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Indicators and Triggers for Potential Movement to Crisis Care

John L. Hick, MD; and Dan Hanfling, MD
Updated July 17, 2020; originally published March 19, 2020

Current topic-specific issues

Hospitals should apply the conventional, contingency, and crisis framework to their critical care surge planning and look for indicators and triggers that apply to critical care practices. Key concepts include:

  • Conventional capacity: The spaces, staff, and supplies used are consistent with daily practices within the institution. These spaces and practices are used during a major mass casualty incident that triggers activation of the facility emergency operations plan.
  • Contingency capacity: The spaces, staff, and supplies used are not consistent with daily practices but provide care that is functionally equivalent to usual patient care. These spaces or practices may be used temporarily during a major mass casualty incident or on a more sustained basis during a disaster (when the demands of the incident exceed community resources).
  • Crisis capacity: Adaptive spaces, staff, and supplies are not consistent with usual standards of care, but provide sufficiency of care in the context of a catastrophic disaster (ie, provide the best possible care to patients given the circumstances and resources available). Crisis capacity activation constitutes a significant adjustment to standards of care. (Definitions from NAM)

Crisis care situations occur whenever the hospital has to balance a risk to patient or providers against the need to do the ‘greatest good for the greatest number’. Often, these are short-lived situations created by mass casualty events that are resolved with additional resources or patient transfers to rebalance resources and demand. Crisis decisions need to be made as proactively as possible at the facility level with approval of the incident commander. Ideally, these decisions should be coordinated with other similar facilities in any given region as soon as possible to avoid having one facility making crisis decisions, while others are not.

Crisis standards of care situations occur during a longer-term event, when crisis care techniques being used across a health-care system are supported by regulatory, legal, and other relief by governmental entities, and a proactive approach is taken to ensure regional consistency of medical care. These decisions are made at the regional and state level by coordinators and public officials and often involve government declarations of emergency and other official actions.

The threshold between contingency and crisis is not usually a black and white distinction – the aim should be ‘graceful degradation’ of services across a spectrum of care provided, and the hospital should plan to implement the surge techniques that place the patient and providers at least risk first, with proportional increases in risk and complexity with advancing demands of the event. Graceful degradation suggests the need to eliminate those services not fundamental or critical to the benefit of patients (eg, cosmetic surgery) so as to preserve those functions that are (eg, trauma surgery). This is particularly relevant and difficult in relation to changes to staffing necessitated by a surge situation.

Hospitals, health-care coalitions/regional construct, and states/governmental authorities should further determine indicators and triggers related to surge capacity with an emphasis on critical care resource availability and incident impact on area hospitals:

  • Indicator: A measurement, event, or other data that is a predictor of change in demand for health-care service delivery or availability of resources. This may warrant further monitoring, analysis, information sharing, and/or select implementation of emergency response system actions.
  • Trigger: A decision point based on changes in the availability of resources that requires adaptations to health-care services delivery along the care continuum (contingency, crisis, and return toward conventional). (Definitions from NAM 2013)

Indicators, such as rapidly rising hospital admission rates, school closures that affect staffing, or running short on ventilators or critical care capacity at a facility or across many facilities, should prompt actions to mitigate the situation or put proactive strategies in place before a trigger point such as no available ventilators is reached (see Table 8-1 in the IOM/NAM Crisis Standards of Care Indicators and Triggers Report and below). Note that for some issues, there is no specific ‘trigger’ point – for example, as the epidemic worsens, the overall acuity increases within the hospital and, therefore, criteria for hospital admission, criteria for admission to certain units, or use of cardiac monitoring will shift based on the demands that day – the next day may allow improved or worsened access to care depending on the trajectory of the epidemic.

