From Flu Wiki 2

Forum: Need Triage Criteria for Hosp ATS

19 October 2006

FloridaGirlat 17:24

I am looking for any guidelines that deal with triage criteria that would determine admittance of patients to either a hospital, an alternative Treatment Site ATS (or Facility) ATF, or sent home for homecare…. in the event of a pandemic situation.

Ideally, the liturature would be either from a peer review source; in the form of evidence based practice guidelines; or recommendations from the CDC, a State government, WHO, or any other recognized, official group.

Any help would be appreciated.

Sniffles – at 17:32

FloridaGirl, I am not aware of anything that has been developed at this point. I have asked a few hospital administrators questions similar to what you were asking above and they did not know how they would do it - they didn’t have anything in writing and it didn’t sound like they were going to do so. Although not specifically stated, part of the problem may be fear of lawsuits (related to turning patients away, inability to treat them, prioritizing patient care/rationing, etc.). IMHO, it may be difficult finding this information in writing (and open for public viewing) at this point.

Leo7 – at 18:00

Floridagirl:

If you find any please share. If they exist no one has seen them.

crfullmoon – at 18:04

Was there anything useful in the Guidance for Medical Reserve Corps units? pandemicflu.gov pdf

ok- not what you’re looking for; “hard descisions must be made” was as far as they got.

Wait - no; doesn’t say what the pre-established criteria is though: EMS from pandemicflu.gov: …”A plan has been developed for triage and management of patients during a pandemic that includes the following:

A system for phone triage of patients calling 911 or other emergency numbers that might be used (provide/post list of appropriate numbers) that includes pre-established criteria and coordination protocols to determine who needs emergency transport. The system includes points of referral for patients who do not need emergency transport.

A plan for coordination with receiving facilities (e.g., hospital emergency departments), other EMS and non-emergent (medical) transport organizations, and local planning groups to manage the transportation of large numbers of patients at the height of the pandemic.

A policy and procedure for transporting multiple patients with pandemic influenza during a single ambulance run.

The plan considers the possible necessity of sharing transportation resources or using vehicles other than those designed for emergency or medical transport (e.g., buses).”

That is only the federal to-do list; I guess all these places are supposed to have been working on these tough issues over the past several months…

Guess I’ll quit looking for now and make supper. Probably I’m not looking in the right places…

This is from Massachusetts Dept.Public Health / Massachusetts Hospital Association (sorry- I have no clue what I want to make for supper)

FAQ about ISCUs pdf version

…”8. How will people know which ISCU to go to?

Once the clusters have been defined and the ISCU sites identified, the local communities and hospitals can begin to develop their public education campaigns to ensure clear and accurate public education materials to direct residents to the most appropriate site of care.

9. What kind of care will be provided in an ISCU?

ISCUs will provide supportive flu care only. Due to financial and logistical constraints, staffing concerns, and supply chain issues, there will be no mechanical ventilation supplied in ISCUs. The use of room air oxygen concentrators will provide low flow oxygen in addition to intravenous fluids,antibiotics and other supportive care. Patients admitted to an ISCU that develop the need for more criticalcare will be transported to the ISCU’s acute care hospital. The provision of a specified level of care for a single diagnosis will permit the pre-stockpiling of equipment, supplies and pharmaceuticals, as well as training of volunteers.

10. How will patients arrive at the ISCU?

Each ISCU will have a triage/evaluation area associated with it. Patients will arrive at the evaluation center where they will be screened and triaged.

Most patients will be cared for at home.

Some may receive short term treatment, such as a few hours of intravenous treatment.

Patients arriving at the ISCU evaluation center that need critical care will be transported from the ISCU directly to the hospital as long as hospital capacity exists.

Those that are too sick to go home and those for whom home care is not possible, but who are not sick enough to require an acute care hospital bed, will be admitted directly into the ISCU.

In addition, ambulances will be permitted under a special waiver to transport a patient directly to an ISCU rather than the hospital.

11. Will all non-critical flu patients in the cluster be directed to the ISCU?

While we are planning on only one ISCU per hospital cluster, we anticipate that there will be a need for additional clinical evaluation and flu information centers. Many residents who are only mildly ill, or are not ill themselves, may need a place to get support, information, advice, or behavioral health assistance in coping with the impact of the pandemic and the associated fear and anxiety.

Therefore, the numbers of persons seeking help is likely to be greater than the ISCU evaluation center can handle.

Therefore, we will be working with communities to identify sites and staffing for additional triage/evaluation centers.

However, all flu patients that require hospital level care will still be admitted to either the acute care hospital if critical, or the ISCU if non-critical”…

FloridaGirlat 19:22

Well, crfullmoon – at 18:04

Pretty much, that is what we have also… However, we are also planning on providing support for those at home via phones with RN’s and MD’s.

The ATF have been chosen… with emphamsis on the flow of patients back and forth between the two based on the level of care needed.

What is needed now are guidelines of some sort that will give the physicians the clinical guidance, the ethical permission, and the accepted decision-making process that they will have to use at various stages of a pandemic.

The process will not work if ALL physicians are not adhering to established guidelines. This is more easily agreed upon before a pandemic.

Additionally, if there is not community involvement, it may appear biased, or preferencial treatment was given…. When in effect, it probably will be the best of a bad situation.

I KNOW there are guidelines out there… I have been told of them. I just haven’t seen them. If I need to share an email address, I certainly will……

Thanks

LMWatBullRunat 20:02

Once this starts, if it is only as bad as 1918, 5–10% of your citizen population will be seriously ill every week. If the CFR is only as bad as 1918, around .25 percent of your local population will die. Half the remainder of the sick will be in hospital for at least 3–4 weeks.

Lets do the math. Assume 100,000 population and 1 hospital. This means that the first week, you will see 5,000 seriously ill patients, of which 125 will die. About half of the survivors will need hospitalization for an extended period or around 2500.

No hospital I know of is ready for such numbers. I predict that in the event, regardless of what protocol is on paper, the following protocol will actually be in use-

Politicians, police and EMTs will be treated as there are facilities and staff available;

cyanotic patients will be sent home to die;

Less severely ill patients will be admitted as space is available, which means never, so will be sent home to recuperate as they can;

the rest will be sent home to recuperate.

To be brutally frank I have NO expectation that the present medical system or most of the current HCW will survive a severe pandemic. 3 days into the pandemic every hospital will be overrun, regardless of triage protocols. The doctors and nurses that don’t die from the flu will be killed by rioters in the civil unrest that will follow the collapse of the health care system. The only way that the hospitals are not going to be overrun is if there are sufficient Guard troops with enough ammo to stop any rioting.

My bet is that I’d have a better chance at home if I were ill than in a hospital, even if I were home alone.

anonymous – at 20:05

FloridaGirl,

I haven’t actively searched for guidelines, but if you find any, please post all details, because we need to examine the assumptions upon which those guidelines are based. I suspect we will find most of those won’t stand up to scrutiny.

Now, I’m writing this not for the purpose of knocking people, but for 2 things, one negative and one positive. We need to point out and challenge those who try to get by with fudging the issue, and we need to use the basis of what they do have experience about, to build on that and make plans that have a better chance of working.

Modifying imperfect plans is probably going to be a lot faster and easier (eg to get consensus) than writing new untested ones.

From the stuff that I do know about, I have a sense that at the very senior level, they are only just waking up to the fact that hard triage is going to be for real. Whatever’s already been written is probably based on ‘normal’ public health experience. We will be very lucky if we don’t need anything else that requires a great deal of ingenuity and compromise.

There is an upside to the fact that serious debate is only just starting, which is that chances are plans are not yet set in stone. We still have a chance of advocating for alternatives if they are unsatisfactory.

One final thing, maybe someone can start this as a FluWiki project, like the ‘patient support group’ thread that flumonitor has started. Someone can write up a framework with items/issues that need to be considered, we can brainstorm various solutions, and then debate the ethics and efficacy of each kind of solution.

