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Definitive Care for the Critically Ill During a Disaster
Frequently Asked Questions
- Why was the Emergency Mass Critical Care framework developed?
The US Department of Homeland Security National Preparedness Guidelines
provide a vision for national preparedness and a systematic approach to
prioritizing disaster preparation efforts across the nation. A major element of the
guidelines is a set of 15 national planning scenarios which are meant to prioritize
disaster preparedness and response activities at the institutional, local, state, tribal,
and federal levels. At least two-thirds of these scenarios may cause hundreds or
thousands of critically ill and injured patients. Currently, most communities
would have extreme difficulty providing life-sustaining interventions to all those
in need. Urgency to reduce this important gap in disaster preparedness has been
stimulated by increasing concern for a severe influenza pandemic. To address this
unmet need, the Task Force for Mass Critical Care developed Definitive Care for
the Critically Ill During a Disaster, a framework intended to provide
comprehensive guidance for clinicians, hospitals and public health authorities
regarding the management of critically ill patients during a mass casualty critical
care event. Emergency Mass Critical Care (EMCC) was developed to provide the
best possible critical care for the most additional people, because development of
such a framework in the midst of a disaster would be difficult if not impossible.
- How is the new framework different from other disaster planning efforts?
The framework offers the most comprehensive guidance for clinicians, hospitals,
and communities in planning for and implementing a coordinated and uniform
response to mass critical care at the local, state, and federal levels. Recent disaster
plans created and/or implemented by disaster planners in New York, Minnesota,
and Ontario, Canada, have addressed mass critical care at the state level and have
focused on specific areas of EMCC, including the allocation of mechanical
ventilators. Although some elements of these EMCC plans have been
incorporated into the current framework, Definitive Care for the Critically Ill
During a Disaster, is the first to identify gaps in EMCC planning and utilize a
broad representation of experts to address these gaps. It also is the first to address
EMCC surge capacity and allocation of scarce resources at the local, state, and
federal levels.
- Which groups are included in the task force?
The task force consists of 37 senior-level participants with broad expertise
relevant to EMCC in fields such as bioethics, critical care, disaster preparedness
and response, emergency medical services, emergency medicine, infectiousdiseases, hospital medicine, law, military medicine, nursing, pharmacy,
respiratory care, and local, state, and federal government planning and response.
- What is the goal of this framework?
The framework provides the necessary foundation to aid clinicians, hospitals, and
disaster planners in providing a coordinated and uniform response to mass critical
care. EMCC is intended to expand the capacity for people to receive lifesustaining
interventions during a large-scale disaster.
- What is surge capacity?
Medical surge capacity refers to the additional quantity of medical care that
health-care systems can provide in response to increasing need.
- Is the framework evidence-based?
The framework and suggestions cannot be based directly on evidence from mass
critical care events, because modern health-care systems have not, to date,
responded to such events. However, the predominant clinical syndromes
anticipated during these events are similar to those seen everyday in ICUs. Any
relevant data from previous disasters, as well as from typical work in ICUs, was
used in the development of the framework. The framework ultimately represents
expert opinion, so members of the task force were chosen for their extensive
experience and knowledge across a number of fields relevant to critical care and
disaster medicine. This selection ensures that the suggestions were derived from a
broad range of expertise.
- How is an EMCC event declared?
Before the decision to implement EMCC can be made, a trigger event must
produce conditions necessitating EMCC, such that many patients who are
critically ill may be harmed unless there is a change from everyday critical care
protocol. Some jurisdictions may require a declared state of emergency. The
decision to initiate EMCC, as well as the allocation of scarce resources, should
occur in conjunction with the existing local and regional emergency management
infrastructure. An example of a decision-making entity would be a public health
department who can receive expert consultation from predesignated health-care
institutional representatives.
- Is this framework a mandate for hospitals to follow?
The task force suggestions were developed to guide disaster but are not intended
as strict policy mandates.
- What advance critical care preparations are suggested for hospitals?
The task force suggests that hospitals with ICUs aim to meet several standards,
including the ability to provide sufficient critical care for at least triple the usual
ICU capacity and the ability to sustain the surge capacity for 10 days withoutexternal assistance. Suggested surge capacity requirements include ensuring
sufficient medical equipment, including mechanical ventilators; optimizing
medication use; designating auxiliary critical care areas; and augmenting critical
care staff. A full description of suggested surge capacity goals is listed in
Definitive Care for the Critically Ill During a Disaster: Medical Resources for
Surge Capacity.
- Will patients be denied care during times of mass critical care?
If everyday care is sufficient to meet every patient’s needs, then EMCC will not
be initiated. If additional surge capacity is needed, then EMCC will be
implemented to increase the number of patients who have access to potentially
life-sustaining critical care. If EMCC is still insufficient to meet everyone’s
needs, then prioritization of patients and allocation of scarce critical care
resources will be instituted. During all circumstances, care processes to minimize
pain and suffering, even for those unable to receive life-sustaining care, will be a
priority.
- Does allocation of scarce resources mean rationing?
Yes. However, the task force advises the rationing of scarce critical care resources
only after the surge capacity has been exceeded and all attempts to use outside
resources have been made. Rationing of critical care resources will be based on
objective medical criteria.
- Who manages the allocation of scarce resources?
The task force suggests that a triage officer and support team implement and
coordinate the distribution of scarce resources. The triage officer assesses and
prioritizes all patients and directs attention to the highest-priority patients. The
triage officer is expected to make decisions that benefit the greatest number of
patients, given potentially limited resources.
- How will fairness be ensured during the rationing of critical care resources?
During EMCC, patients will be treated equally based on objective, physiologic
criteria. When these criteria do not clearly favor a particular patient, “first-come,
first-served” rules will apply. Preferential distribution of critical care resources for
any population group, including health-care workers, is not advised.
- What will be done for patients who do not qualify for immediate critical
care?
During times of EMCC, patients who do not qualify for immediate critical care
will be offered basic medical and palliative care.
- Will clinicians and hospitals be legally protected for providing care during
EMCC events?
The task force suggests that clinicians who follow accepted EMCC protocols be
legally protected for provided care during times of EMCC. Even when following
accepted protocols, clinicians are not guaranteed exoneration for patient care
decisions made during EMCC. Government endorsement of EMCC planning,
implementation, and resource allocation is needed in order to shield practitioners
and institutions acting in good faith from liability.
- What are the next steps for the framework?
The framework serves as the beginning of the EMCC planning process. Hospitals,
communities, and government groups must take the next steps to implement the
framework.
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