Scarce Resource Management
& Crisis Standards of Care
Overview & MaterialsCriticalCare Algorithms ScarceResource Cards Triage Team Guidelines & Worksheets
Washington State Department of
HealthNORTHWEST HEALTHCARE
Response Network
Washington State Departmentof
Health Network.NORTHWESTHEALTHCARE
ResponseNetwork.
SCARCE RESOURCEMANAGEMENTand
CRISIS STANDARDS OF CARE
. INTRODUCTION
In the eventof a large-scale disaster, either a no-notice event such as a natural disaster or a prolonged
situation such as a pandemic, there is thepotentialfor an overwhelmingnumber of critically illor
injuredpatients. In these situations, certain medicalresourcesmay becomescarce and prioritization ofcaremay needtobe considered.
Medical surge is a complex multifactorial event, the response to which is equally complex. In an effortto better understand ,measure , discuss best practices andmanage medical surge, itis essential to havean overall guiding framework .
In 2009, the Institute ofMedicine (currently the NationalAcademy ofMedicine) published a landmark
report, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situation : A Letter Report. Inthis report the authors defined Crisis Standards of Care as follows:
“ A substantial change in usual healthcare operations and the level of care it is possible todeliver, which ismade necessary by a pervasive ( e .g . pandemic influenza ) or catastrophic (e . g .
earthquake , hurricane ) disaster . This change in the level of care delivered is justified by specificcircumstances and is formally declared by a state government in recognition that crisis
operations willbe in effect for a sustained period. The formal declaration that crisis standards ofcare are in operation enables specific legal/ regulatory power and protections for healthcare
providers in thenecessary task of allocating and using scarce medical resources and
implementing alternate care facility operations. ”
They outlineda framework forthe discussion ofsurge capacity definingit as a continuum from
conventionalto contingency, and finally crisis. They definedthis “ Continuum ofCare as follows:
Conventional Capacity : The spaces, , and supplies used are consistentwith daily practices
within the institution . These spaces and practices are used during a majormass casualty incident
that triggers activation ofthe facility emergency operations plan.
Contingency Capacity : The spaces, staff, and supplies used are not consistentwith daily
practices butprovide care that is functionally equivalentto usual patientcare . These spacesor
practicesmaybe used temporarily during a majormass casualty incidentoron a more sustained
basisduring a disaster (when the demandsof the incidentexceed community resources).
Crisis Capacity : Adaptive spaces, staff , and supplies are notconsistentwith usualstandardsofcare butprovide sufficiency of care in the context of a catastrophic disaster (i . e., provide the
best possible care to patients given the circumstances and resources available). Crisis capacity
activation constitutes a significantadjustment to standards of care.
1 IOM ( InstituteofMedicine). 2012CrisisStandardsofCare: A SystemsFramework for CatastrophicDisasterResponse.
Washington,DC: The NationalAcademiesPress.
The NationalAcademyofMedicine also stresses the importance of an ethically grounded system to
guide decision makingin crisis to ensure the mostappropriate use of resources. They definethese
ethical principles as:
Fairness standards that are, to the highest degree possible, recognized asfair by all thoseaffected by them including themembers of affected communities, practitioners, and providerorganizations, evidence -based and responsive to specific needs ofindividuals and the
population .
Duty to care standards are focused on the duty ofhealthcare professionals to care for patientsin need ofmedical careDuty to steward resources institutions and public health officials have a duty to
steward scarce resources , reflecting the utilitarian goalof saving the greatest possible numberof lives.
Transparency – in design and decision making
Consistency in application across populations and among individuals regardless of their human
condition ( e . g . race, age disability , ethnicity, ability to pay, socioeconomic status, preexistinghealth conditions, socialworth , perceived obstacles to treatment, pass use of resources)Proportionality - public and individual requirements must be commensurate with the scale of
the emergency and degree of scarce resources
Accountability – individualdecisions and implementation standards, and of governments forensuring appropriate protections and just allocation of available resources
This framework hasbeen nationally accepted and adopted and hasbeen used by King and PlerceCounties and adopted by the Washington State Department of Health Disaster Medical Advisory
Committee.
I. Background :
In 2012, consistentwith recommendationsfrom the InstituteofMedicine(IOM ), theNorthwestHealthcare
ResponseNetwork developeda DisasterClinicalAdvisoryCommittee(DCAC), a group ofmorethan 45cliniciansfrom healthcareorganizationsacross Kingand Piercecounties, representingmorethan 15 clinicalsubspecialties, workingin coordinationwith PublicHealth Seattle & King County and Tacoma-PierceCountyHealth Department. Since thattime, a WA State DisasterMedicalAdvisory Committee(DMAC) has
beendevelopedand alongwith DCAChave focusedon the developmentof clinically focusedtools and
planningformedicalsurge, includingstrategiesfor theimplementationofCrisis Standardsof Care.
The content of this document is based on a thorough review of the literature , guidelines published by
leading nationalhealthcare specialty colleges and societies, recommendations of the National Academy of
Medicine and detailed discussion and deliberation by theWA State DisasterMedical Advisory Committee(DMAC), the Disaster Clinical Advisory Committee (DCAC ) Central District and included input from both
local and state Community Engagement Reports . 3
II. Contents:
All individualScarce Resource Cards and Triage Algorithmsare continually under review and openfor comments as outlined below in Section D .
5 . -Vollmer , M . Health Care Decisions in Disasters : Engaging the Public On MedicalService Prioritization During a Severe Influenza Pandemic . Journal of Participatory
Medicine. Vol 2 . December 14, 2010 .