Example Indicators, Triggers, and Strategies for Critical Care
Indicator Trigger Selected Strategies – Should be scaled to meet demand and minimize risk for the situation
ICU occupancy / available beds No ICU available
beds in area
  • Suspend/ review elective cases that may require post-operative ICU care
  • Create referral ‘gatekeeping’ function for hospital/coalition
  • Expand ICU care to PACU and other areas
  • Adjust criteria for ICU admission – increased acuity on stepdown and monitored units
  • Provide BiPAP on stepdown units, as incident progresses, provide care for stable ventilated patients on stepdown/intermediate units
  • Select use of cardiac monitoring for only high-risk patients
  • Provide intensive care consultation to outlying hospitals that are boarding critical patients via virtual strategies
  • ‘Load-level’ to assure consistency of care between hospitals in the area, including inter-state if applicable
  • Monitor staffing ratios and strategies across area hospitals to assure consistency of impact
Airborne Infection Isolation Rooms No AIIR rooms available
  • Create cohorted unit for infected patients – this could involve ICU only or combination of ICU and floor by using engineering controls to adjust airflow
Available ventilators No ventilators available (or using transport ventilators, other indicators)
  • Suspend/review elective cases that may require post-operative ICU care
  • Adjust criteria for intubation and weaning – in the case of COVID-19, for example
  • Aggressive use of BiPAP and other modalities understanding the potential increased risk of viral aerosols
  • Use of anesthesia machines and other modalities for ventilation
  • Regional coordination of critical care resources
  • Request for federal ventilators
  • Triage of critical care therapies (ECMO, ventilators, dialysis) as last resort based on comparisons of patients with need and based on prognostic variables of SARS-CoV2.
Available ECMO machines / circuits No ECMO units / circuits available
  • Prioritize ECMO for those with best prognosis and least expected duration based on condition/patient
  • Regional coordination of ECMO resources
  • Consider whether ECMO can be sustained as a therapy from commitment/ benefit standpoint (staffing, space, material resources vs demand for critical care)
Staffing levels / absenteeism Unable to maintain usual staffing
  • Alternative staffing models emphasizing supervisory care of critical care providers over larger numbers of patients
  • Provide child care, housing, other staff support
Distributor shortages of supplies and medications Delayed or allocated shipments inadequate to meet demand
  • Implement PPE, medication, supply conservation, adaptation, other procedures in evidence-based, proportional fashion to shortage

Regional approaches to information sharing and decision-making vary greatly depending on the structure and function of the health-care coalition/jurisdictional emergency management. It is possible, depending on the status of the epidemic, that there will be no public declarations or activation of emergency operations centers, in which case, health-care systems that depend on those functions must plan alternate communication and coordination strategies. This may alter or obviate the ‘triggers’ for governmental action or legal protections.

Regional decision-making must incorporate critical care clinician input, particularly if any resource allocation strategies for critical care are required (see the TFMCC information sheet on Triage for more information). Regional disaster medical advisory committees (RDMAC – NAM 2012) may be very helpful in this situation – membership and role should be determined prior to the epidemic. Note that other physicians will need education on these issues and the process and will need input in other domains – eg, emergency medicine, anesthesia/surgery, infectious disease. The trigger for assembling this team, as well as its members and functions, should be part of its charter/governance structure.

The health-care coalition and critical care physicians should work with their state to assure that the following are understood:

  • What data are followed to demonstrate impact on the health-care system? (eg, admission/discharge data, beds available, ICU census, use of surge spaces)
  • What data are indicators or triggers for ‘load-leveling’ (movement of patients from an overwhelmed facility to one with more resources), and how is this coordinated?
  • How do hospitals communicate current staffing patterns and ratios as indicators?
  • What are the triggers for requesting federal assets (eg, ventilators)?
  • How are intensive care and intermediate care beds in community hospitals used to prevent overload of tertiary care centers? (eg, what are their capabilities and admission criteria and how can they take transfers they might not normally, both as direct referrals and to unload more stable ICU cases from tertiary centers if required)

The regions/coalitions should have a clear understanding with the state of what regulatory or governmental actions and assistance may be required once a specific trigger point is reached. For example:

