Deliberations and recommendations of the Pediatric Emergency Mass Critical Care Task Force: Executive summary

Despite difficult challenges during responses to the terrorist attacks of September 11, 2001, Hurricane Katrina, and the 2009 Pandemic Influenza A/H1N1 and severe acute respiratory syndrome outbreaks, no North American emergency to date has overwhelmed intensive care unit (ICU) services on a widespread basis since the modern development of the field of critical care. However, planners have recognized that in a future public health emergency we may not be so fortunate. To deal with very large emergencies involving many patients whose survival depends on immediate access to intensive care, an international Task Force for Mass Critical Care proposed recommendations in January 2007 to extend critical care resources for the adult population, referred to as the Emergency Mass Critical Care (EMCC) approach (1–5). The EMCC approach triples critical care capabilities for a period of up to 10 days in a very large public health emergency by focusing on immediately life-saving interventions, while delaying or forgoing less urgent care. Crisis standards of care in a large public health emergency would attempt to optimize population outcomes, rather than use unlimited efforts to maximize survival of each individual. Available resources would be substituted or adapted for equivalent or nearly equivalent unavailable resources. Resources would be conserved, reused, and reallocated to those patients most likely to benefit from them. Modest increases in stockpiles and major changes in the organization of care would be essential. While planners in the field acknowledge that mass critical care is a reasonable concept, we lack evidence that such an approach is feasible. However, failure to begin operational planning for mass critical care guarantees a failed response. As public health emergency planners begin to consider the EMCC framework, it is urgent that pediatric implications be detailed for integration into these developing plans. This supplement represents the discussions of a multidisciplinary panel convened by the Oak Ridge Institute for Science and Education (supported financially by the Centers for Disease Control and Prevention), and provides guidance for pediatric EMCC (PEMCC). Work of the PEMCC Task Force was directed by a 17-member Steering Committee selected on the basis of their expertise and experience, and included representatives from the Task Force for Mass Critical Care, World Federation of Pediatric Intensive and Critical Care Societies, American Academy of Pediatrics, American College of Critical Care Medicine, American College of Emergency Medicine, Royal College of Physicians (Canada), and National Commission on Children and Disasters, as well as several unaffiliated disaster preparedness experts. This Steering Committee led development of all manuscripts and selected individuals for the PEMCC Task Force. The full PEMCC Task Force comprised 44 experts from fields including bioethics, pediatric critical care, pediatric trauma and surgery, neonatology, obstetrics, general pediatrics, emergency medicine, pediatric emergency medicine, disaster preparedness and response, emergency medical services (EMS), infectious diseases, toxicology, military medicine, nursing (including critical care nursing), pharmacy, veterinary medicine, information sciences, public health law, maternal and child public health, and local, state, and federal government emergency planning and response agencies. Priority topics were organized on the basis of MEDLINE and Ovid database literature searches, bibliographies, state and federal government planning documents, after-action reports of recent medical responses to catastrophes, and through participation in local, state, and federal government working groups on hospital and disaster preparedness. Where evidence was available, it was utilized in formulating recommendations. Where evidence was lacking, recommendations represent expert opinion. Wherever possible, recommendations are consistent with and easily integrated into prior recommendations of the adult Task Force for Mass Critical Care. The Steering Committee produced draft outlines by synthesizing information obtained in the evidence-gathering process and convened October 6–7, 2009, to review and revise each outline. Eight draft manuscripts were subsequently developed from the revised outlines. The full PEMCC Task Force convened March 29–30, 2010, to present and discuss the draft manuscripts. Feedback on each manuscript was compiled and the Steering Committee modified the draft documents to reflect this input, in addition to updating the manuscripts based on the most current medical literature. The Steering Committee revised the manuscripts from March to October, 2010, working primarily via email and conference calls. New versions were electronically transmitted to all Task Force members to obtain concurrence with manuscript revisions. All authors and reviewers completed disclosure statements; there were no conflicts of interest. The authors were given complete autonomy by the Oak Ridge Institute for Science. The views expressed in these summaries are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Based on the recognition of the special needs of children during disasters and extensive discussion, the following recommendations are made by the PEMCC Task Force. These recommendations are described in detail in nine subsequent articles. Readers should refer to individual articles for all recommendations rather than those highlighted in this executive summary. Treatment and Triage Recommendations for PEMCC (p. S109) PEMCC in Pediatric Hospitals. These