3 WashingtonStateCrisisStandardsofCareCommunityEngagementReport, June2019, DOH
WashingtonStateDepartmentof
Health NORTHWEST HEALTHCARE
Response Network .
A . Scarce Resource Cards
The Scarce Resource Cards (SRC) are based on work done byMinnesota Public provide specific
strategies which can be used in the conservation , adaptation , substitution , re -use, and re-allocation of acritical resource during an emergency . Additionally , the cards provide recommendations to beimplemented
in preparation as well as response thus covering thewhole continuum of care ( conventional, contingency ,
and crisis ) as described above.
The contentand compositionbetween cardsvaries. Somecardsaredesignedto providespecific clinical
treatmentstrategies( e.g . Mass Casualty Burn TreatmentCard) . Others outline specificpatient populations
forwhich therecommendationsaremade (e. g. in-patientvs out-patientdialysispatients) .
Scarce resource cardshavebeen created for the following potentially limitedresources:
• BehavioralHealth
Blood productsBurn
Hemodynamicsupport and IV fluids
MechanicalventilationMedicationadministration
Nutritionalsupport
Oxygen
Renalreplacementtherapy
RespiratorandGeneralPPE
Staffing
WashingtonStateDepartmentofNORTHWEST HEALTHCARE
Response Network .
B . Scarce Resource Triage AlgorithmsandWorksheets
Adult andPediatric CriticalCare Triage Algorithmswhich should be used when Critical Care resourcesare overwhelmed. The Algorithms are designed to beused side-by-side with the respective Worksheetwhich providesmore in -depth clinicalconsiderations and informationneeded to move through eachstep in the Algorithm . Decisionsmadeusing these algorithmsneed to bemanaged by a Triage Team .
Guidelinesfor the composition, rolesandresponsibilitiesof TriageTeamsandtheir oversightare
includedin the Triage Team Guidelinesmentionedbelow .
C . Crisis StandardsofCare ClinicalTriage Team Guidelines
Allocationofa scarceresourceis a complex task and, in order to maintain the ethicalframeworkoutlined above, it is crucial that the decision-making processbeconsistentandthatoversightand review
mechanismsbe established. The TriageTeam Guidelinesprovideinstitutionalandregional
recommendationsfor this process.
D . Updateand InputProcedures
1 All documents contained in this packet aremaintainedbyNWHRN.
2 . Each document is reviewed every 3 years during scheduled plan review . During a specific
response, itis recognized that the clinical situation may change based on numerousincident-dependentfactors . Therefore , in response, documents are reviewed as outlined in
the Triage Team Guidelines .
3 . At any time, input iswelcomed and can be discussed atthe institutionallevelwith specific
institutional DCAC members (if applicable ) . Input can also bemade directly to the Chair orVice- Chair of the WA State DMAC or to the SeniorMedical Advisor of NWHRN . A full list of
local DCAC and state DMAC members and the Senior Medical Advisor is available fromNWHRN .
http: / / www. health . state.mn. us/ oep /healthcare /crisis / standards.pdf
WashingtonStateDepartmentof
HealthNORTHWEST HEALTHCARE
Response Network .
III. InstitutionalDistribution
The institutionaldistribution of the contentsof thispacket willbedetermined by each institution' sEmergency Manager, DCACmember(s ), ifapplicable, and appropriate administration.
IV . WA State Crisis Standardsof Care Guidance Framework
In anymedical surge , the primary goal is to prevent or limit the timein Crisis ” (as defined above by the
NAM ). It is understood thatmovement within the continuum of care is a fluid process and can vary
depending on the resource in question or the situation at hand.
It is also paramount , when faced with potential scarce resources that the response is coordinated and
communications among all ofhealthcare is maintained to provide accurate and up -to -date situational
awareness . WA State in conjunction with State DMAC, DOH , and state healthcare coalitions havedeveloped the WA State Crisis Standards ofCare Guidance Framework and is available through DOH .
This document outlines regional roles and responsibilities , provide an ethical framework and other tools
which will assist in coordinated planning and response.
. Contacts:
For any questions about this document or contents of this packet please contact:
NorthwestHealthcare Response Network at info @ nwhrn. org.
BEHAVIORAL HEALTH - PATIENT PLANNING and RESPONSE 05- 09-2019 FINALSTRATEGIES FOR SCARCE RESOURCE SITUATIONS
ConventionalCapacity The spaces, staff, andsupplies used are
consistentwith dailypracticeswithin the institution. Thesespaces and
practicesareused during amajormass casualty incidentthat triggersactivation ofthefacilityemergencyoperationsplan.
ContingencyCapacity Thespaces, staff, andsuppliesused
arenot consistentwith daily practices, butprovide care to astandardthat is functionally equivalentto usualpatientcare
practices. These spaces or practicesmaybeused temporarilyduringa majormasscasualty incidentor on a moresustainedbasis during a
disaster (when thedemandsof the incident exceed community
resources)
Crisis Capacity - Adaptivespaces, staff, and supplies are not
consistentwith usualstandards of care, butprovide sufficiency of care in
thesetting of a catastrophicdisaster( i. e. , providethe best possible care
to patientsgiven the circumstancesandresourcesavailable). Crisis
capacity activation constitutes a significant and adjustmentto standards
of care (Hick et al, 2009).
RECOMMENDATIONS Strategy Conventional Crisis
Prepare
Prepare
PLANNING
General
1. Encouragepatients to assemble and maintain a disaster kit, to include an extramonth worth of theirmedications, in
additionto food, water, sanitation, and first aid supplies, should they need to shelterin place.