We won’t find the perfect solution, but we gotta start somewhere. And it could start at FluWiki…..Just sayin…

anon_22 – at 20:07

that was me, lost my cookies.

you think maybe someone ate them? lol

FloridaGirlat 20:32

Anon_22 @ 20:05

Anon_22, I am actually surprised that you are the one who wrote the above. Please do not take it wrong, but understanding the situation, the options, the choices, and how the system works is paramount to knowing just how difficult these decisions are going to be for our physicians. Surely, you do not think that given the limited support from anyone higher than the hospital level, our physicians have many choices at all.

You wrote:

“We need to point out and challenge those who try to get by with fudging the issue, and we need to use the basis of what they do have experience about, to build on that and make plans that have a better chance of working.”

I would question respectively, why you would think a hospital would try to “get by with fudging the issue”. We are painfully aware at our hospital, that we will be taking care of patient populations we do not have experience in…. Why? Because every other hospital around will have the same problems. We will not be able to transfer patients during certain periods of a pandemic.

We are trying to take care of our community in every way possible.

You wrote:

“We still have a chance of advocating for alternatives if they are unsatisfactory.”

“Advocating for alternatives” is fine as long as the alternatives are possible. But, do you not think that the best people to know if something is possible are those most famililar with the process, the clinical aspect, the emotional challenge, the social impact and / or consequences?

Someone advocating for alternatives should be prepared to offer viable alternatives…. not just say, “that is not good enough”. Besides, one of the primary reasons we are looking for this information now is to solicit community input. This is not going to be a unilateral decision.

“One final thing, maybe someone can start this as a FluWiki project, like the ‘patient support group’ thread that flumonitor has started. Someone can write up a framework with items/issues that need to be considered, we can brainstorm various solutions, and then debate the ethics and efficacy of each kind of solution.”

I may do that near the end of November… Perhaps you will help?

LMWatBullRun – at 20:02

I do not think about NOT succeeding. That is not part of my make-up. I will do my best, no matter how the dark the senario looks.

One never wins without trying. That is the least I can do. If things fall apart, so be it.

My hope is that we can have a good enough plan in place that can be adjusted up or down as the situation warrents.

Will it be Chaos? maybe… But, it may be that we will still save lives…

Bump - Bronco Bill – at 20:42
ICP – at 21:04

I have not seen any specific criteria for triage in any plans that I have reviewed in my state or other state plans that I researched while writing my draft plan for my facility. Unless an extremely aggressive facility with a legal team willing to put themselves out on a limb sets the precedent for it, or a regulatory agency sets a standard for us, most facilities will write plans that are very vague in the triage language due to fears of legal issues just to have a plan on paper and pray like heck they never really have to use it. Sort of like many of the others we already have…:>)

FloridaGirlat 21:26

ICP – at 21:04

You may be right. Our County plans are becoming very detailed in what we will do under certain circumstances. Our hospital plans (general), build on the county plans, so they compliment each other.

We are going to work with the area LTC facilities, and help them develop plans that will be in line with both the hospital and county plans.

I suppose I will just have to write something that will take into consideration the clinical aspects, the affected population, the ethical issues, and make it flow into a step process that will help clinicians decide who will be treated at which location, etc. The ventillator decisions will have to be made on a case by case basis anyway.

Ventilator criteria is pretty cut and dry….. either you need it or you don’t. I would like to see some information on CPAP, and any studies that may contribute some insight on their use with influenza or ARDS patients.

Prognosis would have to be part of that criteria, as it is my understanding that patients average 7 to 9 days on the vent. (Unfortunately, sometimes determining the prognosis may be interepreted as subjective.)

Co-morbidities may also be used as criteria for selecting patients for the limited vents. However, that may also be construted as “favoring” the younger population, as the elder populations historically have more co-morbidities.

OK.. just thinking out loud…. That usually gets me in trouble…

anon_22 – at 23:19

FloridaGirl,

Well, as us Brits would say, you completely got hold of the wrong end of the stick. :-)

I would question respectively, why you would think a hospital would try to “get by with fudging the issue”.

I’m not saying that people are fudging the issue, since like you I have not found any guidelines to examine for that determination (although there would always be a certain proportion of policymakers at every level who instinctively prefer fudging, at least theoretically but I believe actually.).

All I’m saying is that this question is so crucial that we need to make sure that they don’t.

I would also respectfully add that it’s best to not take good intentions for granted. And even genuine good intentions don’t always translate into good policies.

All I’m saying is that this is so important that we must not accept anybody’s goodwill as sign of competence, nor apparent competence/efficiency as sign of goodwill.

So if we find anything, let’s use each other’s insights and experience to critique and thereby improve on whatever we find. Any ‘alternatives’ will be subject to the same level of critique.

FloridaGirlat 23:54

anon_22 – at 23:19

OK… Deal…

(Sorry, Lady Brit… I did not realize you were speaking of policy-makers…) I do not hold with most of the current policy-makers, which is why I am working so hard to make it work for our county and in particular, my hospital.

And you are right, it is crucial…. and it is one area that has the potential to ruin good doctors. I do not want to see that happen.

As far as goodwill and competence…. Even MY good intentions may turn out to be wrong. I certainly hope not… but, I do not have the final say in this. I can only provide them with the liturature for them to make those decisions. I can advise… They do listen to what I have to say… (for the most part).

And like I wrote above, it may be I will have to provide them with something vague, with guidelines only suggested.

But, right now… I am at square one.

So if anyone knows of anything that may contribute to informed decision-making at the physician or hospital level, I would certainly appreciate the assistance.

20 October 2006

anon_22 – at 00:08

FloridaGirl, sounds like you are already more informed than most of us. It would be very beneficial if you can write up your thinking about this, like concepts, considerations etc. Including problems/issues that you haven’t figured out how to solve yet.

A lot of people either are or will soon have to be working on this extremely difficult subject. I’m absolutely sure that it is so complex that no one person or small group of people can solve it satisfactorily. That’s where the wiki model comes in useful, that you can use non-local talent to solve local problems.

You’ll probably feel that your thoughts on this subject are not mature yet (why else would you want to start this thread?), but they are certainly further along than others. Other people’s incomplete ideas are good places to start.

FloridaGirlat 00:21

anon_22 – at 00:08

I am studying furiously, right now. But, this request of information is related to work, so I will see what I can do.

The first part of November, the issue with a possible basic outline will be presented to the doc’s.

I am somewhat informed… enough to know that much has been done, but not enough is being shared.

And my “thoughts” on this subject are not really the ones that are important. Unfortunately, the reality is, we do not have everything we need to make it work. If we do not have community involement in these decisions, it will fail.

Any model that is created, HAS to be flexible, yet rigid. It has to be fluid, to be able to work with the different phases of a wave.

I will work on something …. Give me some time though….

anon_22 – at 00:28

If we do not have community involement in these decisions, it will fail.

Can you outline your reasoning for that? Or email that to me cos this is directly related to what will be discussed next week in the National Academies roundtable re citizen engagement and IOM meeting, also discussed here

If we can make the case as you stated, it will help a lot, even as an example. Whatever is appropriate to share, of course.

anon_22 – at 00:36

FloridaGirl,

Check this out Singapore Revises Pandemic Flu Plan.

Both Hong Kong and Singapore, small rich urban societies with experience dealing with SARS, have come to the same conclusion that some sort of different/additional setup to see flu patients specifically and away from hospitals will be necessary. Hong Kong has completed preparations for ‘fever clinics’ with high power air extraction, one way flow system, etc. It may or may not apply in your community but I suspect for urban areas, something like this will be needed to do take the primary triage away from hospitals, if you want to keep them open.