recommendations provide the basis for hospitals to prepare for PEMCC: Every hospital with a pediatric ICU or neonatal ICU should plan and prepare to provide PEMCC, and should do so in coordination with regional health planning efforts. Hospitals with ICUs should plan and prepare to provide PEMCC every day of the response for a total critically ill patient census at least double the pediatric ICU bed capacity and at least triple usual ICU capability. Hospitals should prepare to deliver PEMCC for 10 days without sufficient external assistance. Care should be coordinated with the emergency department for triage and transfer of patients to/from ICUs. All communities should develop a graded response plan for events across the spectrum from multiple casualties to catastrophic critical care events. To optimize medication availability and safe administration, the Task Force suggests that modified processes of care should be considered before an event, such as the following: rules for medication substitutions and restrictions; safe dose and frequency reduction; conversions from parenteral to oral/enteral administration; shelf-life extension; and use of length-based weight estimations. PEMCC for pediatric patients ideally should occur in hospitals or similarly designed and equipped structures with experience in providing critical care to pediatric patients. Principles for staffing models should include the following: strategies to achieve and maintain adequate staffing levels; patient care assignments for the unit should be managed by the most experienced clinician available; and assignments should be based on staff abilities and experience, with delegation of some duties and efforts to reduce care variability and complications. PEMCC in Nonpediatric Hospitals All hospitals must plan to care for children in their proportion to the population or for those affected by the mass casualty event. To facilitate such planning, 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. 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. Nonpediatric hospitals may not have the pediatric equipment needed to sustain critically ill patients; therefore, these teams may need to take their own equipment. Establish referral network for pediatrics consultation or transfers to support hospitals that do not normally receive pediatric patients. Nonpediatric hospitals should preidentify hospital staff with experience in care of pediatric patients and create key positions in which these individuals would serve. The Task Force was unable to recommend a protocol for allocating scarce pediatric critical care resources (tertiary triage) during PEMCC. However, they suggest that: Resources should be allocated on the basis of need, benefit, the conservation of resources, and finally lottery or queuing. Younger children should not be discriminated against based on age alone. While a validated pediatric scoring system is being developed, tertiary triage should be based on expert opinion and conducted by triage teams, including experienced trauma surgeons and/or intensivists, using their best medical judgment as is the current standard of practice. The Task Force recommends that the American Academy of Pediatrics and the Institute of Medicine, bodies with subject-matter expertise and necessary positioning, develop a set of research priorities for disaster pediatric medicine such that the evidence base can be established to facilitate the development of necessary tools (i.e., decision matrices). Supplies and Equipment for PEMCC (p. S120) This chapter focuses on strategies and paradigms for purchasing and stockpiling equipment that will be necessary in PEMCC. This includes specific equipment (not including personal protective equipment, which is beyond the scope of this chapter) and supply lists necessary to triple pediatric ICU capacity for up to 10 days for a scenario in which the surge includes patients across all ages, and another scenario in which most patients are from a single age group. Recommendations include the deployment of mechanical ventilators including specifications (see p. 128 for further details), ventilation ancillary equipment (including equipment that could be disinfected or sterilized between patient uses in a pandemic situation), other options for assisted ventilation and nonconventional ventilation, suggestions for a ventilator inventory, equipment for hemodynamic management, and supplies for sedation, analgesic, antimicrobials, and nutrition. Additional equipment and supply recommendations necessary for various types of pediatric hospitals to prepare for disasters have been provided by the New York City Department of Health and Mental Hygiene's Pediatric Hospital Disaster Toolkit (http://www.nyc.gov/html/doh/html/bhpp/bhpp-focus-ped-toolkit.shtml); the toolkit has been positively viewed and is an additional resource that should be considered. Neonatal and Pediatric Regionalized Systems in PEMCC (p. S128) This chapter outlines the present system of care in the United States and Canada, and the systems likely to be available for providing mass critical care. Topics discussed in this manuscript include: gaps between anticipated needs and existing resources, changes in functioning of regional systems necessary for PEMCC, protocols for patient transfer, agreements with healthcare institutions that primarily provide adult care, just-in-time training of healthcare workers, transport systems for patients, and allocating staff to other healthcare facilities. Recommendations are provided for operational planning integrated across jurisdictions necessary to implement PEMCC. All preparations for mass critical care for the general population must include pediatric