• 2. Encouragepatientsto discussplanningfordisruption in their care with their currenthealthcareproviders, includingprimary care providersas well as behavioralhealth providers.
• 3 . Encourage BehavioralHealth Providersto develop a disasterplan with the patientaspart of treatmentplanning.
GatheringResources
• 4. Encouragepatients to identify tools and strategiesthey have found helpfulin symptom reliefand write down whatworks. Includea copy ofthe documentin theirdisasterkit.
• 5. Encouragepatientsto exploreotheravenuesforself-help, such as apps to assistwithmedicationandsymptommanagement, and to practicetheseprior to a disaster. Examples:
o 5a) Headspace (meditation andmindfulness) https: / /www .headspace. com
o 5b ) Virtual Hopebox (distraction , coping exercises, relaxation ) https : // psyberguide.org / apps / virtual -hope-box /
• 6 . Encourage patients to identify family members or friends who are helpful to them and include them as part of theirresources. Familyresources can be found at https: / /www.mentalhealth.gov/ talk / friends- family members
Preparinga Team• 7 . Encourage patientsto reach out and identify a specific individualin their liveswho can be a monitor and coach during
disruptive/ stressfulevents.
8 . Family andfriendsshould be encouragedto take advantageoftrainingthrough Red Cross, NationalAllianceonMentalillness (NAMI, or localcommunitymentalhealth clinics, to assist thepatientduringtimesof disaster.
https: / /www .namiwa.org /index .php /programs/ education-training
Response
• 9 . Patients should be encouraged to locate their physical resources, such as food,water, and medications.
10 . Patients should reach out to their pre-identified support system (family , friends), and to their identified disaster
monitor and coach .11. Patients should retrieve anywritten materials and plansto assist them inmonitoringandmanagingsymptoms.
12. Patientsmaywish to reach outto community organizations ( e . g . Red Cross, NationalAlliance on MentalHealth and
localcommunitymentalhealth clinics) for additionalresourcesif available at the timeof the disaster.
Prepare
AdaptedFrom theMinnesotaDepartmentofHealth, Office of EmergencyPreparedness FINAL: May 9 ,2019
WashingtonStateDepartmentof
HealthNORTHWEST HEALTHCARE
Response Network .
©2020NorthwestHealthcareResponseNetwork.
BEHAVIORAL HEALTH STAFF PLANNING and RESPONSE 05 / 09 / 2019 FINALSTRATEGIES FOR SCARCE RESOURCE SITUATIONS
Crisis Capacity - Adaptive spaces, staff, and supplies arenot
consistentwith usualstandardsof carebutprovidesufficiency of care inthe settingof a catastrophicdisaster( i.e. , providethe bestpossible care
to patientsgiven the circumstancesandresourcesavailable) . Crisis
capacity activation constitutes a significantand adjustment to standards
of care (Hick et al, 2009) .
ConventionalCapacity The spaces, staff, and supplies Contingency Capacity The spaces, staff, and supplies
used are consistent with daily practices within the institution. used are not consistent with daily practices, but provide care to
These spaces and practices are used during a majormass a standardthatisfunctionallyequivalentto usualpatientcare
casualty incidentthattriggersactivationofthe facility practices. These spaces or practicesmaybeusedtemporarily
emergency operationsplan. duringa majormasscasualtyincidentor on a moresustained
basis duringa disaster(when thedemandsofthe incident
exceed communityresources)
RECOMMENDATIONS
GENERAL (For all clinicalsettings: inpatient, outpatient, group homes, specialty care facilities, ACF)1. IncludeStaffmental/behavioralhealth guidance/resourcesin allresponseplansand continue to maintain,
test and updatementalhealth surgeplans.2 . IncludeMentalHealth surgeissuesin trainings and exercisesincludingDe-escalationTraining,Management
of the aggressivepatientand StaffSafety
Strategy Conventional Contingency Crisis
Prepare
PLANNING for PATIENTMental Health Surge
• 3 . Identify all staff with mental health/ behavioralhealth training and appoint key individuals to lead and
organize disastermentalhealth preparedness and response
o 3a ) Recommend specific disaster mentalhealth training for Behavioral Health providers currently
embedded in generalmedicalsettings. These individualswillbekey in providingJust- in - Time( JIT)
training to others in timesofmentalhealth patientsurge.
o 3b) Store resources and JIT disastermentalhealth trainingmaterials. ( e . g . Health Support Team
Curriculum , or Skills for PsychologicalRecovery NationalChild Traumatic StressNetwork) . See
referencesbelow for specificmaterialrecommendations. 3,4,5
Prepare
PLANNINGfor STAFFMentalHealth needs:
4 . Encouragepsychologicalfirst aid trainingto allmedicalstaff especially forkey clinicalleadersand
administrators
5 . Identify and train willing behavioralhealth and non -behavioralhealth providerswith morecomprehensive curricula than PFA , act asmonitors and evaluators for their colleagues. Utilize
based questionnaires as needed to determine current staff functioning. For example, ProQOL is one quickevaluationtool(https: / proqolorg)
6 . Providepsycho-educationfor staff on caregiverfatigue, includingsymptoms, and coping/supporttools4,5,7,8
• 7. Teach appropriate debrief strategies recognizing9,10,11o Group debriefingmay notbeappropriate for all. Prepare andplan to do 1on 1debriefing
o Thepace of the debrief session should be responder driven not agenda driven
o Individuals traumatic situationsat their ownpace. Forcing graphicor stressfuldebriefing can
causeincreasedtrauma.
