Rationing With Respect to Age During a Pandemic: A Comparative Analysis of State Pandemic Preparedness Plans.

BACKGROUND: Faced with possible shortages due to COVID-19, many states updated or rapidly developed crisis standards of care (CSCs) and other pandemic preparedness plans (PPPs) for rationing resources, particularly ventilators. RESEARCH QUESTION: How have US states incorporated the controversial standard of rationing by age and/or life-years into their pandemic preparedness plans? STUDY DESIGN AND METHODS: This was an investigator-initiated, textual analysis conducted from April to June 2020, querying online resources and in-state contacts to identify PPPs published by each of the 50 states and for Washington, DC. Analysis included the most recent versions of CSC documents and official state PPPs containing triage guidance as of June 2020. Plans were categorized as rationing by (A) short-term survival (≤ 1 year), (B) 1 to 5 expected life-years, (C) total life-years, (D) "fair innings," that is, specific age cutoffs, or (O) other. The primary measure was any use of age and/or life-years. Plans were further categorized on the basis of whether age/life-years was a primary consideration. RESULTS: Thirty-five states promulgated PPPs addressing the rationing of critical care resources. Seven states considered short-term prognosis, seven considered whether a patient had 1 to 5 expected life-years, 13 rationed by total life-years, and one used the fair innings principle. Seven states provided only general ethical considerations. Seventeen of the 21 plans considering age/life-years made it a primary consideration. Several plans borrowed heavily from a few common sources, although use of terminology was inconsistent. Many documents were modified in light of controversy. INTERPRETATION: Guidance with respect to rationing by age and/or life-years varied widely. More than one-half of PPPs, many following a few common models, included age/life-years as an explicit rationing criterion; the majority of these made it a primary consideration. Terminology was often vague, and many plans evolved in response to pushback. These findings have ethical implications for the care of older adults and other vulnerable populations during a pandemic.

Mass Critical Care Surge Response During COVID-19: Implementation of Contingency Strategies - A Preliminary Report of Findings From the Task Force for Mass Critical Care.

BACKGROUND: After the publication of a 2014 consensus statement regarding mass critical care during public health emergencies, much has been learned about surge responses and the care of overwhelming numbers of patients during the COVID-19 pandemic. Gaps in prior pandemic planning were identified and require modification in the midst of severe ongoing surges throughout the world. RESEARCH QUESTION: A subcommittee from The Task Force for Mass Critical Care (TFMCC) investigated the most recent COVID-19 publications coupled with TFMCC members anecdotal experience in order to formulate operational strategies to optimize contingency level care, and prevent crisis care circumstances associated with increased mortality. STUDY DESIGN AND METHODS: TFMCC adopted a modified version of established rapid guideline methodologies from the World Health Organization and the Guidelines International Network-McMaster Guideline Development Checklist. With a consensus development process incorporating expert opinion to define important questions and extract evidence, the TFMCC developed relevant pandemic surge suggestions in a structured manner, incorporating peer-reviewed literature, "gray" evidence from lay media sources, and anecdotal experiential evidence. RESULTS: Ten suggestions were identified regarding staffing, load-balancing, communication, and technology. Staffing models are suggested with resilience strategies to support critical care staff. ICU surge strategies and strain indicators are suggested to enhance ICU prioritization tactics to maintain contingency level care and to avoid crisis triage, with early transfer strategies to further load-balance care. We suggest that intensivists and hospitalists be engaged with the incident command structure to ensure two-way communication, situational awareness, and the use of technology to support critical care delivery and families of patients in ICUs. INTERPRETATION: A subcommittee from the TFMCC offers interim evidence-informed operational strategies to assist hospitals and communities to plan for and respond to surge capacity demands resulting from COVID-19.

Minimizing Population Health Loss in Times of Scarce Surgical Capacity During the Coronavirus Disease 2019 Crisis and Beyond: A Modeling Study.

