manage pediatric patients beyond their typical age limits.
- Adult hospitals should provide stabilization of critically ill pediatric patients pending transfer.
- Adult hospitals should plan to provide care for noncritically ill pediatric patients other than infants (children with special needs may be an exception).
- Adult ICUs, during a mass casualty event, should keep adolescent patients without consultation and patients older than 5-8 yrs following consultation with pediatrics.
This is likely the most novel and most important recommendation that the Task Force has made. During the review of the current data and during its deliberations, the Task Force recognized that, given the organizational system for pediatric care and the limitations in capacity discussed earlier, the only way to effectively save children's lives would be to draw upon the proportionally larger pool of resources within nonpediatric hospitals. The implications of the regionalized model for the delivery of pediatric care and the ethical issues related to the allocation of resources between adults and children during a disaster are both discussed in detail elsewhere in this publication. The current discussion will focus on the recommendations for providing PEMCC in nonpediatric hospitals.
When considering how to safely engage nonpediatric hospitals in the care of children during a disaster, the fundamental principle used to guide the Task Force's recommendations is that the most complex and most acutely ill children should be managed at pediatric hospitals that have the most experience in treating such patients. Thus, nonpediatric hospitals should only be asked to manage less acutely ill children or critically ill children that are the least physiologically different from adult patients (i.e., adolescents). Nonpediatric hospitals should include a pediatrician or pediatric medical liaison in those committees responsible for disaster planning, appeals, and determining when crisis standards of care should be implemented. New York State has published guidance for nonpediatric hospitals to manage pediatric patients during a disaster (http://www.omh.state.ny.us/omhweb/disaster_resources/pandemic_influenza/hospitals/bhpp_focus_ped_toolkit.html).
An equally important rationale prompting the Task Force to make this recommendation is evidence indicating that the majority of victims will self-extricate from the site of the disaster and present to any hospital, often the closest, but not necessarily the hospital that authorities direct patients to use (37). As a result, many nonpediatric hospitals may be faced with critically ill pediatric patients presenting at their doors, particularly if entire families are affected as a unit. Under normal circumstances, most nonpediatric hospitals have plans and processes to provide initial resuscitation or stabilization of pediatric patients in the emergency departments but then proceed with very early transfer of the pediatric patient to a pediatric facility. In the event of a large-scale disaster, rapid transfer may not be feasible. First, given their resource limitations, pediatric hospitals will likely be overwhelmed very quickly and therefore may not be able to accept transfers. Additionally, transportation may not be available depending on the nature of the disaster. In many circumstances, emergency medical services resources will be fully committed to the on-scene response, negating any interfacility transfers. Finally, the transport of critically ill patients is very staff intensive and takes nurses, respiratory therapists and physicians away from areas of need (5).
2) During a disaster, it may be more efficient to transfer skilled pediatric critical care teams to nonpediatric centers to support those facilities in providing care to critically ill pediatric patients. However, if healthcare workers are going to be moved between institutions, then hospitals and government authorities must be prepared to credential incoming teams expeditiously.
When it is not feasible or efficient to transfer individual pediatric patients for management at a pediatric facility, an alternative consideration would be to dispatch teams of pediatric providers to nonpediatric facilities to support them in managing pediatric patients there. Not only does this approach relieve the pressure on the pediatric sites, it also likely provides for safer care of pediatric patients in nonpediatric centers and provides a “force-multiplier” effect similar to the care team model discussed above. Finally, the transportation of the pediatric teams to the nonpediatric hospital does not require a vehicle fitted for patient transport. Other modes of emergency or nonemergency transportation can be used. This is particularly effective if the nonpediatric hospital already has a store of the necessary pediatric equipment on site. Equipment recommendations for nonpediatric hospitals are presented in the New York State guidance mentioned earlier (http://www.omh.state.ny.us/omhweb/disaster_resources/pandemic_influenza/hospitals/bhpp_focus_ped_toolkit.html). If nonpediatric hospitals do not have the pediatric equipment needed to sustain critically ill patients, pediatric critical care teams may need to take their own equipment.