Prepare
Prepare
PLANNING FOR IN-PATIENT PSYCHIATRIC FACILITIES:
• 8 . Encourage inpatientpsychiatric facilities to develop connectionswith other inpatient psychiatric
facilities to develop planning for potentialpatient transfers, evacuationsand staffing.
• 9. All inpatientpsychiatric facilities should develop generaldisaster planning to includebasic care for
patientse .g. adequatefood/water/ shelter, staffingshortfalls, medications, transportofpatients,methods
oftransport, andmanagementof patientswhomayrepresenta danger to themselvesor others.
© NorthwestHealthcareResponseNetwork.
Substitute/
Adapt
Substitute/
Adapt
RESPONSE
PatientSurge
10 . Notifypre-trainedprovidersto prepareforsurge. ImplementJIT trainingofotherstaff to helpwith
patient surge.
11. Ensure Alternate Care Facilitieshavewritten educationalmaterials to assistwith patients, andaccess
to mentalhealth consultationasneeded.
• 12 . In preparationforpossiblelossofelectronicmedicalrecords, have printedpatientinformationto
include diagnosis, allergies and currentmedications/dosages.
• 13.Modify individual treatment to shorter, symptom focused appointments .14. Utilize - educational, andbrief evidence-based interventions.
15. Use Telehealth mentalhealth providersas off- site resource.
16 . Shift treatment to emphasize coping strategies, interventions to manage symptoms, and identifyingand accessingpersonalresources.
sponse teams as needed to provide Just in Time training for healthcare
providers /organizations , and to provide consultation on Behavioral Health interventions including
medications and crisis management .
18 . Shift from individualtherapyto group intervention.
StaffSelf Care19 . Consider" deliberateCopingand Calming strategiesor "PersonalReflectiveDebrief techniquesover
and prescribed CISD for staff during and after traumatic events. , 10
• 20 . Encourage and support staff self- care .When possiblemaintain schedules , routines and shifts .
21. During an event encourage personal “pauses” for reflection and self -evaluation .
22 . Encourage utilization of organizational support systems, (e . g . employee assistance program , wellness
programs, etc. ).23 . Maintain consistentscheduled communicationbetween administratorsand providers duringand after
acute event. ( e . g . huddles, check - ins, sign outs, etc)
MEDICATIONS RECOMMENDATIONS:
• 24 . Psychiatricmedicationsmay not be available due to supply chain disruptionsduring amajor event .Encourageall facilitieswho careformentalhealthpatients( outpatient, in -patientmedical, longterm care,
grouphomes, orspecialtycarefacilities) to developpsychiatricmedicationsupply strategies. Consider
increasingparlevels, developingstockpiles, and/or planningwith localretailpharmaciesaspotentialpsychiatricmedicationsupply strategies.
Substitute/
Adapt
Prepare
Adapted From theMinnesota DepartmentofHealth, Office of EmergencyPreparedness FINAL: May 9, 2019
:/ /handlewithcare.com / wp-content / uploads/ 2010 08/ -mentalhealth.pdf
https: / /www .crisisprevention .com: / /learn. org / course /index.php ?categoryid = 11
4ContactHealth Support Team directly athttp :/ /healthsupportteam .org for curriculum .
Shttps:/ / www .nctsn.org / resources/ skills-psychological-recovery -spr online. Requires free registration formaterials.https: / / learn . org /course / index.php? categoryid = 11
Killian , K . Helping Till ItHurts? A Multimethod Study of Compassion Fatigue, , and Self-Care in Clinicians Working with TraumaSurvivors. Traumatology . 2008, Vol 14(2) June 32-448Mendenhall, T ., Trauma-Response Teams: Inherent Challenges and PracticalStrategiesin Interdisciplinary Fieldwork . Families Systems, & Health , 2006 , 24(3):357 -362.
, E., Pietrantoni, L., Palestini, L. , & Prati, G . (2009). Emergency workers quality of life: The protectiverole of sense of community, efficacy beliefsand coping strategies. SocialIndicatorsResearch, 94 (3):449
: // www .massey.ac.nz/ trauma/ issues/ 2003 -1/ orner.htm
11Joint Commission: https: //www. jointcommissionjournal. com / article / -7250(08)34066 -5 / fulltext
Washington State Department of
HealthHealth NORTHWESTHEALTHCARE
ResponseNetwork
© 2020NorthwestHealthcareResponseNetwork.
WashingtonState DepartmentofNORTHWESTHEALTHCARE
ResponseNetworkW HealthBlood Products - LastUpdated 2 / 17 /2020STRATEGIES FOR SCARCERESOURCE SITUATIONS Highest relevance: 1) P = pandemic 2 W =weather 3)MCI
.
ConventionalCapacity Thespaces, staff, and suppliesused are consistentwith daily practiceswithin the institution.
These spaces andpracticesare used during a majormasscasualty incidentthat triggersactivation of the facility
emergency operationsplan.
ContingencyCapacity Thespaces, staff, and suppliesused are not
consistentwith dailypractices, butprovidecareto a standard that is functionally
equivalentto usualpatientcare practices. Thesespaces or practicesmay be usedtemporarilyduringa majormasscasualty incidentor on a moresustainedbasis
during a disaster(when the demandsof the incidentexceed community
resources
Crisis Capacity - Adaptivespaces, staff, and suppliesarenot
consistentwith usualstandardsofcare, butprovidesufficiencyofcare
in thesettingofa catastrophicdisaster (i. e., providethebest possible
care to patients given thecircumstancesand resourcesavailable) . Crisiscapacity activation constitutesa significantandadjustmentto standards
ofcare(Hick etal, 2009).