OBJECTIVES: Coronavirus disease 2019 has put unprecedented pressure on healthcare systems worldwide, leading to a reduction of the available healthcare capacity. Our objective was to develop a decision model to estimate the impact of postponing semielective surgical procedures on health, to support prioritization of care from a utilitarian perspective. METHODS: A cohort state-transition model was developed and applied to 43 semielective nonpediatric surgical procedures commonly performed in academic hospitals. Scenarios of delaying surgery from 2 weeks were compared with delaying up to 1 year and no surgery at all. Model parameters were based on registries, scientific literature, and the World Health Organization Global Burden of Disease study. For each surgical procedure, the model estimated the average expected disability-adjusted life-years (DALYs) per month of delay. RESULTS: Given the best available evidence, the 2 surgical procedures associated with most DALYs owing to delay were bypass surgery for Fontaine III/IV peripheral arterial disease (0.23 DALY/month, 95% confidence interval [CI]: 0.13-0.36) and transaortic valve implantation (0.15 DALY/month, 95% CI: 0.09-0.24). The 2 surgical procedures with the least DALYs were placing a shunt for dialysis (0.01, 95% CI: 0.005-0.01) and thyroid carcinoma resection (0.01, 95% CI: 0.01-0.02). CONCLUSION: Expected health loss owing to surgical delay can be objectively calculated with our decision model based on best available evidence, which can guide prioritization of surgical procedures to minimize population health loss in times of scarcity. The model results should be placed in the context of different ethical perspectives and combined with capacity management tools to facilitate large-scale implementation.

Ramping Up a Pediatric Hospital Medicine Advanced Practice Provider Team Rapidly.

Pediatric Hospital Medicine (PHM) is a growing subspecialty with a broad scope. The Covid-19 pandemic demands flexible staffing models. Advanced practice providers (APPs) can be a valuable addition to hospital medicine teams, although there is no established training program for APPs within PHM. The authors' purpose is to describe how one institution rapidly established a PHM APP team by collaborating with experienced APPs working in other areas of the hospital. This APP team cared for 16% of the average daily census during the pilot period with no significant difference in length of stay compared to traditional teams.

Predicted Effects of Stopping COVID-19 Lockdown on Italian Hospital Demand.

OBJECTIVES: Italy has been one of the first countries to implement mitigation measures to curb the coronavirus disease 2019 (COVID-19) pandemic. There is currently a debate on when and how such measures should be loosened. To forecast the demand for hospital intensive care unit (ICU) and non-ICU beds for COVID-19 patients from May to September, we developed 2 models, assuming a gradual easing of restrictions or an intermittent lockdown. METHODS: We used a compartmental model to evaluate 2 scenarios: (A) an intermittent lockdown; (B) a gradual relaxation of the lockdown. Predicted ICU and non-ICU demand was compared with the peak in hospital bed use observed in April 2020. RESULTS: Under scenario A, while ICU demand will remain below the peak, the number of non-ICU will substantially rise and will exceed it (133%; 95% confidence interval [CI]: 94-171). Under scenario B, a rise in ICU and non-ICU demand will start in July and will progressively increase over the summer 2020, reaching 95% (95% CI: 71-121) and 237% (95% CI: 191-282) of the April peak. CONCLUSIONS: Italian hospital demand is likely to remain high in the next months. If restrictions are reduced, planning for the next several months should consider an increase in health-care resources to maintain surge capacity across the country.

How to Surge to Face the SARS-CoV-2 Outbreak: Lessons Learned From Lombardy, Italy.

Italy is fighting against one of the worst medical emergency since the 1918 Spanish Flu. Pressure on the hospitals is tremendous. As for official data on March 14th: 8372 admitted in hospitals, 1518 in intensive care units, 1441 deaths (175 more than the day before). Unfortunately, hospitals are not prepared: even where a plan for massive influx of patients is present, it usually focuses on sudden onset disaster trauma victims (the most probable case scenario), and it has not been tested, validated, or propagated to the staff. Despite this, the All Hazards Approach for management of major incidents and disasters is still valid and the "4S" theory (staff, stuff, structure, systems) for surge capacity can be guidance to respond to this disaster.

Medidas temporales para asegurar el suministro de productos necesarios para la salud durante la Emergencia Sanitaria declarada como consecuencia del COVID-19 / Temporary measures to ensure the supply of products necessary for health during the Health Emergency declared as a consequence of COVID-19

El documento contiene las medidas temporales para asegurar el suministro de productos necesarios para la salud durante la Emergencia Sanitaria declarada como consecuencia del COVID-19, así como el Decreto Supremo que la modifica (DS N° 015-2020-SA)

Translating COVID-19 Pandemic Surge Theory to Practice in the Emergency Department: How to Expand Structure.