Swann – at 00:42

After reading this article about Fort Wayne, Indiana’s draft flu plan, Monotreme said he has added Fort Wayne to his list of cities he believes will survive a severe pandemic. You may find something by following up, so here’s the link to the article. Luck!

http://tinyurl.com/hr2ds

Leo7 – at 01:33

FloridaGirl,

I’m seeing writing some guidelines for local people to discuss in your future. I do agree with ICP that exposure of triage plans (let’s face it it’s a rough call) is a legal nightmare. One recent Canadian poster demanded to know how dialysis and chemo would be delivered and called it unfair. People still debating who should get the non existent vaccines even get upset. Discrimination is rampant in emergencies. However, triage is based on the simple premise of saving as many as you can with what you have. It’s not a touchy feely premise—it’s cold stark reality.

 Everyday in almost every hospital a physcian shows up in intensive care to move the least sick patient out to a floor or step down, to free a critical bed for someone waiting in the ED.  Sometimes, the one chosen , worsens and dies because critical care is there for a reason, close monitoring.  Medical people should write the plans not special interest groups.  Good Luck, it won’t be easy.  Maybe you can get input from retired ED doctors.  They have the experience and wisdom of aging and needing health care, like a focus group for advice.  Let us know what you decide to use for criteria.
crfullmoon – at 07:09

Life is unfair. Look at all the past deaths in earthquakes, pandemics, epidemics, countries today that have rich pampered leaders and citizens having short life expectancies and dying with no preventative nor intervening health care for them, places that have excellent care for the rich, health insurance for some, no coverage for others. We are just another animal species on the planet, and human civilizations have risen, felt very modern and smug, and, fallen, for past thousands of years.

“triage criteria that would determine admittance of patients to either a hospital, an alternative Treatment Site ATS (or Facility) ATF, or sent home for homecare…. in the event of a pandemic situation.”

I’d sort of think it would all have to go backwards from what can the hospital still handle?

Are they keeping isolated maternity facilities, or, still treating first responders/essential workers who need surgery or heart attack care, ect?

Does the hospital have staff, supplies, power, to take more ICU patients?

Does the Influenza Specialty Care Unit (ATF) have staff, supplies, and power to provide care to more cases?

If there is no capacity, what will callers, or people who bring family members in, be told to do instead?

“cyanotic patients will be sent home to die” Isn’t that an extra logistical step? If they are there already, will there be separate “hospice tents” ? (And where, local, non-hcw, officials, are the preparations for fatality surges & paperwork & gravedigging?)

Start planning backwards; from when systems fail ; sounds like in worst-case that would happen before pandemic was over, so, why start from doing all the paperwork, careful, by-the-current-book plans for, “if the hurricane is Cat 1 at landfall, if at Cat.2 at landfall, ect..?

Too many of the public still don’t have any idea pandemic is possible in their world, nor that people may very well die because we don’t know everything about viruses, the world is an imperfect place where people don’t follow even safety rules - so, we aren’t “so modern” “pandemic isn’t possible”, or “is containable”, and there just may be so many sick that beds, meds, vents, and staff may run out.

They have no idea what the current H5N1 case fatality rate is now, nor that “that bird flu thing?” has not gone away. Politicians, and health departments, and other officials, who didn’t want the public to know, bear responsibility.

(gets down off soapbox, puts it over head and wanders off…trying to imagine how trying to call up and ask for the triage criteria would go - either people don’t have a clue, or, they are swore to secrecy, seems like. Neither category wants that phone call…)

ICP – at 08:20

FG:

We are in a rural area but our plan basically calls for triage outside of the main facility by trained staff, yada, yada, to a designated area for patients suspected of having PI…. We have a wellness/rehab center the hospital owns next door that will be used for flu patients so that the main hospital will hopefully be reserved for non-flu patients, such as surgical cases, OB, cardiac, etc. Non-critical patients will be triaged to outlying facilities set up as flu clinics beginning in an outer perimeter from the hospital and working outward into the county (which is very large and made up of several subdivisions with their own police depts, high schools, etc.)

As far as specific triage guidelines, for: Assessment, vital signs, age, prognosis: assign to this area for this level of treatment, there is nothing other than a vague statement that appropriate triage will be done. If it happens tomorrow, that call will be left up to the person stepping up to car at that particular time, unfortunately.

Let’s hope that the American College of Emergency Physicians (ACEP) or some other professional organization will take this bull by the horns (they usually are pretty prompt in issuing a position statement)and get a fire under someone to call attention to this so that some sort of universal standards can be considered before this gets out of hand. We are all going to be flying by the seat of our pants the best we can do but it will be sad that one locale may be flying a little smoother than others when we could all be crashing at the same speed.

FloridaGirlat 16:48

anon_22 – at 00:28 Can you outline your reasoning for that?

Yes, I certainly can. I will get you the info either tonight or in the morning. There is some risk communication guidelines that deal with this; there is also a couple of guidelines that discuss this. I will locate them.

Leo7 – at 01:33 Maybe you can get input from retired ED doctors. They have the experience and wisdom of aging and needing health care, like a focus group for advice.

We have retired doctors on our county committee and our hospital planning committee. They are a big help in being blunt about the realities.

crfullmoon – at 07:09 I’d sort of think it would all have to go backwards from what can the hospital still handle? The plan is based in a staging fashion, where it can be changed easily, depending on the need.

Are they keeping isolated maternity facilities, or, still treating first responders/essential workers who need surgery or heart attack care, ect? yes, this is a must.

Does the hospital have staff, supplies, power, to take more ICU patients? Staff will be moved as needed from other units or departments. Supplies are going to be held in an emergency order, we have no choice here. If power fails, we have backup generators… as long as the plan for fuel(emergency) does not fail, this will be fine. ICU paitients? Unless we get venilators from the State or another source, we will not be able to take anymore patients on vents… If they just need ICU care, then we can handle that.

Does the Influenza Specialty Care Unit (ATF) have staff, supplies, and power to provide care to more cases? Yes, this is set up by the public health department.

If there is no capacity, what will callers, or people who bring family members in, be told to do instead? People who call in will be telephone triaged and told what to do. The assessment will include not only the patient, but also the caregivers to make sure they are able to provide care. A support line with RN’s and MD’s is being set up for those at home to call with questions, and if the situation changes. Home Health will play a role in this also.

There are a lot of partial answers to your other questions, but right now, I have to get busy.

Sniffles – at 18:54

ICP – at 08:20 While none of the hospital administrators I spoke with had any written plans at the moment for triage, a couple of them discussed the possibilities of using tents outside their hospitals as well. I asked them if they were planning to pitch the tents in the snow. One of them looked at the ground and said nothing after my comment. The other person mentioned maybe putting a heater into the tent. When I said that there were federal and state warnings that utilities could be down during a pandemic (and a heater would not function without electricity or a generator), they said they didn’t know what to do. The person honestly wanted a good alternative and didn’t have any to provide. There really will not be a good location just outside of a hospital to triage patients in states that have cold temperatures/snow, especially if the electrical grid goes down.

ConnectRNat 20:02

Clinical Triage Guidelines During a Pandemic

Other comorbid medical conditions

A. Adults and teens >12 years of age: modified pneumonia severity index (PSI)calculation

Characteristic Points assigned

Age Number of years Significant comorbid illness +10

Physical exam

Altered mental status +20 Respirations >30 +20 Systolic BP<90 +20 Pulse >125 +20 Pulse oximetry <90% +20

(1) Admission to hospital: Score > 90 or

    a. Toxic appearance or rapid decompensation (especially important in
    adolescents and in pregnant women)
    b. Significant hypoxia – O2 saturation < 88%
    c. Patients whose level of disability or medical complexity (e.g., on
    dialysis, severe quadriplegia, dementia, etc.) would overwhelm the
    ability of assigned staff to provide basic care for other patients at
    Influenza Care Centers

(2) Admission to Influenza Care Center: Score < 90 and

    a. Needs closer monitoring and nursing care (for example, IV fluids, IV
    antibiotics, etc.), or
    b. Unable to care for self or return if symptoms worsen, or
    c. No hospital beds available

(3) Discharge to home:

    a. Score > 90 with poor prognosis and unlikely to benefit from
    hospitalization, or
    b. Score < 90 and able to care for self or has caregiver, and able to
    return if symptoms worsen.