aspects. For this to occur, pediatric experts must be involved in all aspects of emergency and disaster planning. States and Regions. States and regions should: Facilitate PEMCC by providing legal protections for those involved in PEMCC. Reaffirm ethical norms in PEMCC. Ensure that all hospitals are prepared to provide care for children in a mass casualty scenario, including a level or scope of care beyond what they might ordinarily provide during normal operating conditions. Plan to share scarce resources with neighboring states and ensure effective public-private collaboration to meet the needs of a pediatric patient surge and optimize pediatric critical care capacity in a mass casualty event. Develop pediatric-specific performance criteria to hold regional systems accountable for PEMCC preparations and responses. Perform vulnerability analyses to estimate anticipated pediatric mass critical care needs, including especially vulnerable populations. Inventories of functional resources (space, equipment, supplies, and staff) for mass critical care must be performed at every hospital with an ICU. State information systems must be developed to track critical care needs and resources in real time during public health emergencies. Integrate operational plans for mass critical care and triage allocation (rationing) across all jurisdictional levels and all response agencies, and integrated with all aspects of emergency preparedness planning. Define regional mechanisms to direct the distribution of patients and resources in a public health emergency. Federal. Action at the federal level should include: Plans for federal involvement are consistent with state plans for mass critical care and triage allocation (rationing). Federal expertise and guidance to promote consistency in informing state laws and regulations regarding mass critical care and triage allocation (rationing) in public health emergencies. Federal incentives, specific readiness requirements, readiness, and performance measures germane to pediatric care capabilities and capacity to ensure that all states prepare sufficiently for mass critical care and triage allocation (rationing). Federal support for research on best practices ahead of time, as well as real-time surveillance, epidemiologic research, and clinical trials during a public health emergency, which will result in better evidence-based practices at the level of regional systems of care, and better clinical care. Education in a PEMCC setting (p. S135) Prospective and just-in-time training modules for pediatric critical care providers and the public are discussed within this article. Recommended topics for skilled clinicians, particularly those who do not typically treat pediatric patients, include: training in pediatric triage, administration of EMCC coordination and planning, and training in use of nonstandard equipment. As part of comprehensive emergency preparation, educational needs should be identified and addressed. Practitioners should work to maintain their basic pediatric care levels pertinent to their job, and contemplate whether additional training might benefit them in preparation for potential mass critical care events. If they are likely to be involved in a PEMCC response, they should seek out additional proactive training. Hospitals should: identify team leaders and pediatric care providers and encourage them to receive additional training and stay current in the management of critically ill children; identify just-in-time resources that could be used in times of need, and contemplate how they could best implement those resources, particularly if infrastructure, such as internet access, is compromised; and, if they do not have pediatric critical care capabilities, establish a relationship with a regional children's hospital to look for potential educational and training collaboration and offer these courses to their hospital staff. Regional pediatric critical care centers should: maintain an active educational role in both self-education in management of critically ill children and in regional education in their usual referral network; identify potential local hospitals that could help with surge capacity and ensure that those hospitals are receiving necessary training to manage potential surge patients; and work to develop just-in-time resources for remote assistance in training, such as telemedicine or telephone consultation. State/federal/professional societies should fund and develop additional training courses for pediatric mass critical care, both proactive courses and for development, evaluation, and distribution of just-in-time training modules. PEMCC: The role of community preparedness in conserving critical care resources (p. This of the supplement the role of the community in for disasters and PEMCC. preparedness use of hospital resources and scarce critical care resources by care in the community by the following: care pediatric-specific and (i.e., and integration with a health emergency to community The Task Force recommends the following by pediatric who care and for promote to before and during a an and the education of children and in the Centers for Disease Control and on community for a community level of preparedness that to of the information that best the public to provide basic information and and and health for the of and systems and and as during public health emergencies. for telephone triage with criteria and protocols for the use and of and during Work with community planners to identify the support necessary for and operating care and identify and create patient management based on the types of patients that would be managed in such facilities. for operational that provide guidance