Multiple professional societies, nongovernment and government agencies have studied the science of sudden onset disaster mass casualty incidents to create and promote surge response guidelines. The COVID-19 pandemic has presented the health-care system with challenges that have limited science to guide the staff, stuff, and structure surge response.This study reviewed the available surge science literature specifically to guide an emergency department's surge structural response using a translational science approach to answer the question: How does the concept of sudden onset mass casualty incident surge capability apply to the process to expand COVID-19 pandemic surge structure response?The available surge structural science literature was reviewed to determine the application to a pandemic response. The on-line ahead of print and print COVID-19 scientific publications, as well as gray literature were studied to learn the best available COVID-19 surge structural response science. A checklist was created to guide the emergency department team's COVID-19 surge structural response.

A Spatial and Temporal Investigation of Medical Surge in Dallas-Fort Worth During Hurricane Harvey, Texas 2017.

OBJECTIVE: When 2017 Hurricane Harvey struck the coastline of Texas on August 25, 2017, it resulted in 88 fatalities and more than US $125 billion in damage to infrastructure. The floods associated with the storm created a toxic mix of chemicals, sewage and other biohazards, and over 6 million cubic meters of garbage in Houston alone. The level of biohazard exposure and injuries from trauma among persons residing in affected areas was widespread and likely contributed to increases in emergency department (ED) visits in Houston and cities receiving hurricane evacuees. We investigated medical surge resulting from these evacuations in Dallas-Fort Worth (DFW) metroplex EDs. METHODS: We used data sourced from the North Texas Syndromic Surveillance Region 2/3 in ESSENCE to investigate ED visit surge following the storm in DFW hospitals because this area received evacuees from the 60 counties with disaster declarations due to the storm. We used the interrupted time series (ITS) analysis to estimate the magnitude and duration of the ED surge. ITS was applied to all ED visits in DFW and visits made by patients residing in any of the 60 counties with disaster declarations due to the storm. The DFW metropolitan statistical area included 55 hospitals. Time series analyses examined data from March 1, 2017-January 6, 2018 with focus on the storm impact period, August 14-September 15, 2017. Data from before, during, and after the storm were visualized spatially and temporally to characterize magnitude, duration, and spatial variation of medical surge attributable to Hurricane Harvey. RESULTS: During the study period overall, ED visits in the DFW area rose immediately by about 11% (95% CI: 9%, 13%), amounting to ~16 500 excess total visits before returning to the baseline on September 21, 2017. Visits by patients identified as residing in disaster declaration counties to DFW hospitals rose immediately by 127% (95% CI: 125%, 129%), amounting to 654 excess visits by September 29, 2017, when visits returned to the baseline. A spatial analysis revealed that evacuated patients were strongly clustered (Moran's I = 0.35, P < 0.0001) among 5 of the counties with disaster declarations in the 11-day window during the storm surge. CONCLUSIONS: The observed increase in ED visits in DFW due to Hurricane Harvey and ensuing evacuation was significant. Anticipating medical surge following large-scale hurricanes is critical for community preparedness planning. Coordinated planning across stakeholders is necessary to safeguard the population and for a skillful response to medical surge needs. Plans that address hurricane response, in particular, should have contingencies for support beyond the expected disaster areas.

Pharmacy Functionality During the Hurricane Florence Disaster.

OBJECTIVES: The aim of this study was to analyze pharmacy functionality, or the volume of operational pharmacies, among areas in North Carolina and South Carolina affected by Hurricane Florence. METHODS: Using geographic information system software and data from the Federal Emergency Management Agency and Healthcare Ready, we computed, mapped, and analyzed pharmacy functionality measures for the period of September 12, 2018, through September 20, 2018, among counties in North Carolina and South Carolina to examine health-care-related disaster readiness for and response to Hurricane Florence. RESULTS: In the Hurricane Florence-impacted region, counties located along the coast had the most suboptimal pharmacy functionality, whereas counties located more centrally within North Carolina and South Carolina had more optimal pharmacy functionality throughout the disaster. Generally, functionality was high at Hurricane Florence's landfall on September 14, 2018, for which operating pharmacy capacity was reported at 85% in North Carolina and 88% in South Carolina. Both states had the lowest functionality on September 16, 2018, at 71% for North Carolina and 62% for South Carolina. CONCLUSIONS: During the Hurricane Florence event, suboptimal pharmacy functionality was detected for coastal areas and during the disaster response period. Hurricane readiness plans and infrastructure strengthening should be emphasized for community pharmacies in hurricane-prone areas.