A significant limitation of this approach, and a problem frequently faced in disaster response, is the difficulty associated with credentialing (9, 38, 39). For such an approach to work, a system for rapid credentialing or advanced credentialing would be required. Government bodies and professional colleges can prepare for disasters by developing programs to credential healthcare workers in advance, such as the Emergency System for Advance Registration of Volunteer Health Professionals and Medical Reserve Corps/National Disaster Medical System (http://www.medicalreservecorps.gov/File/ESAR_VHP/ESAR-VHPMRCIntegrationFactSheet.pdf). One possible alternative to avoid these difficulties is to use telemedicine technologies to provide pediatric support to nonpediatric hospitals (See the article, “Pediatric emergency mass critical care: The role of community preparedness in conserving critical care resources”).
3) A referral network for pediatrics consultation or transfers should be established to support hospitals that do not normally receive pediatric patients.
With adult hospitals providing care for some pediatric patients during a disaster, consultation and pediatrician support will be required for these facilities. While most adult centers see children in their emergency departments and thus have some experience with transferring such patients to a pediatric referral center, such transfer arrangements are often of an informal, ad hoc nature; therefore, it is prudent to provide adult hospitals with a plan for referral and consultation in advance of a disaster. When developing this referral network, it is important to consider all pediatric resources within a region and not academic centers only. There may in fact be nonacademic centers near the affected hospital that can quite capably provide advice and/or management.
4) Nonpediatric hospitals should preidentify hospital staff (physicians, nurses, nurse practitioners, physicians assistants) with experience in care of pediatric patients (may include emergency medicine, anesthesia, otolaryngology, trauma surgery, general surgery, and certain medical specialties or nurses with past experience in pediatrics), create key positions in which these individuals would serve (including job action sheets), and integrate them into the hospital's plan to manage pediatric patients.
It is important to remember that, even in an adult hospital, there may be staff who have experience working with pediatric patients. These staff members can form a cadre from which to draw in the event of a disaster involving many critically ill children.
For centuries, many have struggled with the issue of how to manage situations where healthcare resources (supplies) do not meet the demands. Although present to some degree in many healthcare systems on a daily basis, resource allocation decisions often become most apparent and pressing during acute surges in demands, such as disasters. When faced with a shortfall of resources, a number of potential options exist for allocating the available resources. The default option would be to do nothing and just continue practice as normal on a first-come, first-serve basis until all the available resources are used. Although this approach requires the least deviation from normal practice, excess mortality is the likely result, and the public and healthcare professionals tend to consider it an unacceptable response to crisis situations. Further, this approach may exacerbate preexisting discrepancies in access to healthcare based on economic, social status, or other factors. As an alternative, one may consider a lottery approach for the allocation of scarce resources (40). If conducted properly, this approach to triage would overcome the issues of perpetuating various discriminations in access, but it is not feasible because of logistic issues, the most significant being that it is impossible to know in advance who is going to be injured or fall ill and require a medical resource.
Faced with similar challenges during the 1700s, the Surgeon General of Napoleon's army issued the first rules of triage (French for “to sort”) whereby he directed that the wounded should be treated in priority of their injuries rather than their rank or status. From this point onward, triage has become the primary method for allocating scarce resources and has evolved to have two functional components: the first to sort or prioritize patients, and the second to ration resources to optimize their availability so they may be directed to the patients who are most likely to benefit from them. This concept of triage is based on utilitarian principles and is the most common, but it is not the only approach that can be taken. Alternative perspectives, such as that of egalitarianism whereby resources would be directed to those most in need, could also be taken. The ethics of triage have been extensively discussed elsewhere (40–43).
Regardless of the particular goals used to guide the development of triage, the process of triage is an iterative one that occurs at multiple points along the continuum of care: primary triage (prehospital decisions concerning priority for referral to health facilities, such as hospitals or alternate care sites); secondary triage (emergency department decisions concerning initial priority for primary treatment); and tertiary triage (decisions regarding priority for definitive management and critical care). Critical elements of triage at any level, when using a utilitarian approach, are knowledge of the demand on the system, knowledge of the supply of resources, and the ability to predict which patients will or will not benefit from the resources. Systems-level triage also occurs at command and control levels concerned with how resources will be distributed at the macro level via the health emergency operations center (44).