and protocols to the needs of the pediatric during PEMCC events (p. is a for healthcare and facilities during PEMCC. While many of the legal with providing PEMCC are not within the of disaster health care, the scope of of state, of and should be considered in PEMCC planning and response efforts since and legal may be unavailable to in decision during This the legal in planning for and to catastrophic emergencies and recommendations for PEMCC legal preparedness. To gaps in existing protections for public health and PEMCC emergency the Task Force recommends several of legal preparedness. As in the Institute of crisis standards of care guidance legal protections must be provided for healthcare and institutions that implement crisis standards of care plans. protections are state must existing health and protections to crisis standards of care. and other should consider whether to the Institute of guidance provides evidence of the standard of care and legal of standards of care during in medical addition to the Institute of the following suggestions should be considered for PEMCC PEMCC disaster protocols should be and when providing pediatric mass critical care, who such and protocols in should be from PEMCC protocols should be included in state disaster plans. Health facilities should ensure that their pediatric disaster plans are consistent with state plans and, to the possible, with neighboring health facilities. that care for pediatric patients should develop specific and protocols to into their disaster plans. that do not normally care for pediatric patients or that do not provide care for critically ill pediatric patients should consider such planning or with other facilities that provide such care in the that pediatric patients at their facilities during emergencies. PEMCC: on care (p. care is especially a and in PEMCC. This the between and effective disaster a of suggestions for into each of the following healthcare during a disaster, including a PEMCC emergency pediatric general pediatric and Disaster and PEMCC responses must to the in a of healthcare Care in Care of suggestions have been developed for planning for and to mass events that These include local and local groups to in every of planning and preparation for in Emergency and ICUs in a Mass staff and of during triage an and The of such as to the as a of and of the health of the critical to the of disaster The following are some recommendations for emergency department as they plan and to the needs of children and their in a mass possible, and emergency should a to with the child during the triage and This may providing care for in addition to The local triage and tools should for a and should a of including at least date of and should be obtained as and as possible, and if necessary to the National for and Children an by the government to with in a mass Mental health in triage and emergency of children should be available on the the pediatric and of a liaison such as a child or nursing to and general information of to could reduce on the and skilled medical to the acute needs of critically or patients. in should include a for children with and for The Task Force recommends planning for during PEMCC at and a medical strategies to of when are and and including those with and in PEMCC (p. The specific is ethical to children in disasters to their and that children should be not in proportion to existing resources, to their proportion of the general population or those affected by the event. While the ethical of triage the for and the lack of a validated pediatric scoring system on expert opinion. The the to individuals between and of capacity for children should be based on their proportion of the population, or in proportion to those or likely to be affected by the mass critical care event, rather than in proportion to existing standards are to be resources should be allocated on the basis of medical need, medical benefit, and the conservation of resources. the of a validated pediatric the recommends the use of expert opinion. lists are to the Resources should not be allocated based on the complete or on or to in this is essential. The of PEMCC in the developing (p. care in developing is as well as the that can be for mass critical care in developed during in scarce resource and difficult allocation This and recommendations for providing the most with resources through with existing healthcare and using available resources to The of pediatric critical care should include of the child with a or in without for the and including emergency, and intensive to disasters in developing have to take into the available resources and (i.e., to provide special needs care that as a of immediate The response in these needs to be to the of development of the health services and resources. the must be on care, and basic emergency care, in care should without care resources. in for a pandemic in a developing from public health and and developing strategies for community and care strategies must on using the United Health and for of and of and assistance is provided to during through provided by the Health of 2007 and the Regional emergency response capabilities and their through the Regional with international such as for government (Canada), Department for and will the deployment of scarce resources. are many to PEMCC that are such as of triage and decision and research priorities that need to be addressed. institutions need to use of these recommendations as to their readiness and in preparation for PEMCC. The Pediatric Emergency Mass Critical Care Task Force the American Academy of Pediatrics and Disaster for their review and to this

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