Hospital Safety Index analysis in Fars Province hospitals, Iran, 2015-2016.

BACKGROUND AND OBJECTIVES: Hospitals are the vital part of disaster management and their functionality should be maintained and secured. However, it can be the target of natural and man-made disasters. In Iran, Fars Province is prone to major incidents and disasters in its hospitals at any time during the course of a year. This study aimed to examine the Hospital Safety Index (HSI) in all hospitals (public and private) affiliated to Shiraz University of Medical Sciences (SUMS). MATERIALS AND METHODS: This cross-sectional study was conducted during 2015-2016, using the World Health Organization's HSI checklist. All 58 hospitals in Fars Province affiliated to SUMS were included. The hospital assessment team was formed to collect the data retrospectively and by visiting and interviewing hospital's authority based on the checklist. The collected data were analyzed using Microsoft Excel. RESULTS: The results showed that in the above-mentioned years, the structural safety of hospitals reached the highest optimal level, whereas functional safety reached the lowest level. The results of the studies conducted in 2016 showed that during this year, the overall hospital safety level improved (6 and B). CONCLUSION: Although safety in hospitals located in Fars Province has improved due to continuous disaster mitigation and preparedness activities, there is still space for more improvement to achieve and maintain higher levels of safety in hospitals. Paying attention to this, the authors recommend that proper policies, legislation, and intra and inter-institutional coordination are the requirements for a successful outcome.

Utilizing a Pediatric Disaster Coalition Model to Increase Pediatric Critical Care Surge Capacity in New York City.

A mass casualty event can result in an overwhelming number of critically injured pediatric victims that exceeds the available capacity of pediatric critical care (PCC) units, both locally and regionally. To address these gaps, the New York City (NYC) Pediatric Disaster Coalition (PDC) was established. The PDC includes experts in emergency preparedness, critical care, surgery, and emergency medicine from 18 of 25 major NYC PCC-capable hospitals. A PCC surge committee created recommendations for making additional PCC beds available with an emphasis on space, staff, stuff (equipment), and systems. The PDC assisted 15 hospitals in creating PCC surge plans by utilizing template plans and site visits. These plans created an additional 153 potential PCC surge beds. Seven hospitals tested their plans through drills. The purpose of this article was to demonstrate the need for planning for disasters involving children and to provide a stepwise, replicable model for establishing a PDC, with one of its primary goals focused on facilitating PCC surge planning. The process we describe for developing a PDC can be replicated to communities of any size, setting, or location. We offer our model as an example for other cities. (Disaster Med Public Health Preparedness. 2017;11:473-478).

Continuous Development of a Major Incident In-Hospital Victim Tracking and Tracing System, Withstanding the Challenges of Time.

OBJECTIVE: To describe the development of the Patient Barcode Registration System (PBRS) over time and confirm the usability and feasibility of the system's latest version during a large trauma drill. METHODS: The development of a PBRS started around 1993 aiming to provide an effective tool for patient registration, tracking, and tracing during major incidents. The PBRS uses wristbands with barcodes to follow and register patients in the care process. During a large trauma drill, 120 patients and 40 relatives were registered and traced in the system. Errors in registration, tracking, and tracing of persons were registered. RESULTS: Of the 120 patients, no patient data were lost and patients could be traced in real time throughout the treatment process by the command team. Strategic decisions could be made based on the information provided by the system. Patient relatives were easily matched and government agencies received regular updates on the number and characteristics of the patients. CONCLUSION: The PBRS is a usable, feasible, and sustainable patient tracking and tracing tool to be used during the hospital response to major incidents. Lessons learned during the last 20 years include the need for continuous updates to withstand the challenge of time. (Disaster Med Public Health Preparedness. 2017;11:244-250).

Hospital evacuation: Exercise versus reality.