  • Ongoing use of nontraditional patient care areas may prompt request for relief of regulatory requirements for the environment of care or relief of usual requirements for reimbursement (eg, state hospital standards or CMS 1135 waiver)
  • Use of nontraditional staff (relief of licensure requirements by state boards or granting of state responder status to members of medical reserve corps, etc)
  • Requirements to triage critical care resources (request for federal assistance, release of state guidance, enactment of provider legal protections)
  • Initiation of alternate care sites (request for regulatory relief, release from state fire marshal requirements for residential facilities, liability relief for providers working in alternate care sites, assistance with obtaining supplies – financial and logistic)
  • Conservation strategies for provider PPE due to shortage (state OSHA and other agency concurrence with strategies)

Key resources for planning include:

  • 2012 IOM Crisis Standards of Care – A Systems Framework
  • 2013 IOM/NAM Crisis Standards of Care Toolkit for Indicators and Triggers
  • NAM perspective paper on CSC and coronavirus
  • ASPR TRACIE Crisis Standard of Care Topic Collection
 

Topic-specific evidence over the past 5 years

  1. US Dept of Health and Human Services Office of the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). Novel Coronavirus Resources. https://asprtracie.hhs.gov/COVID-19#covid-19-healthcare-planning-resource-collections
  2. US Dept of Health and Human Services Office of the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). Alternate care site plans (technical assistance response). https://files.asprtracie.hhs.gov/documents/aspr-tracie-ta-alternate-care-site-resources-3-23-2020.pdf . Accessed March 14, 2020.
  3. Federal Emergency Management Agency. NRCC Healthcare Resilience Task Force. Medical Operations Coordination Cells Toolkit. https://files.asprtracie.hhs.gov/documents/fema-mocc-toolkit.pdf . Accessed July 12, 2020
  4. US Dept of Health and Human Services Office of the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). Topic collection: Crisis Standards of Care. https://asprtracie.hhs.gov/technical-resources/63/crisis-standards-of-care/0. Accessed March 14, 2020.
  5. Einav S, Hick JL, Hanfling D, et al; Task Force for Mass Critical Care. Surge capacity logistics: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e17Se43S.
  6. Hick JL, Einav S, Hanfling D, Kissoon N, Dichter JR, Devereaux AV, Christian MD; Task Force for Mass Critical Care. Surge capacity principles: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4 Suppl):e1S-e16S.
  7. US Dept. of Health and Human Services Office of the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). 2017–2022 Health care preparedness and response capabilities. https://www.phe.gov/Preparedness/planning/hpp/reports/Documents/2017-2022-healthcare-pr-capablities.pdf  . Accessed March 14, 2020.
  8. Minnesota Department of Health. Patient care strategies for scarce resource situations. https://www.health.state.mn.us/communities/ep/surge/crisis/standards.pdf  . Accessed March 14, 2020.
  9. US Dept. of Health and Human Services Office of the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange (TRACIE). Healthcare coalition influenza pandemic checklist. https://files.asprtracie.hhs.gov/documents/aspr-tracie-hccpandemic-checklist-508.pdf  . Accessed March 14, 2020.
  10. Minnesota Department of Health. MN crisis standards of care framework. https://www.health.state.mn.us/communities/ep/surge/crisis/framework.pdf . Accessed March 14, 2020.
  11. Hanfling D, Hick JL, Stroud C, eds.; Committee on Crisis Standards of Care. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Institute of Medicine. Washington, DC. The National Academies Press; 2013. http://www.acphd.org/media/330265/crisis%20standards%20of%20care%20toolkit.pdf 
  12. Hanfling D, Altevogt BM, Viswanathan K, Gostin LO, eds. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Institute of Medicine. Washington, DC: The National Academies Press; 2012. http://www.nap.edu/openbook.php?record_id=13351. Accessed March 14, 2020.