B. Children 12 yrs of age and younger:

     Indications for hospital admission include any of the following
   a. Fever and age < 2 months
   b. Significant tachypnea
   c. Hypoxia on pulse oximetry
   d. Chest retractions, cyanosis, intermittent apnea, nasal flaring
   e. Toxic appearance

3. PPE: respiratory masks, antiseptics, bleach for household surfaces

4. Isolation: Keep separated from other family members as much as possible, use hand washing, and dispose of tissues in plastic bags. Wear respiratory mask when outside the home. Patient should remain isolated from other persons for at least 7 days after the onset of symptoms.

5. 911:EMS: The ability of EMS to deliver patients to a non-hospital location will require

    changes in current state statutes, which may come about in the context of a declaration
    of emergency.
ConnectRNat 20:03

Sorry, that got all jammed together. Will clean it up tomorrow.

ICP – at 20:12

At least you got hospital administrators to show up. That is more than some have done. Most think it is nothing to worry about. (I would love to share my story with all of you so some would appreciate what their communities are really doing for them -think Andy/Mayberry meets In The Heat of the Night meets Crossing Jordan meets Scrubs). LOL

FloridaGirlat 23:02

Sniffles – at 18:54 Are any of your hospital administrators communicating with the public health department? County Comminissioners? etc? I do not think a hospital stands a chance in Hel* without a unified effort. We are a rural hospital, our community depends on us to provide needed services. The integration of ALL aspects of the possible effects of a pandemic have to be considered. The hospital cannot do it all….

ConnectRN – at 20:02 Do you have a link? I was hoping for a more detailed version of what you posted. It would need to be fair, unbiased, objective, and consistent. A method of scoring so that you would be more likely to know who would survie the treatment that was provided.

ICP – at 20:12

 (I would love to share my story with all of you so some would appreciate what their communities are really doing for them -think Andy/Mayberry meets In The Heat of the Night meets Crossing Jordan meets Scrubs). Please do share your story. I think about half of our population fit more along the lines of the Andy Mayberry picture.

I assure you, my experience traveling around says… the Andy Mayberry’s will work the hardest and find the weirdest solutions.

21 October 2006

crfullmoon – at 04:24

FloridaGirl, sorry. I wasn’t expecting answers from you personally, (I think I sometimes imagine lurkers; who aren’t getting asked the right questions during all these “planning” meetings, as well as the public, who belives spin that implies long “stages” of what they consider some sort of normal care, when they don’t even know right now H5N1 has very bad outcomes).

(Seeing the triage ConnectRN listed would help them be motivated to prep, and perhaps, not expose vulnerable family members, and perhaps try harder to not be one of the ones that you hcw have to deal with.) (Even reading the ISCU material would be a wake-up call to some.)

I will have to ask what the state public health has for ISCUs, as I know the town health dept. didn’t ask the public for money for it 6 months ago, (nor start explaining to the public 12 months ago why it was going to need to ask for money ).

Still I’d like the “staging” to get written/imagined worst-case-first. Stages might go very quickly, especially if infection rates are way higher than spreadsheets assume, or as supplies are used up, or after the power fails.

Like in the Cat5 hurricane, turns out it might have been better to have the public fully informed, and ready to try and make better community contingency plans and have things clearer before any response was needed. This needs households and communities aware and preparing how to take care of themselves and their communities’ vulnerable, not being kept unaware just to avoid any early bobbles in the economy. Officials have some clue about what pandemic may be like; did they quit paying their bills, quit their jobs, and riot in the streets? Why do they say they can’t tell the public, or that will happen? People will have adjustment reactions, and complain, perhaps very emotionally, but hospitals need community support; a preparing community it will lessen their burden come a pandemic.

Have hospitals told all their employees? Can’t run isolated units for regular hospital care, if the staff has not been told to be getting their households ready. Triage won’t work without staff. (I also saw reference somewhere to plan for when “unaffiliated volunteers” show up -can’t recall which context I saw that; dmort?)

Sniffles’ administrators admitted, “they didn’t know what to do”. Pandemic influenza is too much for a top-down solution; the public needs to get told now that care will be disrupted come pandemic, and, that triage will be heartbreaking. (Maybe they can try out some of the planned “hotlines” to answer questions, or, just keep referring people to pandemicflu.gov. It would still be news to some.)

(And, at the end of the triage plans, the plans must dovetail into the Mass Fatality Management Plans, somewhere - if you see any references, please, add them to that thread.)

All the best to you all.

ConnectRNat 09:38

Clinical Triage Guidelines During a Pandemic

Other comorbid medical conditions

A. Adults and teens > 12 years of age: modified pneumonia severity index (PSI) calculation

Characteristic = Points Assigned Age = Number of years Significant comorbid illness = +10 Physical exam

     Altered mental status = +20
     Respirations>30 = +20
     Systolic BP<90 = +20
     Pulse>125 = +20
     Pulse oximetry<90% = +20

Admission to hospital: Score>90 or a. Toxic appearance or rapid decompensation (espicially important in adolescents and in pregnant women) b. Significant hypoxia - O2 saturation<88% c. Patients whose level of disability or medical complexity (e.g., on dialysis, severe quadriplegia, dementia, etc.) would overwhelm the ability of assigned staff to provide basic care for other patients at influenza care centers.

Admission to Influenza Care Center: Score < 90 and a. Needs closer monitoring and nursing care (for example, IV fluids, IV antibiotics, etc.), or b. Unable to care for self or return if symptoms worsen, or c. No hospital beds available.

Discharge to home: a. Score > 90 with poor prognosis and unlikely to benefit from hospitilization, or b. Score < 90 and able to care for self or has caregiver, and able to return if symptoms worsen.

B. Children 12 years of age and younger: Indications for hospital admision include any of the following: a. Fever and age < 2 months b. Significant tachypnea c. Hypoxia on pulse oximetry d. Chest retractions, cyanosis, intermittent apnea, nasal flaring e. Toxic apearance

ConnectRNat 09:46

Florida Girl. Obviously I need to study Fluwikie text formatting this weekend. I will see if I can find where I got this triage protocol from when I go back to work on Monday. I’ve been reading, cutting, pasting, and putting together pandemic plans for over a year now and it may take me awhile to find the source for the above. Hopefully I’ll be able to steer you to the reference material your looking for.

FloridaGirlat 10:44

ConnectRN, Do not worry about the formatting. The link would be great!!

My physicians do much better building on something that has been established rather than put something together from scratch. They have always been receptive to EBP to all aspects of the care they provide.

When I approched them about the criteria being their responsibility, (for the most part), they had not previously given it any thought.

Presenting them with some kind of established guidelines will give them a comfort level to work in.

Thanks much…

Jody – at 11:48

While you may already be aware, Mauser 98 at CE posted extensively on the use of C-Pap, and might be a source of info. Mauser is a pediatric respiratory physiologist.

LMWatBullRunat 13:10

I don’t mean to be harsh, but I see a lot of people ignoring reality here. In a severe pandemic, reality will be extremely harsh, and won’t care what the paper says.

Harsh reality is that in the event of even a mild pandemic, you will not have either the beds available or the staff available to provide care to present standards.

Let’s take a hypothetical hospital I know about, Hooville Hospital. It has about 565 beds, and presently averages 81% fill rate for those beds. It has about 700 doctors and 1600 nurses. It’s located in Hoo County, which is around a hundred miles from a very large metro area (5 million people) and about 60 miles from a large metro area (1 million people).

Hoo county has about 90,000 permanent residents, and houses about 25,000 students at HooU, and is the health care service hub for the surrounding counties which have about another 160,000 people in the surrounding area.

Assume that all students are immediately sent home at the start of the pandemic so that the 10,000 beds of student housing are made available for flu patients.