In addition to the variability in the possible goals of tertiary triage (e.g., utilitarian vs. egalitarian principles), the process of undertaking tertiary triage also varies greatly. Traditionally, primary and secondary triage has been conducted by a sole triage officer (or multiple, independently functioning triage officers) based on either protocols (typical for primary and secondary triage) (45–48) or expert experience and judgment (tertiary triage in trauma settings). Although protocols have been developed for primary and secondary triage, virtually none of these are evidence based or have validated outcomes of their performance in real-time disasters (49). However, with the development of proposed adult tertiary triage protocols (6, 50, 51), some groups (52) have suggested the use of a triage panel or committee. While this may be beneficial in diffusing responsibility and the pressure of decision making from any one individual, committee-based decision making is cumbersome under the best of circumstances and unlikely to be feasible or efficient in the midst of a disaster, particularly for time-sensitive decision-making. The Adult EMCC Task Force has considered these issues in detail (6).
The original intent of the Task Force Steering Committee was to propose a protocol for allocating scarce pediatric critical care resources (tertiary triage) during a disaster. Currently, the Task Force is unable to identify a pediatric prognostic scoring system, a critical factor required for the development of a tertiary triage protocol that would be appropriate for use. Although several pediatric prognostic scores are used for research purposes (Table 1), their performance characteristics limit their utility in directing resource allocation. The proposed adult tertiary triage protocols use prognostic scoring systems to identify patients who have an excessively high mortality despite critical care therapy, thereby allowing resources to be directed to patients who are most likely to benefit (6, 43, 50). The current pediatric scoring systems fail to sufficiently discriminate between those who are likely to survive and those who are not. The Pediatric Risk of Mortality II score, for example, has been used extensively since it was introduced in 1988, but has had waning reliability in predicting mortality over the past decade, and has never performed well among populations with particular conditions and from selected locations outside of North America. Its successor, the Pediatric Risk of Mortality III, has improved discrimination and is continually being refined with newer and larger patient datasets, but to date remains proprietary. Studies (53–61) describing the Pediatric Index of Mortality II score have documented good discrimination between PICU survivors and nonsurvivors, but the score has been tested primarily in Australia, New Zealand, and the United Kingdom, and its performance in broader populations remains uncertain. Additional to these considerations, given the physiologic resiliency that children possess, mortality rates even in the most critically ill children are still very low compared to the adult ICU population. Thus, pediatric triage algorithms driven solely by tools that predict a high risk of mortality are unlikely to have a significant impact on the allocation of PICU resources, since only a very small proportion of children are likely to reach the probability-of-mortality threshold at which resources will be withheld or withdrawn.
Recently, several pediatric protocols have been proposed that use exclusion criteria based on preexisting conditions for the use of life support in pediatric patients during a catastrophic event. Unfortunately, the Task Force concluded that it could not endorse these protocols. Although the Task Force did not outright reject the principle of exclusion criteria, the primary difficulty with the proposed exclusion criteria is that they would exclude so few patients that no significant impact on resource availability is likely to be appreciated. The inability of the Task Force to recommend a tertiary triage protocol unfortunately does not negate the potential need for resource allocation decisions to be made if a major disaster were to occur. While the necessary development activities are undertaken to create the components for a pediatric tertiary triage protocol, the Task Force offers the following considerations in the event that resource scarcities occur. The approaches are divided into considerations for sudden-impact disasters and sustained-impact disasters (1).
Sudden-impact disasters are unexpected and involve trauma from either natural or man-made kinetic events. In such cases, the existing primary and secondary triage protocols are most relevant and should be used. Effective use of primary and secondary triage may mitigate the need for tertiary triage by limiting overtriage (59) and ensuring the most efficient use of available critical care resources. In the event that efforts at surge management, including PEMCC, are insufficient to meet the demand, tertiary triage should be conducted by experienced trauma surgeons and/or intensivists (pediatric or adult) using their best medical judgment as is the current standard of practice. As with any triage circumstance, the degree of rationing should be proportional to the expected or realized shortfall in resources, and should be conducted within the framework of an incident management system under the command and control of a regional health authority to ensure all possible resources are mobilized.
Sustained-impact disasters occur over a prolonged period of time and/or large geographic area and are most likely to result from bioevent disasters, such as a pandemic or bioterrorism event. Unlike sudden event disasters where the vast majority of the patients would be the result of the surge event itself, in a sustained-impact disaster, patients for critical care would be a mixed group comprising patients related to the surge event as well as those with other critical illness/injury conditions. In a sudden-impact disaster (lasting for hours to days at most), the baseline demand for intensive care will result in a proportionately smaller number of patients compared to the numbers generated by the surge event. The baseline demand will be further decreased during a sudden event disaster when elective procedures are all cancelled. As a result, triage decisions are essentially all disease specific (e.g., trauma). In a sustained-impact disaster, the cumulative number of patients as a result of baseline demands for critical care is proportionally much higher. Further, in a sustained-impact disaster it is not possible to stop all surgical procedures or other treatments to focus only on the surge event. As a result, triage must address all patients with a variety of illness or injuries, making disease-specific triage protocols (particularly those designed for trauma) of limited utility. Triage at the primary and secondary levels remains important, but tertiary triage becomes much more important and complex.