INTRODUCTION: The Dutch Major Incident Hospital (MIH) is a standby, highly prepared, 200-bed hospital strictly reserved to provide immediate, large-scale, and emergency care for victims of disasters and major incidents. It has long-standing experience training for various major incident scenarios, including functioning as a back-up facility for the Netherlands. In 1995, the MIH had experience with overtaking an evacuated hospital when that hospital was threatened by flooding. In November 2014, an exercise was performed to transfer an evacuating hospital to the MIH. The scenario again became reality when a neighbouring hospital had to evacuate in September 2015. This article evaluates the events and compares the exercise to the real events in order to further optimise future training. METHODS: All three events were analysed using the Protocol for Reports from Major Accidents and Disasters, a standardised protocol to evaluate medical responses to a major incident. RESULTS: During the 2014 exercise, 72 patients were received, compared with 143 and 70, respectively, in the real events in 1995 and 2015. Personnel from the evacuating hospitals accompanied the patients and continued working in the MIH. The patient surge differed on all three occasions. The information technology (IT) systems proved to be more prone to fail during the real event, and legal implications to have staff from another hospital work in the MIH had to be put in protocol during the deployment. The acute phase was comparable in all three events, and performance was good. However, the exercise did not last long enough to analyse the implications on multiday care, as experienced during a multiday deployment. CONCLUSION: Large-scale major incident exercises are a great benchmark for the medical response in the acute phase of relief. The MIH was shown to be highly prepared to admit an entire evacuating hospital or large groups of patients in such a scenario. Experiences from the past, combined with regular training that closely resembles reality, guarantee the level of preparedness. Key differences between a true deployment and an exercise are the inability to train multiple days, and in our experience, a successful operation of IT systems in test environments does not guarantee their successful use during live events.

Medical Surge Capacity in Atlanta-Area Hospitals in Response to Tanker Truck Chemical Releases.

OBJECTIVE: We designed and conducted a regional full-scale exercise in 2007 to test the ability of Atlanta-area hospitals and community partners to respond to a terrorist attack involving the coordinated release of 2 dangerous chemicals (toluene diisocyanate and parathion) that were being transported through the area by tanker truck. METHODS: The exercise was designed to facilitate the activation of hospital emergency response plans and to test applicable triage, decontamination, and communications protocols. Plume modeling was conducted by using the Defense Threat Reduction Agency's (DTRA) Hazard Prediction and Assessment Capability (HPAC) V4 program. The scenario went through multiple iterations as exercise planners sought to reduce total injuries to a manageable, but stressful, level for Atlanta's health care infrastructure. RESULTS: Atlanta-area hospitals rapidly performed multiple casualty triage and were able to take in a surge of victims from the simulated attack. However, health care facilities were reticent to push the perceived manageable numbers of victims, and scenarios were modified significantly to lower the magnitude of the simulated attack. Additional coordination with community response partners and incident command training is recommended. Security at health care facilities and decontamination of arriving victims are two areas that will require continued review. CONCLUSION: Atlanta-area hospitals participated in an innovative regional exercise that pushed facilities beyond traditional scopes of practice and brought together numerous health care community response partners. Using lessons learned from this exercise coupled with subsequent real-world events and training exercises, participants have significantly enhanced preparedness levels and increased the metropolitan region's medical surge capacity in the case of a multiple casualty disaster.

Foreign medical teams: what role can they play in response to a catastrophic disaster in the US?

Hurricane Katrina demonstrated that a catastrophic event in the continental United States (US) can overwhelm domestic medical response capabilities. The recent focus on response planning for a catastrophic earthquake in the New Madrid Seismic Zone and the detonation of an improvised nuclear device also underscore the need for improved plans. The purpose of this analysis is to identify the potential role of foreign medical teams (FMTs) in providing medical response to a catastrophic event in the US. We reviewed existing policies and frameworks that address medical response to catastrophic events and humanitarian emergencies and assess current response capabilities by a variety of FMTs. While several policies and plans outline the role of the US in providing medical assistance during foreign disasters, further planning is necessary to identify how the US will integrate foreign medical assistance during a domestic catastrophic event. We provide an overview of considerations related to federal roles and responsibilities for managing and integrating FMTs into the overarching domestic medical response to a catastrophic disaster occurring in the continental US.