Assuming only a 1918 level pandemic, at the end of week 1, Hooville Hospital will have seen at least 4500 patients. of those, at least 2250 will “require” admission; 450 will require ICU level care with ventilators. Assuming all the current patients are discharged immediately and that less ill patients will be discharged to make room for the more severly ill, there will be room for the 450 critical patients and 115 of the rest. Average stay for these patients is 2–4 weeks.

Assume all deaths occur only in critical patients. Of these critical patients, 225 will die, many quickly, some slowly. Assume half die quickly, and the rest die within 4 weeks; other patients will be admitted as soon as beds are cleansed and cycled.

At the end of week 1, the hospital will have 338 critical patients, 227 less severely ill patients, only 630 doctors left, and only 1440 nurses. It will also have 113 dead bodies to dispose of, and the morgue facility has space for only 24. Local funeral parlors have space for about 25. The local ice skating rink can stockpile as many as 600 bodies, however. The student dorms are now housing around 4000 very ill flu patients.

At the end of week 2, the hospital will have 565 critically ill patients. Some critically ill patients will not be seen at the hospital, all others will not be seen, and the docs will be down to 560, assuming all show up. Nurses will be down to 1300 or less. The dorms will be about full, with 8000 patients. (Who feeds these people or changes the linens?) This assumes that there is no civil disturbance, and that no locals “insist” with use of force, that their relatives be seen, a considerable assumption.

Q- how many nurses are required per day to support one ICU patient? 2? 3?

Q- How many ventilators are required (565)? How many does Hooville Hospital have? 25?

Q- Where are all the bodies going to go?

Q-What about all the people from the outlying counties, the other 160,000 of them? Where do they get medical care? There is another smaller hospital in town with a couple hundred beds, but they’ll be overrun too.

Q- Who takes care of those in the dorms?

Q- What happens if the large cities to the north and east collapse?

So, 2 weeks into the pandemic we see that the health care system in one real hospital, in one real town, is overwhelmed in less than 2 weeks, and in many ways this is much better than can be expected in most locations in the US.

My point is, that if we are to be serious about trying to plan for an emergency, that we have to start with what the reality is now, and the reality is that we have NOWHERE NEAR the capacity required to deal with a pandemic using present protocols.

We have no antivirals. We will have no vaccine. we will have a tiny fraction of the ventilators needed. We will have a small fraction of the professional HCW needed.

Therefore, it is simply absurd to state that we will be able to care for the pandemic victims under these circumstances. Realistic plans for such an event will have to be based on telling people to stay home if they have the flu, on providing expedited burial services, and trying to prevent collateral damage. We will need docs and nurses after the pandemic to treat bacterial pneumonia. Panflu is a viral tidal wave. Killing our HCWs trying to stop it is like trying to stop a tsunami by lying down on the beach.

We WILL need HCW skills to treat those who survive the virus; not only is that a situation where trained HCWs could make a difference, but we will need plasma from the survivors to transfuse the newly ill and save lives. IMO, the only thing to do at the start of a pandemic is to close the hospitals, send everyone home, and tell everyone that they are on their own. alternately, you might set up a screening and triage station outside the facility, or several of them. There you could screen everyone, give them the knowledge they need to care for the sick, admit no-one with the flu, and send them all home.

This location, btw, is Charlottesville Virginia.

Tom DVM – at 13:23

LMWatBullRun. That was an excellent piece of writing.

1) there will be no healthcare system at the end of two weeks…other than maybe for politicians and sick healthcare workers.

2) the demand for pharmaceuticals will skyrocket overnight. Not only will there be no healthcare, no vaccines and no antivirals (these two won’t work anyway and I wouldn’t take either even if they were avaliable)…

…but in addition there will be no antibiotics, oral electrolytes, antifever medications or antishock drugs prednisolone.

We are going to have young susceptible adults with young susceptible children…and NOT ONE THING TO TREAT THEM WITH OTHER THAN MAYBE PRAYERS AND PLACEBOS!!

Thanks for re-enforcing the simple truth of the matter.

Bottom line? We had better all be wrong here and this thing blows over because if we get a pandemic under the present infrastructures, it is going to be UGLY.

Thanks again.

LMWatBullRunat 13:46

TomDVM-

One of the things I study is engineering failures. I have always been intrigued by how such things happen, as one learns a great deal from past mistakes. To quote Bismark- “Fools may learn from their mistakes. I prefer to learn from the mistakes of others!”

I prefer to learn from the mistakes of others too, yet it seems that even intelligent people shy from ugly truths simply because they don’t want to look at them. Humanity has been bitten by the “this can’t happen here” attitude so many times that God couldn’t count them all, and yet we see that same stupid mistake being made all over again. Kipling knew this all too well, witness his poem - TGOTCH.

I hope that I am wrong too. In the past, when I have wished that, my wishes have far too rarely come true.

crfullmoon – at 13:52

Thanks, LMWatBullRun. (I too want to know what people will do after the first two weeks; after the Cat1 plans fail to a Cat5 hurricane. Otherwise, we’ll all find out the hard way, and survivors will wonder, What would have happened, if we had…?)

ICP – at 14:59

FloridaGirl:

Well, I have tried to “tell my story” and have written and deleted three posts. I have yet to write one that doesn’t come across as sounding bitter, unprofessional, uneducated and just plain sour grapes. Actually, I am a highly educated, professional RN with 29 years ED and IC experience who prefers to keep my posting very simple and to the point (if you work with ED patients and live in the South, you learn slow, basic and simple is good…).

In a nutshell, if your Administrator thinks it is all a joke, you can write all the plans you wish, but if TPTB won’t sign the purchase orders and won’t make the meetings madatory to educate the employees, you are going to end up with nothing more than many unnecessary dead folks, some of which I will always feel could have been prevented.

A beautiful new hospital that is aesthetically pleasing to look at, with new furniture, artwork, flat screen TVs and exotic plants will be useless when thousands in the community fail to survive due to lack of medications, and supplies if pan flu hits this winter because the CEO thinks it is all hype and doesn’t buy into it. When my community wants to know why my local hospital wasn’t prepared, I will tell them that a draft plan was written in 2005, submitted in March, 2006 and requests for PPE and supplies denied all the way up to the morning I awoke in October, 2006 and realized that if it happened in the next year, I would feel like I failed my community. That was the day I resigned.

I accepted the fact that one cannot do it alone and I can better use my talents helping ones are interested in getting the job done. Bless those who just show up and expect someone to be there to care for them for they kmow not what goes on behind the scenes…

FloridaGirlat 15:09

LMWatBullRun – at 13:10 Tom DVM – at 13:23

First, Let me say that I am not denying that what you propose cannot happen. It may very well be as bad as you portray. I expect it to be very ugly. That being said…

This does NOT change the fact that there still needs to be a plan in place to deal with how to triage patients. THAT is the reality.

When you deal with uncertainty’s, there is always an element of….. ? Yep! You got it!… Uncertainty.

What we are facing is not a “for sure” thing…. The outcome is unknown… The severity is unknown… The timing is unknown… It is unknown if H5N1 will become the pandemic virus…

What are my feelings? I have been watching this particular virus evolve for almost 2 years… I do not have “rosy” feelings about what I have been watching.

Without a plan, there is NO chance of maintaining a hospital system. With a plan, at least there is a chance. At least this is my way of thinking…

So, to the both of you…. What would you have me do differently? Just say up front to our community… “I give up?”

I don’t think so… Personally, I am not that type of person. And I do not believe the people I work with are either….

But, In the event you have information that may help with formulating a plan, I will be most appreciative.

LMWatBullRunat 15:31

Florida Gal-

I never counsel despair or inaction.

That was not my point.

My point was that you need an accurate appreciation of exactly what you have. Start there, with what you have.

Then figure out what might happen. I’d suggest that you plan for mild, moderate, severe, and very severe pandemics.

