PREPARING YOUR ICU FOR DISASTER RESPONSE J. Christopher Farmer, MD, FCCM, Editor Randy S. Wax, MD, FCCM, Editor Marie R. Baldisseri, MD, FCCM, Editor ix CONTENTS FOREWORD xi CHAPTER ONE What Matters? The Role of an ICU During Disaster 1 D. E. Amundson, MS, DO, FCCM; Mary J. Reed, MD, FCCM TWO Assessing Your ICU: Are You Ready to Respond to Disaster? 9 John S. Parrish, MD; Jeffry L. Kashuk, MD THREE Leadership During a Disaster 23 Asha Devereaux, MD, MPH; Jeffrey R. Dichter, MD FOUR Building an ICU Response Plan for Disasters 49 Christian Sandrock, MD, MPH, FCCP FIVE Implementing an Effective ICU Disaster Response Plan 67 Vincent M. Nicolais, MD, Macp, FCCM; Elizabeth Bridges, PhD, RN, CCNS, FAAN, FCCM SIX Communication During Disaster 79 James A. Geiling, MD, FCCM SEVEN How to Build ICU Surge Capacity 93 Lisa Burry, PharmD; Dauryne L. Shaffer, MSN EIGHT Ethical Decision Making in Disasters: Key Ethical Principles 107 and the Role of the Ethics Committee Dan R. Thompson, MD, MA, Facp, FCCM NINE Behavioral Health Issues 117 Merritt Schreiber, PhD; Sandra Stark Shields, LMFT, ATR-BC, CTS; Dan Hanfling, MD TEN Pediatric Considerations: What Is Needed in My ICU to 127 Care for These Casualties? Dana A. Braner, MD, FCCM; JoDee M. Anderson, MD, MEd APPENDIX ONE Disaster Education and Training Resources 141 Abhijit Duggal, MD, MPH, Facp; Jonathan Simmons, DO, MS; Pablo A. Perez D’Empaire, MD TWO Additional Resources and Websites 151 Brittany A. Williams, MS, Bsrt, NREMT-P x THREE Clinical Strategies During Disaster Response 155 John L. Hick, MD FOUR Developing an ICU Supply and Other Templates for 173 Disaster Response Lisa Burry, PharmD; Jana A. Stockwell, MD, FAAP, FCCM; Babak Sarani, MD, Facs, FCCM; Catherine Goulding, BScPhm, ACPR FIVE Scenario-Based Pandemic Planning Templates 185 Curtis F. Buck, CRNA, Rrt; J. Christopher Farmer, MD, FCCM SIX Communication Templates 199 James A. Geiling, MD, FCCM; Maureen A. Madden, MSN, PNP-AC, CCRN, FCCM SEVEN Rush University Medical Center Communication Protocols 203 for Nursing Personnel Ruth M. Kleinpell, PhD, RN, FCCM EIGHT ICU Lessons from a Mass Casualty Incident 207 James A. Geiling, MD, FCCM NINE Long-Term ICU and Healthcare Lessons Learned from 211 the 2003 SARS Pandemic Michael D. Christian, MD, MSc, FRCPC TEN Complex ICU Issues that Arise During an Influenza Pandemic 219 Anand Kumar, MD, FCCM; Omar Rahman, MD ELEVEN The 2011 Japan Earthquake and Tsunami: Lessons Learned 227 from the Loss of Medical Infrastructure Makoto Uchiyama, DO; Lewis L. Low, MD, FCCM TWELVE Mount Sinai Hospital ICU Disaster Response Plan 231 Lynn M. Varga, BScN, MEd, CNCC(C), RN, Jocelyn Bennett, MScN, RN; Karen Baguley, MScN, RN; Cynthia Harris, HBSc, RRT; Stephen E. Lapinsky, MD; Lisa Burry, PharmD; Leah Steinberg, BA, MA, MD, CCFP; Alison Gilmour, MN, PNC(C), RN; Leanne Verscheure, BScN, MEd, GNCC, RN INDEX 267 xi FOREWORD One cannot plan when disaster will strike, but you should be prepared when it does. Is your ICU ready? Where do you begin? What are the necessary tasks and priorities? How do you optimally manage the incoming flow of critically ill and injured patients? The Society of Critical Care Medicine recognizes that many ICUs lack a systems approach to forecast response to an external disaster that effects their unit. To ensure a smooth response, ICU professionals must take into account resource utilization, staffing, triaging patients, communications strategies, and other important issues for their ICU so that surge capacity planning strategies are accurate and timely. Preparing Your ICU for Disaster Response was developed to answer these needs. This guidebook will help ICU professionals assess their current levels of ICU preparedness, as well as provide resources for strategizing and implementing a standing plan for disaster preparedness. The information included will help to align your ICU disaster response within your institutional disaster preparedness plan. It also offers tips regarding how to translate your ICU plan to accommodate specific resource needs in the event of a critical care surge. Presented in an easy-to-follow design, key information in the chapters is presented in box format among five categories: General Concepts Action Items Communication Advice Disaster Tips Case Study xii The icons associated with these categories appear throughout the book to guide readers to the type of information they need. Appendix 1-Appendix 12 also supplement this toolkit with additional resources, templates, protocols, case studies, and sample plans to use when preparing your ICU disaster response plan. The development of this book could not have been possible without the continued involvement of the individuals listed as contributors. They are experts in critical care medicine and disaster response, and we thank them for their time and dedication to the project. Unfortunately, disaster happens. When it does, have a plan and be prepared. Use this resource as a guide to equip your ICU with the appropriate disaster