Page 90 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

58 PART 1: An Overview of the Approach to and Organization of Critical Care

TABLE 9-1 Epidemiology of Natural Disasters TABLE 9-3 Emergency Department Triage: Conventional Explosions and Other Trauma
Earthquake Flash Flood Volcano Eruption • Major needs: surgical evaluation and intervention
Deaths Many Many Many • Resources: trauma teams, diagnostic radiology capacity, blood products, staffed operat-
ing rooms, burn beds
Injuries Many Few Few • Goal: sorting through many less seriously injured patients to identify those who will
Damage to health care Severe Severe but localized Severe benefit from rapid resuscitation and surgery
facilities

TABLE 9-4 Explosions Versus Outbreaks
TABLE 9-2 Disasters With Traumatic Injuries
Conventional Explosion Outbreak
Example: Conventional explosions
Nearest hospital most impacted Casualties can be large Casualties can be very large
Initial wave of patients self-refer and are less injured Mostly trauma patients Mostly medical patients
<20% survivors critically injured Critically injured usually die before hospi- Large proportion may require critical
Most survivors have non-life-threatening soft-tissue injuries talization, many ED visits, fewer inpatients care services
Nearest hospital most impacted Patients may present to many hospitals
For example, in 1995, a terrorist attack destroyed the Alfred P. Murrah Emergency department, surgical and men- Inpatient services (especially ICUs) may be
Federal Building. What came to be known as the Oklahoma City tal health services most impacted most impacted
Bombing resulted in 759 casualties and 168 deaths. Eighty-three victims, Event recovery likely to begin within hours, Length of event may be weeks to months
10
11 of whom died, were admitted to the hospital. The following year, a days, or weeks or longer
bomb exploded in the Centennial Olympic Park in Atlanta, Georgia,
during the Summer Olympic games. This terrorist attack resulted in 111
injured people and two deaths. Twenty-four individuals, 22 of whom Level 1 trauma centers was closed to ambulance arrivals during part of
died, were admitted to the hospital. Terrorists crashing two airplanes the outbreak. 16
11
into the World Trade Center on September 11, 2001, resulted in 3825 In summary, comparing the patient demographics of an explosion to
casualties and 2726 deaths. Of the 181 victims admitted to the hospital, an infectious outbreak clarifies the benefits of conducting an HVA in
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five died. ICU disaster planning (Table 9-4). 17
In a conventional explosion, the majority of patients will have trauma
injuries (Table 9-2), with 30% having an Injury Severity Score of greater EXERCISES AND MODELING DISASTER RESPONSE
than 16. Some of these critically injured patients die before they can be ■
stabilized enough to be admitted to the hospital. Such patients will result ROLE OF EXERCISES RELATED TO ICU NEEDS FOR MEDICAL SURGE
in many emergency department (ED) visits, with approximately 30% Multiple resources exist to support exercising plans for emergency
becoming ICU patients. Burns that occur, unless associated with fire, preparedness within the critical care setting in all-hazards scenarios.
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tend to be superficial thermal flash burns. 14 Outside of Joint Commission–required hospital emergency exercises
Within 90 minutes following a sudden impact event like an explosion, within the United States, other programs exist to fund and support
50% to 80% of acute casualties will likely arrive. However, the initial efforts in training, all-hazards preparedness planning, exercising,
wave of patients will be minimally injured self-referrals who leave the response, and recovery. Two principal examples are the US Department
disaster scene by their own accord. The most common injuries are eye of Homeland Security Exercise Evaluation Program (HSEEP) and the
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injuries, sprains, strains, minor wounds, and ear damage, whereas the US Department of Health and Human Services Hospital Preparedness
most severe injuries are fractures, burns, lacerations, and crush injuries. Program (HPP) grant. Hospitals are incentivized to utilize HSEEP and
19
The hospital closest to the catastrophe will be the most impacted, with other current standards as the backbone for exercise planning evaluation
ED, surgical, and mental health services being most affected. Other to aid funding for efforts to build emergency preparedness. HPP and
surrounding hospitals usually receive few or no casualties. Disaster other programs encourage participation and planning for contingencies
14
recovery will likely begin within hours, days, or weeks. Following the such as alternate care sites to transfer noncritical inpatients to commu-
collapse of the World Trade Center in 2001, 448 victims were treated in nity-based centers to reduce the hospital burden. Utilization of local,
a 24-hour period at New York Downtown Hospital, the closest one to regional, and state resources by a community to support a hospital that
the event. The hospital, which transferred only 21 patients, was able to has become overwhelmed is a cornerstone of public health emergency
stay open. 15 preparedness. The national medical surge standard for public health
When trying to predict the number of victims who will present emergencies such as infectious disease outbreaks is 500 additional beds
after a mass casualty trauma event, it is important to remember that per one million individuals. 20,21
such patients typically arrive quickly and that approximately half of all
casualties will arrive at the hospital within a 1-hour window. To predict ■ MODELING FOR MEDICAL SURGE PATIENTS AND RESOURCES
the total number of victims a hospital can expect one can double the
number of casualties the hospital receives in the first hour (Table 9-3). 14 A variety of modeling efforts have demonstrated expected casualties
Conversely, an outbreak will result in mostly medical patients, a large in specific mass emergencies to better inform hospitals and clinicians
proportion of whom may require critical care services. These patients of expected casualties and required resources. Specific to pandemic flu
may go to physician offices or clinics, or present to hospitals where the is the CDC’s Flu Surge 2.0. Flu surge is a spreadsheet-based model where
inpatient services, especially the ICU, will be most impacted. Because the user inputs the length and virulence of a flu pandemic with the
the event itself could occur over weeks, months, or longer, recovery typi- following model outputs.
cally will not begin for at least a similar time interval. Over a 4-month • Hospitalizations
period, approximately 375 SARS patients (suspected and confirmed) • Number requiring ICU care
were cared for at hospitals in Ontario, Canada. More than 33% of the
ICU beds were closed at some point during the outbreak. Some hospi- • Number requiring ventilator support
tals had to refuse additional patients for weeks to months. One of two • Deaths 22

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