Category RECOMMENDATIONSHealthcareFacility Blood
CenterStrategy Conventional Contingency Crisis
1. Increasedonationsand consider localincreasein frozen reserves P
Increase positivelevels P, W , MCIConsidermaintaining a frozen blood reserve if severe shortage
Increaserecruitment for specific productneeds
Prepare
AllBlood
ProductsAdapt
Prepare
2 . Consider adjustment to donor HGB/HCT eligibility / explore FDAvariance *
3 . • Relax travel deferrals for possible malaria and BSE (bovine spongiformencephalitis )
o 3a . Consider using ABO -type specific whole blood if components
cannotbeproducedMCI, P , W
4 . cell-saverand autotransfusionto degreepossible* * P, W , + / - Re-use
5 . Limit negativeuse to women of child-bearing age P, W , MCI Conserve
Whole
PackedRedBloodCells
Conserve
6 . positive in emergent transfusion in males or females who are nolonger childbearing , to conserve negative * * (Seattle Children ' s and MaryBridge Children 's currently uses in males < 18 yrs )
7 . donations from whole blood to 2x RBC apheresis collection ifspecific shortage of PRBC' s (Cascade has current capability ) Adapt
Conserve8 . • Use aliquots from parentproduct for severalchildren when possible P,W ,MCI
9 . Encourage use of blood sparing protocols for all patients P, W Adapt
Adapt10. Consider use of erythropoietin (EPO) for chronic anemia inappropriate patients
11. Prioritize freshest blood for infants and small children Conserve
12. aggressive crystalloid resuscitation prior to transfusion in
shortage situations (blood substitutesmay play future role) Use RBC :Plasmain 1: 1 ratio in Trauma cases.
P
Conserve
13. Long term shortage, collectautologousbloodpre-operativelyand
considercrossovertransfusion Conserve
14 . Implementlower hemoglobintriggers for transfusion P , W , MCI * Conserve
© 2020 NorthwestHealthcareResponseNetwork.
V* * Conserve
15. Considerlimitinghigh-consumptionelectivesurgeries(selectcardiac,orthopedic, spinal, etc.)* * (procedureslikelyto requireblood transfusions)P , W , +/ -
16 . Consideruse ofEPO in patientswith anticipatedacutebloodlossP ,W , MCI
17 . FurtherlimitPRBCuse, ifneeded, to activebleedingstates, considersubsequentrestrictionsincludingtransfusionfor treatableshockstatesonly * * (modificationof transfusionthresholds) W , P,MCI
* * Re-allocate
18. Consider Minimum Qualificationsfor Survival (MQS) limits on use of
for example , only initiate for patients thatwillrequire < 6 unitsand/ or consider stopping transfusion when > units utilized )
specificMQS limits should reflectavailable resources at facility . * * P , ,MCI
V * * Re-allocate
19. Reduce or waive usual 56 days inter-donation period * based upon
pre- donation hemoglobin / explore FDA variance * , MCI Adapt
20. Reduceweightrestrictionsfor 2x RBC apheresisdonationsaccording
to instrumentsusedandmedicaldirectorguidance* W P , MCI Adapt
21. increase in red cell: Plasmaratio ( 3 : 1) in massive transfusion
protocols in consultation with blood bank medical staff* * W , Conserve
Plasma 22. early use of plasma in trauma with anticipated massive
hemorrhaging and/ or brain injury . Thaw early and use blood warmer. Conserve
23 . Switch community inventory to liquid plasmaP, W , MCI * * Adapt
24 . using Group A Plasma P, W , MCI V * * Adapt
25 . female donors withoutwhite cell antibody testing. P , W , MCI * * Adapt
Substitute
26. Thoughnot true substitute, consideruse of fibrinolysisinhibitorsor
othermodalitiesto reversecoagulopathicstates (tranexamicacid ,
aminocaproicacid, activated coagulationfactor use, fibrinogen
concentrate, prothrombin complexconcentrate, or otherappropriatetherapies)MCI, P , W
27 . FDA variance to exceed24 collectionsper year for critical
types* = - W ( . . GroupAB) P , W , MCI Adapt
28 . Encourage early use of cryo in trauma with anticipated massive
hemorrhaging and/ orbrain injury. Thaw early and use blood warmer. Conserve
Cryoprecipitate29. nottrue substitute, consider useoffibrinolysis inhibitors or
modalities to reverse coagulopathic states ( tranexamic acid,aminocaproicacid , activated coagulation factor use, fibrinogen
concentrate, prothrombin complex concentrate, or other appropriate
therapies). MCI, P , W
Substitute
30 . Obtain FDA varianceto exceed 24 collectionsperyearfor critical
types* = - W ( . . GroupAB). P Adapt
Substitute
Platelets31. Thoughnottrue substitute, consideruse of desmopressin (DDAVP) tostimulateimprovedplateletperformancein renalandhepatic failurepatientsMCI P, W
32. Consideraliquotingfrom apheresisplatelets. For children, considersplitting whole blood platelets formore than onerecipient. P, W ,MCI
© Northwest Healthcare Response Network.
