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CHAPTER 9: Preparedness for Catastrophe 59

The Agency for Healthcare Research and Quality (AHRQ) hospital containers. Production and delivery are both restricted by availability of
surge model is used to estimate “the hospital resources needed to treat personnel, transport vehicles, and transportation routes—all of which may
casualties from biological, chemical, foodborne, nuclear, radiological, or be in limited supply or compromised during a catastrophe. Compressed
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conventional explosive attacks.” Inputs into the model are the scenario gas cylinders may provide a temporizing measure, as may oxygen concen-
selection and the estimated number of casualties to treat within the hos- trators. Though these devices cannot support the high demands of ven-
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pital. Model outputs are day-based estimates for tilators, they may be used to provide oxygen to less critically ill patients. 32
Finally, providing usual critical care is a staff and resource-intensive
• Number of casualties by severity, number of casualties in each unit endeavor. Normal ICU patients with cardiovascular and respiratory
(emergency department, ICU, floor) compromise require sophisticated monitoring, treatment devices, and
• Cumulative number of discharged and dead patients consumables (eg, IV lines, drains, pumps, solutions, cables, ECG
• Required hospital resources (personnel, equipment, supplies) 23 patches, and medications). Streamlining processes and developing basic
disaster formularies to meet the needs of most critically ill patients will
One example for community preparedness and public health plan- help ICUs strategize an efficient response effort. 25,33
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ning is the All-Hazards Modular Emergency Medical System (MEMS).
MEMS provides a framework for integrating hospitals and public health ■ STAFF
assets for mass casualties and medical surge. The Resource Requirements
and Allocation Model (RRAM) (a companion to MEMS) estimates Most ICUs continually face the challenge of finding adequate, qualified
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community resource requirements (personnel, equipment, supplies) for staff to meet the rising demands for critical care. 34-36 Given the already-
pandemic responses. strained personnel demands of daily care, catastrophes will exacerbate
the problem, both due to high patient demands but also perhaps by lack
of staff due to illness (or fear of illness if they come to work), personal
SURGING CRITICAL CARE RESOURCES injury, or personal tragedy at home. Thus ICUs must also surge staff.
The Task Force and others propose a “tiered strategy” to augment
Once an ICU has participated in the hospital’s plan for determining likely critical care providers. In this scheme, critical care providers supervise
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catastrophes, predicted ICU impact, and conducted realistic training knowledgeable non-ICU HCWs in providing critical care. For example,
exercises, preparations for expanding capabilities must occur in order to intensivists may supervise a team of hospitalists, while they themselves
provide care for increased numbers of critically ill patients. The initial perform only those direct care activities unique to their expertise.
goal will be to provide normal dimensions of care. Alternatively, in order Similarly ICU nurses may supervise a team of ward nurses, critical care
to reorganize care to treat increased numbers of patients, Rubinson et al pharmacists may oversee outpatient or other pharmacists, and critical
proposed a streamlined standard armamentarium of basic critical care care respiratory therapists may oversee non-ICU RTs. Preparation for
interventions to meet the needs of patients in a bioterrorist attack or this scenario requires advanced training and/or access to simplified
other similar disaster posing high demands on critical care resources. 26 “on-the-job training” in order for these non-ICU providers to assume
In 2007, the Task Force for Mass Critical Care (hereafter referred to their new roles. As an example, the United States DHHS’ Agency for
as the Task Force) met in Chicago to develop proposed mechanisms to Healthcare Research and Quality has developed such a tool to assist
surge resources to meet the needs of a variety of disasters. The princi- non-RT providers in learning the basics of mechanical ventilation. 37
pal focus was on pandemic flu due to its predicted high impact on the
model evoked the domains of “stuff, staff, and space” in order to catego- ■ SPACE
need for critical care, specifically mechanical ventilation. The proposed
rize the efforts to expand normal ICU capabilities during a disaster. 27 Finally, ICUs will need to expand their footprint in order to meet the
■ STUFF increased demand. Since many ICUs are normally at or near capacity,
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shaping that demand will be necessary to meet the needs of the influx
ICUs require an expansive and expensive array of equipment for the provi- from an event. Discharging or moving stable patients to step-down
sion of critical care. Paramount is the use of mechanical ventilators. The units, postanesthesia care areas, surgicenters, or other locations with
number of ventilators available to a facility, region, or nation is hard to limited monitoring capability may help. Canceling elective surgeries and
define, but it continues to increase. In 2010, Rubinson et al reported the procedures on patients who normally require limited postop ICU stays
median number of full-featured mechanical ventilators per 100,000 popu- is another useful strategy. Even with these measures, ICUs remain likely
lation in the United States was 19.7; many hospitals and regions also have to be overcrowded.
ventilators with less sophisticated features, such as transport ventilators, Critically ill patients have overwhelming specific monitoring and
that can be used in disaster settings. Thus, as ventilator supplies wane therapeutic needs. Currently, provision of this type of care outside health
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during an event, ICUs may have to develop other sources including repur- care facilities, such as in buildings of convenience (gymnasiums, cafete-
posing anesthesia machines, transitioning stable patients to noninvasive rias, etc) or under tents is a capability that only exists within the military.
positive pressure ventilation, or even manual ventilation for short periods. Therefore, the Task Force recommended that every effort should be
When local and region or state ventilator capacity is exhausted, made to make hospitals the focused location for the provision of emer-
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requests to the federal government through a state’s emergency manage- gency mass critical care. Surge facilities in the community as described
ment agency may result in delivery of ventilators and other stockpiled below should be reserved for stable, less ill patients. Thus to expand ICU
emergency equipment and supplies (antibiotics, nerve agent antidotes, capability, once step-down units and others have been exhausted, ward
etc) from DHHS’ Strategic National Stockpile. The ventilators in this patients should be moved to these community resources in order to
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cache have a basic set of features that streamline delivery of mechanical expand ICU care further, but within the confines of the hospital. This
ventilation and avoid the costly, labor- and knowledge-intensive aspects model can only work with predetermined, exercised plans with local
of using full-featured ventilators. Should ICUs locally or regionally disaster planning authorities and strategic partners.
decide to stockpile such devices, guidelines regarding critical capabilities
have been published elsewhere. 29,30 INTEGRATION OF ICU INTO HOSPITAL AND
The availability of oxygen is key to both the provision of critical care COMMUNITY EMERGENCY PLANNING
and mechanical ventilation. It is important to note that many of the
above-mentioned resources may be able to provide equipment, but the The ICU remains a hospital’s most valuable resource for care of criti-
“software” oxygen may not be included; this specifically applies to the SNS. cally ill patients in any level of emergency. Awareness of how the ICU
Most hospitals rely on bulk delivery and storage in on-site liquid oxygen integrates into the hospital and how the hospital thereby assimilates into

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