Then identify what the shortfalls are, and where they happen. Start at the high level then work down. Don’t make the fallacious assumption that because you are a health care worker that you can do something. My guess is that if you take an honest look at the effects of even a mild pandemic on your present facility you will see a number of major problems to be solved.

FloridaGirlat 16:03

LMWatBullRun – at 15:31 You Wrote: “I’d suggest that you plan for mild, moderate, severe, and very severe pandemics.”

Actually, This is what we are doing… Not only the Hospital, but also the COunty. We have 3 different senarios we are planning for with very specific trigger points. Our hospital plan falls into line with what the County is doing each step of the way.

You wrote: “Don’t make the fallacious assumption that because you are a health care worker that you can do something.”

Pardon the assumption you are a person who sees the glass half empty… but, you do not give the impression that one person can make a difference.

I know I make a difference…

But, aside form looking at this from a personal point of view… The hospital is the one place where most people would look to for help in the event of a pandemic. Even if the attack rate is 30% and the CFR is 50%, there are still people who will need help…. even if they have no power. Basic human nature may dictate some of your foretold reactions, but as you said… HCW’s will still be needed after a pandemic.

BUT, Without HWC’s (and hospital’s) putting forth the effort of assistance… faith in HCW’s would diminish…

People are not dumb… They recognize abandonment easily. They also recognize those who try to help.

And you wrote:

“My guess is that if you take an honest look at the effects of even a mild pandemic on your present facility you will see a number of major problems to be solved.”

I have taken a hard look… You are right. We have some major obstacles to overcome… I recognize that many are insurmountable.. We can do nothing about those at this time. Maybe never……

But, there are many that we CAN solve. If the only thing we can give is solace…. Then so be it.

But for those we can help, before the worse in your senario occurs… I still need triage criteria, to help maintain an established method of deciding who and where to treat people.

22 October 2006

ICP – at 00:11

FloridaGirl:

This is how I envision tbe scenerio to be:

While it would be nice to have a very organized and efficient triage process with adequate RNs and MDs lined up to properly screen patients in an orderly manner, we are more likely to have those staff members assigned elsewhere caring for the critical patients we are overwhelmed with and more like an LPN, Secretary Tech or EMT doing triage at best in a controlled or uncontrolled chaos setting.

Triage guidelines can be written very formally but will probably deteriorate quickly as lines overflow and backlog and become more realistically, a cursory exam of LOC, whether the person has a rapid pulse, adequate breathing, maybe a quick O2 sat checked, a capillary refill check and if he/she is potentially salvagable (again, a judgement call) referred to wbatever acute care treatment area is available. If stable, referred to an off-site medication/home-care advice dispensing locale.

You are correct in that you just cannot fail to plan, yet, making up your own guidelines on this is about the only way to do it until a recognized body takes the initiative to do so and someone puts a seal of approval on it to set as a standard of care.

I will be happy to work with you on anything I can do - email dvsilk@wctel.net

anon_22 – at 01:21

FG,

I’m going to throw in some ideas very briefly. I’m not well today, so this is vnot well organized, but i think probably useful.

  1. in mild pandemic, the sickest have priority
  2. in moderate pandemic, protection of HCW has higher priority, as this scenario is where the availability or not of HCW will make the biggest difference to collective outcome.
  3. in severe scenario, security of infrastructure is most important. eg there may be situations where it might be deemed safer to shut down a hospital cos of the severe risk of looting.

also, it may be more important as well as more practical (re ICP’s post) to set out clear triage guideline principles eg under what circumstances should age count more than severity of illness, rather than attempt to set up actual clinical criteria, eg fever for how many days, since the full spectrum of considerations or symptoms will not be known till then. Setting out principles will also allow new developments, unexpected symptoms or situations to be plugged into the identified principles without modification.

It then becomes immediately obvious that we are sitting on huge and complex ethical dilemmas. For me the ethical bottomline is consent ie people have a right to be consulted if their normal expectations for treatment will not be fulfilled. Particularly in this instance where there is plenty of forewarning.

To make plans to refuse treatment to someone because of triage criteria set up ahead of time (ie premeditated) without consulting the public, while the (same) public was not told that this might happen (so that they may choose alternate paths ie stocking up and SIP, is highly unethical right now.

FloridaGirlat 17:36

Well anon_22, That about says why I am looking for triage criteria!! (Still need me to post in your other thread?)

Most studies and guidelines that I have chanced upon deal with these very issues… as far back as the late 1990′s. You would think That by now someone would have put things into some type of system, simular to START (trauma triage).

I don’t know if these article are publicly available, because most I retrieve through the hospital library. But, If anyone is interested, I will try to find links. All are copied verbatum…

Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: Recommendations of the Working Group on Emergency Mass Critical Care

Criteria for declaring a critical care crisis as well as the nature of the changes in care standards ideally would be publicly discussed and transparent to hospital staff and the community before implementation during an event (36). Page E6

Hospitals in the region should ensure that the intent, mechanics, and ethical considerations of the proposed triage process are understood by hospital staff and the community. Page E8

BIOSECURITY AND BIOTERRORISM: BIODEFENSE STRATEGY, PRACTICE, AND SCIENCE Volume 4, Number 2, 2006

Meeting Report Hospital Preparedness for Pandemic Influenza ERIC TONER, RICHARD WALDHORN, BETH MALDIN, LUCIANA BORIO, JENNIFER B. NUZZO, CLARENCE LAM, CRYSTAL FRANCO, D. A. HENDERSON, THOMAS V. INGLESBY, and TARA O’TOOLE

Proposed Solution #2: “Regional” Hospital Planning and Response Groups (RHPRGs)

• Local groups should be established across the country to involve every general hospital. The essential functions of such groups would be to: . . .

__ Coordinate the implementation of the surge process (the expansion of patient capacity within individual hospitals while retaining near-normal practice standards) and the supersurge process (the further expansion of patient capacity involving use of alternative care sites and/or significant alteration in practice standards);

__ Facilitate a communitywide approach to ethical and political challenges (e.g., altered standards of care);

‘’‘Altered Standards of Care in Mass Casualty Events’‘’ From AHRQ 2005

Principle 2: Planning a health and medical response to a mass casualty event must be comprehensive, communitybased, and coordinated at the regional level. Effective planning should:

�� Be done at the facility level. However, facility-level planning alone is not sufficient. �� Integrate facility-level planning into a regional systems approach.

�� Involve a broad array of public and private community stakeholders.3 �� Begin with the agreement on shared responsibility among all partners in the planning process. It is not adequate for individual institutions and systems to have emergency response plans unless those plans are coordinated into a single unified response system.

�� Be consistent. Planning also should be integrated with Federal, State and local emergency plans.

(3 These stakeholders include: emergency management agencies, police and fire departments, emergency medical services, ambulance and other transport providers, health departments and community health centers, hospitals, ambulatory care centers, private physician offices, medical examiners, nursing homes, health centers, mental health services, morticians, and others. They also may include schools, churches, hotels, businesses, and other organizations that can provide space for alternate care facilities and cooperate in the preplanning required to activate such sites.)

AHRQ Altered Standards of Care Continued

Principle 5: Clear communication with the public is essential before, during, and after a mass casualty event. To manage expectations and educate the public about the impact of an event, whom to call for information, where to go for care, and what to expect, the following points should be kept in mind:

�� The public should be brought into the discussion during the early stages of planning so that citizens develop a clear understanding of concepts such as rationing of resources. �� Public understanding and acceptance of plans are essential to success.

�� Messages should be consistent and timely at all stages. �� Official health and medical care messages should be delivered through public media by a local physician whom the public perceives to have knowledge of the event and the area, a representative of the Centers for Disease Control and Prevention (CDC), or the Surgeon General, depending on the level of communication necessary.

�� Spokespersons at all levels—local, State, regional, and Federal—should coordinate their messages. �� It may be necessary to vary the modes of communication according to the type of information to be communicated, the target audience for which it is intended, and the operating condition of media outlets, which may be directly affected. Variations that illustrate this point but that do not reflect expert discussion include the need to use languages other than English and the need to use alternatives to usual media outlets in the affected area. Also, national audience messages would be less detailed and specific than messages to the affected area.