Nonleukoreduced
Adapt Leukoreduced
33. • Convert whole blood donors to apheresis donors . Standard Practice.W , P , MCI
Adapt
34. Transfuse platelets only for active bleeding, further restrict to lifethreatening bleedingifrequired by situation P, W ,MCI Conserve
35 . prophylacticuse of platelets. P, W , MCI Adapt
36 . • Accept female platelet donors regardless of HLA antibody , W , P, MCI Adapt
37 . changingbacterialdetectionstrategy. MCI, P. Potentially Adapt
38. Obtain FDA variance to allow new Pool and Store sites to ship across
state lines* P , W , MCIAdapt
39. for variance of 5 day outdaterequirement* P , MCI Adapt
Adaptedfrom theMinnesotaDepartmentofHealth, OfficeofEmergencyPreparednessFDA approval/ variancerequiredvia Associationof BloodBanks(AABB)
* *Education and/orexperienceisnecessary in thesettingof a community-widecriticalshortage
UPDATED: Feb 17, 2020
Next Revision Due: 2023
© 2020 Northwest Healthcare Response Network .
MASS CASUALTY BURN TREATMENT – 2 / 24 / 2020 FINALREGIONAL RESOURCE CARD
Harborview MedicalCenter (HMC)
Transfer Center 1-888-731-
INITIALASSESSMENT PRIMARY ASSESSMENT & INTERVENTIONS SECONDARY ASSESSMENT & INTERVENTIONS
CallUW Transfer Center to talk with a Burn
Fellow / Attending, who can assist with triage, care ofburninjured patients and transfer
Mass Casualty Burn ConsultationGuide:
1. TBSA adults, > 15 peds( 2nd/ 3rd degree)
2 . Circumferential3rddegreeburnYES
3 . Respiratoryinjury/ inhalation
4 . Burn plustraumaor other comorbidities
5. High- voltageelectrical( 1000V) or chemicalinjury
NO
OUTPATIENTMANAGEMENT< 20 % TBSA adults, < 15 % TBSA pediatrics
• Oral fluid ( sports drinks, electrolyte solution )PO painmanagement
• Refer to burn dressing guide and supply listElevate extremity burns
6 . Protect yourself using body substance isolation. Stop the burning
process, cover with loose linen, keep warm
7. Perform standard primary and secondary survey for any trauma
patient. Donotbedistractedby burn tissue
8 . Airway/Breathing- Assess for altered LOC, obstruction, respirat
compromise, burnsto face or oropharynx
• 8a. Administer 100 % oxygen via non rebreather/ETT, if suspected
inhalation injury (enclosed space, carbonaceous sputum , 10%
• 8b Carbon monoxide (CO ) exposure signsandsymptoms:
and nausea (20 % -30 % )(30 % -40 %
Coma (40 % -60 % )
Death ( >60 % )
• 8c. Consider intubation for GCS < TBSA , direct upper
airway injury , deep facial burns
9 . Circulation - Assess vital signs. Hypovolemic shock signs including
tachycardia are common > 20 % TBSA
. large bore /
9b . InitialfluidsLR /NS if estimated TBSA 20 adults and > 15
pediatrics : (See secondary assessment for nextsteps in fluidresuscitation # 12c)
years: 125 /
years: 250 /years 500 /
• 9c. Treatadult SBP < 90 and pediatric SBP < (2x age in years) ]
with IV / bolus. Avoid extra fluid when possible
10. Disability – Assess neurologic status: GCS/ AVPU , check pupils,cervical spine protection , if trauma, high -voltage > 1000 V ) injury11. Expose / Estimate - Brush away loose material if concern for chemical
exposure , remove clothing, jewelry , and contact lens. Protect from heat
loss; hypothermia occurs quickly. Circumferential trunk or extremity burn : elevate extremities ,
check pulses. Full- thicknessescharmayneed surgicalrelease
12. Adjuncts
• 12a.Nasogastric or orogastric – Intubatedpatients
12b . EstimateTBSA usingRule of Nineschart
12c. Consensusformula LR / NS: 3 x % TBSA =
fluids in 24 hrs. Give in first 8 hrs and next 16 hrs.
Increase/decrease fluidsby 20 % hourly to targetYES
12d . Pediatrics , addmaintenance fluid (below )
using in addition to Consensus formula in # 12c
1st 10 kg
o 2 m 2nd 10 kg
1 remainingkg = total /
• 12e. Foley – Target urineoutput( uo) 30 / hradultsor
/kg/ in pediatrics < 30 kg.• 12f. Pain control - small doses of opioids
13. History AMPLET or SAMPLE mnemonic
14. Head to Assessment
YES
CRITICAL BURN FEATURES9 % RULEOFNINES
for adult and child
18 %front
15 . TBSA > 25 % partial thickness or > 10 % full - thickness burns
16. Circumferential full thickness burns
17 . Burn plus trauma or other comorbidities
18 . Hemodynamic instability despite ongoing fluid
resuscitationas outlinedin 9b and
18 %
back
18 %front
18 %
back18 % 18 %
CRITICAL: High priority fortransferto Burn Center. YES NO
1114% 14%
SERIOUS BURN FEATURES
DO NOTCOUNT DEGREE BURNSwhen calculating the
RuleofNinesTBSA (TotalBodySurfaceArea)
AdditionalBurn Center ConsultsCyanidePoisoning - Consider ifseveremetabolicacidosis despite adequatefluid resuscitation as outlined in 12c .
Electrical- myoglobin in urine (red pigment) there is a risk of rhabdomyolysis
Chemical and radiologic - consider need for antidote or specific therapies .