In the event of a sustained-impact surge when critical care resources are scarce, hospitals should consider withholding or withdrawing care from patients who have do-not-resuscitate orders, experience cardiac arrest, or have intractable hypotension not responsive to vasopressors, or other conditions where critical care is considered futile (60, 61). Under normal circumstances, many of these patients are not admitted to ICU, so it is recognized that these actions are unlikely to significantly impact resource availability and that resources are not squandered unnecessarily. In the event that a critical care resource (e.g., a ventilator) is available, then physicians/hospitals would consider a trial of critical care to identify if the patient will respond to therapy, and would consider withdrawal of life support if the patient does not respond. However, the Task Force is unable to offer any specific recommendations regarding duration for appropriate time trials or markers of response. These issues would fall simply to expert opinion. In the event that there are multiple patients for a single-resource hospital, physicians must decide between using a first-come, first-serve approach or an expert-based (nonprotocolized, nonevidence-based) triage opinion from an experienced physician. Neither situation is ideal and both are fraught with pitfalls. At this juncture, the Task Force cannot recommend one option above the other.
Despite the current inability to propose a tertiary triage protocol for use in pediatric populations, the Task Force continues to support the need for such a protocol to be developed and recommends that researchers work to develop an appropriate scoring system for use in tertiary triage. This effort is likely best coordinated by a collaboration of professional societies (particularly pediatric critical care) supported by government agencies that hold responsibility for emergency management.
The Task Force recommends that a tertiary triage score for use in pediatrics take a different approach than what has been applied in the adult critical care field. Since a PICU allocation algorithm based exclusively on predicting a high likelihood of mortality is unlikely to have a significant impact on resources, ideally a pediatric triage protocol would identify both those patients who are unlikely to survive, regardless of whether they receive critical care, as well as those children likely to require an extended duration of critical care to achieve survival. Using a combination of these outcomes and cumulative incidence, restricting critical care from patients who are unlikely to survive, or who will require a prolonged ICU course, would allow physicians to optimize resource utilization. To have a significant impact on resources, a pediatric triage protocol would have to identify both those children with high predicted mortality (e.g., 80%, as suggested for the adult protocol) and additionally predict excessive resource utilization (e.g., mechanical ventilator utilization) among those with lesser mortality. The thresholds for diverting critical care resources from critically ill children would be fluid, depending on the relative scarcity of those resources. To date, no scoring system, either adult or pediatric, has been developed to perform in this manner.
The Task Force recognizes that critical care is but one element in a health system that is attempting to provide the best opportunity for survival to all those who might benefit. Discipline-directed triage management protocols will only be as important as the manner in which these tertiary level algorithms can be integrated into a larger, system-wide triage scheme that begins at the primary triage care level and ends with whatever additional resources a regional support system can mobilize. Many “uncomfortable but real” decisions that have not, to date, been operationalized at the local level will, out of necessity, be made. Triage management requires an infrastructure, such as health emergency operations centers (as outlined in the article, “Pediatric emergency mass critical care: The role of community preparedness in conserving critical care resources”), central triage committees, data collection/analysis, and triage officer education. Although attempts to provide independent hospital-centric plans are noble, they do not solve what ultimately requires an integrated, population-based, system-wide solution.
Disasters producing overwhelming numbers of critically ill children are rare. However, rather than diminishing the importance of planning and preparation, this fact serves to increase the importance of having preparations in place to respond when they do occur, since clinicians have no routine experience in responding to them. This paper presents recommendations for the provision of critical care to large numbers of children and considerations for resource allocation.
The Pediatric Emergency Mass Critical Care Task Force thanks the American Academy of Pediatrics and its Disaster Preparedness Advisory Council for their review and contributions to the issue.
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Keywords:©2011The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies
critical illness; emergency mass critical care; medical surge capacity; pediatric; resource allocation; treatment; triage