Step 1: Develop general and event-specific guidance for allocating scarce health and medical care resources during a mass casualty event.

Public and private organizations, including professional societies, should develop guidance in specific areas related to allocating scarce clinical resources. Examples include but are not limited to the following:

�� Triage guidelines and measures for specific types of events.

�� Allocation guidelines for scarce resources, such as ventilators, burn beds, or surgical suites.

�� Guidance for the triaging and treatment of children, specifically the ways in which altered standards of care might differ for a pediatric population.

‘’‘Step 9: Develop a Community-Based Planning Guide for Mass Casualty Care.’‘’

Experts agree that local and regional planners need a resource to assist them in enhancing surge capacity plans so that they include situations involving mass casualty events.

A Community-Based Planning Guide for Mass Casualty Care could be developed that includes guidelines, principles, templates, and examples of promising or tested practices for addressing the many and varied aspects of this task, whether the focus is site-specific, local, regional, or statewide.

Although some tools and resources exist that could be incorporated into a Planning Guide, others—including guidelines for the allocation of scarce resources during a mass casualty event—have yet to be fully developed or evaluated.

It is important that the Planning Guide not be prescriptive, but rather offer suggestions and identify tools and resources that may be useful in guiding triage and the allocation of scarce resources.

(It is a Pity the above has not yet been done…) There are many studies that say pretty much the same thing…

This is the way I envision some of it….

Concept of Operations for Triage of Mechanical Ventilation in an Epidemic John L. Hick, MD, Daniel T. O’Laughlin, MD

Development of triage criteria must reflect basic medical ethics principles. However, in a resource-poor environment, the traditional bioethical focus on patient autonomy (which assumes respect for the individuals’ freedom to make decisions) shifts to a utilitarian or ‘‘distributive justice’’ model that attempts to do the ‘‘greatest good for the greatest number’’ with the resources available.24–26

We attempted to develop a tiered, scalable framework for restricting mechanical ventilation. Ideal attributes were determined from our drill experiences.

1. They should assist the individual physician by providing a guideline and policy basis for determining criteria for resource allocation or withdrawal, which will reduce the potential for each physician to have to design and defend individual strategies for individual cases and improve consistency.

2. They should be implemented on a regional, not institutional basis, with a government agency providing policy support for implementation.

3. Appropriate liability protections for providers and institutions cooperating with the public health directives should be assured in advance, or as part of an emergency order.

4. Aside from disease-specific criteria, restrictions should apply equally to all patients (e.g., both those infected and those who are hospitalized for other reasons).

5. Criteria should be implemented in a tiered or stepwise fashion, so that as resources are exhausted, another (stricter) tier of exclusion criteria is implemented in an attempt to provide the best care possible to those with the best chance of survival.

6. Whenever possible, tiers should be based on objective determinations of effectiveness of care affecting survival, and of resource utilization, rather than subjective determinations regarding the value of either the intervention or the value of the patient’s life.27

7. The final tier should ideally provide a numeric assessment of survival probability. This figure may be then compared within and between institutions and regionally to allow resources to be shifted to equalize the care provided and also provide a ‘‘sliding scale’’ of care guidelines that may be adjusted depending on the demand on the resources (e.g., unable to provide mechanical ventilation to patients with score > X, tomorrow may change to score > Y).

8. The numeric scoring system should rely on as many clinical variables (rather than laboratory) as possible. It should be easily correlated with survival. It should be available in the public domain (e.g., nonproprietary). It should be easily adapted to Internet or personal digital assistant calculation programs. Ideally, it should involve simple calculations and few variables.

So, I have in mind an outline… Guidance, that what I think should work, is possible.

I was just hoping for that scale or system that should have already been developed.

So, I guess we will make it work another way….

FloridaGirlat 17:47

ICP – at 08:20 Haven’t forgotton you… Will email you later. I think I have found your Scoring system. It is for pneumonia.

FloridaGirlat 19:40

ConnectRN – at 09:46

The above scoring system Comment was meant for ConnectRN. (Sorry).

The pneumonia Scoring index is in one of the supplements of the HHS plan on pandemicflu.gov

(I think it is also on the CMS website).

23 October 2006

rrteacher – at 00:57

FloridaGirl. Above references are top shelf papers. In the absence of real experience, its all theory, however. The premise that the limiting factor will be resources (people, equipment and energy) and not need, is the real issue. The objective will be to improvise and maximize resources.

Leo7 – at 01:48

I’m missing something. Triage goes on every day and we aren’t telling people about it. For instance an MI sitting in the ED for 24–48 hours isn’t conducive to best ethical care, but that is all that is available. If there is no vent—there is no vent! Most of us aren’t going to take a 60 year old off a vent to die, so a tweny nine year old can have it. I will as a nurse just go home at that point. Frankly, we’re just not that cold blooded in health care, that’s murder in my book. However, if the two patients above present at the same time and a vent is open triage says save the one most likely to survive—the twenty nine year old. Even then there will be an evaluation of each patients health care history. If the sixty year old has never been sick and has normal BP and the twenty nine year old has chronic health problems, IV drug abuse, or uncontrolled diabetes or a history of severe asthma, the sixty year old could get the vent. Why are we complicating this? As as been discussed the first ill will get the ventilator support, no way, will any HCW (after the arrest of the Katrina HCW’s)take older or people getting more critical off the vents. Won’t happen. If it does there will be a line of HCW’s going home.

Ethical action is this---when the hospital is full close the doors. For the ones who come after the doors close—the choice is on the family—go home or try another facility. It’s no one’s fault there isn’t enough beds or HCW’s—that’s triage too.

EnoughAlreadyat 02:11

The Texas Medical Center, and “community” (all of Houston and surrounding suburbs I guess), have “triage plans.” Not sure what they are exactly, but here is a thread about one of the world’s largest, most modern, and best equipped medical centers… Texas Medical Center in Houston:

http://www.fluwikie2.com/pmwiki.php?n=Forum.PreparednessResponseGuide

FWIW, even with 2% of the “reported” population of “this metropolitan community” being struck with this flu… I don’t have confidence in this plan. And, I don’t think they are thinking “seriously” about the potential of this type flu.

ConnectRNat 09:05

FloridaGirl: The source is from the Santa Clara County Public Health Department. Your right - it is also in the HHS plan. Try this URL http://tinyurl.com/vojnv and go to Tool 32, pages 322 and 323.

I lost the author of this, but it’s in the public domain - “The only thing harder than planning for an emergency, is explaining why you didn’t”.

25 October 2006

FloridaGirlat 19:27

Does anyone know what occured at the NIH (I think) meeting where they were going to look at the feasibility of caring for all flu patients outside the hospital environment? I thought that meeting was sometime this week….

Any info would be helpful, as it may impact any triage plans…

Thanks

28 October 2006

FloridaGirlat 17:32

This is an interesting find…

The title of this document is Clinical management of patients with an influenza-like illness during an influenza pandemic

http://tinyurl.com/y6ypr4

Provisional guidelines from the British Infection Society, the British Thoracic Society, the Health Protection Agency, in collaboration with the Department of Health.

Not exactely triage criteria, but certainly a very useful document…

FloridaGirlat 22:25

I was partly right… :)

I should have said “not much triage Criteria” There is however a scoring scale method that is discussed. It may be this scale can be useful in determining whether a patient is admitted to the hospital, ATS, or goes home.

It is Extremely useful to use as a tool for physicians who may need to be trained for a pandemic. (i.e. those physicians who normally have a speciality in something like surgery, or dermatology.)

In fact, it has enough detail, that many nurses could use this to provide care…. (I can hear the grumblings, now).

I recognize in this document, it is based on current Evidence based practice…. The choice of antibiotics, the timing of the antibiotics, etc.