Consult Poison Control
19. Secondary priority for transfer-may have to manage in
place awaiting transfer (up to 72 hours)
• 20. Referto burn dressingguideandsupply list
• 21. Infectioncontrol provider gown, glove, andmaskwhen wounds exposed . No prophylactic antibiotics
• 22. Intubated : Consider tube feeds
22a . Non- intubated: encouragehigh calorie PO
1st degree : red intact skin no blisters
2nd degree : red/ pink ,moist, sensate , blisters , blanches
• 3rd degree: dry, leathery, insensate , non- blanching
( see photos below for reference )
NorthwestHealthcareResponseNetwork. Burn TriageSRC.
Resource and Recommendations Strategy Conventional Contingency Crisis
CommandandControl,Communication,
Coordination
GeneralPreparednessInformation
• 23 . HMCBurn Center is an ABA/ACS verifiedburn centerin theWAMIregionwith 18 ICU and 23 acutecarebeds.24. Massburn incidentsare unusualbutdo occur. Theabilityofnon-burn hospitalsto triage and initially treat
victimsis criticalto successfulresponseand should be a planninggoalofallhospitalswithnumbersofvictims
depending on the facility size and role in the community .
• 25. In amajor incident, victimsmay require care at the initialreceivinghospitalfor up to 72 hoursuntiltransfer
to definitive burn care.26 . The role of the DisasterMedical Control Center (DMCC ) in anymajor event is to distribute patients from the
scene to area hospitals . There are different DMCC s in the region . HMCis the DMCC for King County . Patientdistribution is often done by the DMCC with limited information from the field. In an event involvingmany burn
patients it is highly probable that multiple ED' s will receive patients and be responsible for their initial
triage/stabilization.
• 27. Notification: In a majorburn incident, HMC,DMCC, NWHRN, Publichealth and area EOC'swillbenotified.
• 28. IfHMCisunableto accommodatecasualtiesorrequireassistancewith transportation/resourceissues,communicationwillneedto occurbetween areahospitals, DMCC, Healthcare
coalitions, PublicHealth, area EOC' s andpotentiallyotherregionalburn centersdependingon themagnitudeof
the eventand extentofinjuries. (See Burn Surge Annex, pending 2021)
Prepare
Capacity
• 29. Each facility is encouraged to activate its own internal contingency / disaster plan ifneeded to manage
multipleburn patients.
• 30. In a majorevent, someburn ICU patientsmayneedtobe cared for in non-burn centeracute care units.
31. In coordination with HMC Burn Center, forwardmovementto other burn centers in adjoining statesmaybe
needed .
Adapt
Space
• 32. NationalDisasterMedicalSystem (NDMS) patientmovementmayneedto beutilized. Adapt
© 2020 NorthwestHealthcareResponseNetwork .
ResourceandRecommendations Strategy Conventional Contingency Crisis
Outpatient/ Supplies Planning
• 33. Institutions should prepare based on role in community. Outpatientclinics andurgentcare centersmay alsocacheappropriatesupplies for their locationandpatientpopulation. Suggestedburn dressingsupplies(per
patient) (seebelow) Prepare
Supplies(for72hours)
Inpatient Supplies Planning
34. Institutionsshould prepare based on rolein community . In contingency or crisis situationsnon-burn centers
maybe asked to stabilize or potentialprovide extended care to burn patients.
Suggested burn dressingsupplies(per patient) (see below )
Increase
Supply
Adapt
Adapt
Staffing
Staff
• 35. Strongconsideration shouldbe given to trainingphysician and nursingstaffon care ofmajorburnspreincidentandhavingquick-referencecards/materialsavailableforburn stabilization.
36 . Level & IIITraumaCentersshould considerhavinga cohortofproviderstrainedin the ABA Advanced
Life Support(ABLS) and ACS DisasterManagementEmergencyPreparedness( DMEP) .
37. Identify staff with priorburn treatment experience (i. e .military ).
• 38 . See Staffing Scarce Resource Card for further staffing considerations .
• 39. Staff should have access to just- in -timetraining provided to non -burn nursing and physician staff reinforcing
key pointsofburn patient care (including importance of adequate fluid resuscitation, urineoutputparameters,principlesofanalgesia, dressing changes, wound care andmonitoring
• 40. In a Mass casualty event, call the HMC Transfer Center 1-888 -731-4791for consultation in caring for burn
patients.
41. NDMSpersonnelandothersupplementalstaffmayberequired.
Conserve
Adapt
Subst
Prepare
SpecialSpecial Considerations
Consider availability ofresources for:. Pediatrics: age-and size appropriate equipment: intravenous, intraosseous access devices,medication dosing
guides. Consider using color - coding pediatric guides.
© 2020 NorthwestHealthcareResponseNetwork .
ResourceandRecommendations Strategy Conventional Contingency Crisis
CriticalBurn Features : Survivability Grid
• . The following grid provides an example of triage decisions thatmay become necessary in the setting ofoverwhelmed resources or in austere conditionswhere crisis standards of caremay be instituted. The
survivability grid utilizesthe same 4 color scheme used for EMS personal. Survivability will differ if the patient hassustained an inhalation injury .
44 . Use of the survivability table should be done in close collaboration with the Burn Center but should NOTsubstitute for amore globalassessment of thepatient. (See ABLS 2018 update) http ://ameriburn .org /wpcontent/uploads/2019 /08 / 2018 -abls -providermanual.pdf
45 . IfBurn Center resources are limited , critical burn patientsmay need to be cared for in non-burn centers. Justin Time training and on -line resources are available to non -burn centers in these situations. Please refer to
https://crisisstandardsofcare utah.edu /Pages/ home.aspx; This website requires registration and login password .please consider planning ahead and gaining access before an event occurs.