response. J. Christopher Farmer, MD, FCCM Randy S. Wax, MD, FCCM Marie R. Baldisseri, MD, FCCM CHAPTER 1 1 WHAT MATTERS? THE ROLE OF AN ICU DUCHAPTERRING DISASTER ONE WHAT MATTERS? THE ROLE OF AN ICU DURING DISASTER Is disaster preparedness important? Why devote You should use this scarce ICU resources to preparedness activities? chapter as a(n): ■ Although a disaster affecting your ICU is a low probability, if ■ Introduction to the one does occur, it likely will be a high-consequence event. role of the ICU during disaster response ■ Remember, preparation does not necessarily mean that you must buy “things.” Spending money does not always equal ■ Starting point improved response capabilities. Preparation may be limited for developing to planning, education, and training, which are cost-effective an ICU disaster measures. preparedness plan ■ If you want a candid answer to these questions, ask someone ■ Guide for how to who has experienced a disaster that impacted their hospital use this publication and ICU. Consider the case in Box 1-1. to improve disaster response in your ICU Box 1-1. Case Study: A Real Tragedy On February 20, 2003, a fire broke out in a crowded nightclub in West Warwick, Rhode Island. In less than 10 minutes, the club was engulfed in flames. More than 450 people were in the nightclub; about half were injured from burns, smoke inhalation, and trauma resulting from trampling. Within the first hours, more than 40 critically ill patients were transported to the nearest hospital two miles away. Transportation by ambulance and private vehicle made consistent communication difficult.T he 350- bed institution nearly ran out of ventilators because the majority of the initial patients needed intubation for smoke inhalation and facial burns. The pharmacy dispensed one gram of 1 2 CHAPTER 1 WHAT MATTERS? THE ROLE OF AN ICU DURING DISASTER morphine in 4 hours’ time, approximately 3 months’ supply in normal circumstances. Although the hospital was less than 15 miles from Providence, Rhode Island, and the weather was clear, nearly 5 hours lapsed before any transfers of critically ill patients to other institutions occurred; these centers needed time to make room in their own ICUs to accommodate incoming patients. To further complicate communications, 200 family members needed to be informed of the status of their loved ones’ injuries, and emotional support needed to be provided.1 Consider the logistics of this disaster response—if one conservatively estimates that each critically ill patient received 3 L of IV fluid while at the first hospital, a total of 120 L of IV fluid was required during the first 4 hours after the event. Additionally, how many personnel were needed to provide care for 40 critically ill patients during the first few hours of resuscitation, when the patients were the most unstable? If patient transfers had been delayed due to inclement weather for a full 24 hours, the logistical strain for basic resuscitation supplies, medications, and personnel would have become a second disaster. If a disaster occurs, what makes the greatest difference for an ICU? How do we ensure a successful response? ■ Pre-event planning for ICUs is essential and is the most important variable to ensure a successful disaster medical response. ■ Staff education and training are the most effective modalities to enhance ICU preparedness. ■ This publication is intended as a toolkit to help critical care directors and hospital administrators review, analyze, and ameliorate potential gaps in the ability to surge critical care services expeditiously. CHAPTER 1 3 WHAT MATTERS? THE ROLE OF AN ICU DURING DISASTER What is disaster medicine, and how many ICU patients (casualties) constitute a disaster? Disaster medicine is the coordinated medical response to an unexpected disruption of the normal system of healthcare delivery. The goal of a disaster medical response is to mitigate death, disease, and further injury. Over the last decade, multiple events have repeatedly demonstrated that local critical care services may be quickly strained or overwhelmed with a minimal to moderate influx of unstable patients. Several contributing factors have been cited: ■ Increased need for critical care services as our population ages, combined with decreased availability of critical care providers of all disciplines, has resulted in near-capacity occupancy of intensive care beds on a consistent basis. ■ Monetary constraints have led to the elimination of healthcare services in many communities, placing further strain on those that remain. ■ Hospitals do not normally maintain a surplus of critical care supplies because overstocking increases cost. Just-in-time supply processes keep stocks to a minimum and much of the durable equipment is rented rather than purchased to decrease required expenses for maintenance and storage. ■ These and other factors contribute to the inability of many institutions to handle patient surges and sustain care for the unexpected critically ill and injured.