It also has some very cool algorhythms to direct the care under certain conditions that are met…

Pixie – at 23:37

Udar Norge had a suggestion that really needs to be considered. She made the assumption that we, here in the U.S., were of course not going to bunch our pandemic flu people together in hospitals and pandemic flu holding centers but would instead make use of hotels and other kinds of pre-existing but adaptable buildings. I responded that no, I had heard of no solid plan that had moved pandemic flu treatment out of the hospital environment and into other facilities as of yet.

Udar Norge seemed surprised, and wondered aloud if we had not learned anything here from the experiences of 1918. Apparently the Scandanavian plans have already incorporated a more multi-faceted plan for treating flu patients, and one that is relies on best-outcome scenarios based on the knowledge gained in 1918.

You might take a look at the portions of the Norwegian pandemic plan, as well as the plans from other Scandinavian countries (I understand Finland’s is excellent also), to gain some ideas as to how others are approaching this topic, and how they are conveying it in their written pandemic planning materials. It sounds like they are a bit ahead of us on the practical plans for handling pandemic flu patients, so why reinvent the wheel if what they have come up with is adaptable to our purpose here.

It may also help those of you who need to convince others of the path that you are encouraging them to take if you discover that, for example, Norway is already moving in that direction.

30 October 2006

FloridaGirlat 19:47

Pixie,

I do know that hotels were discussed at one point… (here anyway) I seem to remember that was a suggestion because they have linens available, kitchens available, bathroom facilities, etc.

Two questions / problems came up… 1. What were the laws regarding “taking over” any hotels for that use. One mention was that there had to be compensation for the use…. and that the hotels might never recover from the image of being a “flu alternative care site”. and therefore would not recover their business.

2. The second question really was about staffing. How was the limited staff going to be able to take care of patients that were scattered all over a hotel if they had to go from room to room, floor to floor.

The answers to these questions still remain, so we looked at alternative care sites in a new way… We are still going to have them, but they will be in buildings that have other uses than a business.

We found several likely candidates, and have picked a few for further consideration. One is a old school… and if it needs to be torn down later, then the county has not lost a lot. Whatever money we would spend on paying a business for the use of their buildings for maybe a year or more, will certainly be better spent in building a new school.

Secondly, staffing at the school can be done in many different ways. The classrooms can be small wards, or the gym and be a large ward. There is a kitchen, bathrooms and shower facilities, and large parking areas that can also be used for triage if necessary.

And Pixie, Thanks for the tip… I had not considered other countries plans.. I will post a link to what I have found.

FloridaGirlat 19:48

Pixie,

I do know that hotels were discussed at one point… (here anyway) I seem to remember that was a suggestion because they have linens available, kitchens available, bathroom facilities, etc.

Two questions / problems came up… 1. What were the laws regarding “taking over” any hotels for that use. One mention was that there had to be compensation for the use…. and that the hotels might never recover from the image of being a “flu alternative care site”. and therefore would not recover their business.

2. The second question really was about staffing. How was the limited staff going to be able to take care of patients that were scattered all over a hotel if they had to go from room to room, floor to floor.

The answers to these questions still remain, so we looked at alternative care sites in a new way… We are still going to have them, but they will be in buildings that have other uses than a business.

We found several likely candidates, and have picked a few for further consideration. One is a old school… and if it needs to be torn down later, then the county has not lost a lot. Whatever money we would spend on paying a business for the use of their buildings for maybe a year or more, will certainly be better spent in building a new school.

Secondly, staffing at the school can be done in many different ways. The classrooms can be small wards, or the gym can be a large ward. There is a kitchen, bathrooms and shower facilities, and large parking areas that can also be used for triage if necessary.

And Pixie, Thanks for the tip… I had not considered other countries plans.. I will post a link to what I have found.

FloridaGirlat 19:59

OK…. Here is what I have found.

This is the link to Canada’s Plan

http://tinyurl.com/vjpu7

And this is the link to the portion of the plan that deals with Clinical guidelines and triage.

http://tinyurl.com/yxjedy

These guidelines are extremely detailed for almost everything I can think of… The triage guidelines outline what to do, and how to do it, based on the patient symptoms. It breaks this down into adult, children, and children under 6 years.

It also deals with phone triage, or self triage.

It has guidelines on patients who live in long term care facilities…

It even has what tests to order, when to order those tests, and what to look for in the test results.

I am not sure, but I don’t think anything that would be published, is going to get any better than this…

Your thoughts are welcome and needed…

25 November 2006

FloridaGirlat 10:05

For those who missed this:

http://www.cmaj.ca/cgi/reprint/175/11/1377

Someone heard of our need……..

(I am sure someone had been working on this prior to my asking… ) :)

Carlo – at 15:49

Here is an article I have often quoted as being the only article attempting to work through principles of catastrophic triage.

http://www.aemj.org/cgi/content/abstract/13/2/223

26 November 2006

ANON-YYZ – at 00:30

FloridaGirl – at 19:59

I am not sure, but I don’t think anything that would be published, is going to get any better than this…

I read in the news that this was requested by the Ontario government in 2004, and this paper is the starting point with more revisions before it becomes policy. From the press article (not this paper) one of the authors said they have not used age as an exclusion criterion but it will be reviewed after public consultation. You may already know this, but just in case…

crfullmoon – at 08:09

Thanks, Carlo, (this is from the first paper on that page- hm, remembering; a pandemic is not over after 6 weeks…and I think under current “plans” the bodies will be hopelessly backlogged by day 6)

…”Models of the potential impact of a pandemic on the Ontario population predict that hospital admissions for influenza will peak at 1823 per day over a 6-week period.9

This translates to 72% of the total hospital capacity being used by influenza patients. Similarly, the demand for intensive care unit (ICU) resources, solely for patients with influenza, would peak at 171% of current ICU bed capacity and 118% of the ventilator capacity. These figures do not take into account the current usage rate of critical care for patients without influenza, which is nearly at 100%.

Nor does this model factor in the availability of human resources. Surge response strategies10 (e.g., scaling back elective procedures, opening additional critical care areas and implementing the use of “mass critical care”11,12) will partially mitigate the sudden demand for medical care during an influenza pandemic; however, these strategies will be inadequate to fully address the demands on the health care system.

When resource scarcities occur, the tenets of biomedical ethics and international law dictate that triage protocols be used to guide resource allocation.13–15 International law requires a triage plan that will equitably provide every person the “opportunity” to survive. However, such a law does not guarantee either treatment or survival.16 We have developed this triage protocol in an effort to ensure the equitable and efficient use of critical care resources if scarcities occur during an influenza pandemic. “…

crfullmoon – at 08:12

1,823 per day ? Ok - the bodies may be backlogged by hour six.

28 November 2006

rrteacher – at 08:53

FlGirl and All. A nice collection and a good start. We should remember that triage in this case will be sorting infecteds with nots. The infecteds level of care will be based signs and symptoms of primarily, respiratory failure. The levels of support should be staged. 1. Oxygen. 2. CPAP/Positive Pressure w/ Oxygen. 3. Non Invasive Ventilation w/ Oxygen. 4. Invasive Ventilation. Patients move to higher or lower levels based on symptoms and non invasive monitoring, such as pulse oximetry. Antivirals and other supportive care, such as parenteral fluids, etc, again based on sighs and symptoms. Blood Gases, CXRs will be scarce. We should spend this time honing our assessment and examination skills. This staging will give our resources the biggest bang for the buck.

Gort – at 09:22

Development of a triage protocol for critical care during an influenza pandemic

http://www.cmaj.ca/cgi/content/full/175/11/1377

Pandemic triage: the ethical challenge

http://www.cmaj.ca/cgi/content/full/175/11/1393

Medical Offices and Clinics Pandemic Influenza Planning Checklist

http://www.pandemicflu.gov/plan/medical.html

Patient Triage During Pandemic Influenza By Grattan Woodson, MD, FACP

http://www.birdflumanual.com/articles/patTriage.asp

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