Re
Triage Allocate
© 2020 NorthwestHealthcareResponseNetwork .
UW MedicineHARBORVIEW
MEDICALCENTER
REGIONALBURNCENTER
(
Jar)
SSD9 % RULE OF
for adult and child
ElasticAdult
Greasygauze(
roll)
(
tubes) Antibiotic
ointment
Kerlixroll(6
in)
4x4
Gauze
(
Boator
package)
4x8Gauze
18x18Gauze
netting(
inch)
drg Silver
Impregnated18 %
front
18 %back
18 %
Head 1 / 418 %
front 10 inch
18 %
back face18 % 18 % /
Arm Three 8x
8 1- 2 6 inch
One 8x 20
Hand/ Fingers
Hand4 in
1 4 1/ 4 1 12 1Fingers1 in
Torso Four 8 x2 each
side2 16 12 inch
(ant/ post) Two 8x
Burn DressingGuideandSupply Estimates:Goalforpartialthicknessburnhealingis to keep
the woundmoist and free from infection
• degreeburn :o degreeburnsdonot countwhen
calculating the TBSA using the Rule ofNines
burn chart. Apply lotion or ointment and
leave open to air . No dressings needed
• 2nd degree burn :
o Apply a greasy gauze dressing with thin layer
ofantibioticointment. Changeevery 1-2 days
o Or applysilver impregnateddressingto moistburns on flat surfaces. Dressingmust lay flat
againsttheburn . Secure in placewith elastic,
netting etc . Change every 7 days3rd degree burn :
o Apply SSD and cover with thin layer of gauze
Change every 1- 2 days
Perineal
1/ 2
( ant/post) 1/4 1 12 inch Two 8x
each side
Six 8x
2 3-4 10 inch
Four 20
Foot/ Toes400 gm jar : 1jar per 9 % tbsa
o Antibiotic ointment: 1 tubeper 9 % tbsa
o Greasy gauze 4 in 9 yard roll: 1 roll per 9 % tbsa
o Gauze 6 inch x 3 yd roll: 1roll per 9 % tbsa
gauze : ( 1box or boat)per 4 % tbsa
1 / 2 each 1/4 1 1/2 1-2 6 inch
©2020 Northwest HealthcareResponse Network .
2 / 2020
References:
• i . American Burn Association. Advanced Burn Life SupportProvider Manual2018Update. http :/ / ameriburn. org /wp-content/uploads/ 2019/ 08/ 2018- ablsprovidermanual.pdf
• ii. AmericanBurn Association. 2013 Burn Care Resourcesin North America USBurn Centersavailablefrom http: / / ameriburn. org/ BCRDPublic.pdf
• iii. American CollegeofSurgeons, ATLS: AdvancedTraumaLife Support , Chapter9, Pgs 169- 185
iv . DMEP: DisasterManagementandEmergencyCourse, AmericanCollegeof SurgeonsCommitteeon Trauma, Subcommitteeon DisasterAndMass Causalities2016
112 - 120
v . Buidelines for Burn Care Under Austere Conditions: Introduction to Burn Disaster, Airway and Ventilator Management, and Fluid Resuscitation ; ABA , BurnCare & Res; Sep Oct Kearns, Randy D .
• v1: Guidelines for Burn Care Under Austere Conditions: Special Etioloiges: Blast, Radiation, and Chemical Injuries; ABA , JBurn Care& Res 38 ( 1) e482 ; Cancio , LeopoldoC; Jan - Feb, 2017
viii. https: / / crisisstandardsofcare .hsc.utah.edu /_ Requires login and password , recommend obtaining during planning not response .
1st degree Superficial 2nd degree Partial Thickness 3rd degree Full Thickness
FINALAPPROVED : 2 24 /2020
NextRevision due: 2023
WashingtonStateDepartmentof
HealthNORTHWEST HEALTHCARE
ResponseNetwork.© 2020 NorthwestHealthcareResponseNetwork .
HEMODYNAMIC SUPPORT AND IV FLUIDS March 19, 2019 FINALSTRATEGIES FOR SCARCE RESOURCE SITUATIONS
ConventionalCapacity– The spaces, staff, and suppliesused areconsistentwith daily practiceswithin theinstitution. These spacesandpracticesareusedduringa majormass casualtyincidentthattriggersactivationof the facility emergencyoperationsplan.
ContingencyCapacity – Thespaces, staff, andsuppliesusedare notconsistentwith daily practices, butprovide care to a
standard that is functionally equivalentto usualpatient care
practices. These spacesor practicesmaybeused temporarily during
a majormass casualtyincidentor on a more sustainedbasisduringa disaster(when thedemandsof the incidentexceedcommunity
resources)
Crisis Capacity Adaptivespaces, staff, and suppliesarenotconsistentwith usualstandardsof care, butprovidesufficiencyof care inthesettingof a catastrophicdisaster (i .e ., providethebestpossiblecareto patientsgiven thecircumstancesand resourcesavailable). Crisiscapacityactivationconstitutesa significantandadjustmentto standardsofcare (Hick et al, 2009).
RECOMMENDATIONS Strategy Conventional Crisis
Equipmentand Suppliesand Training1. Cacheintravenous(IV ) cannulas, tubing, fluids, medications, andadministrationsupplies, oralrehydrationpackets(ORS) and
intraosseous( 10 ) equipment, includingdrillandmanualplacementneedles.
2. Conduct training and education re: oraland enteralhydration, andhypodermoclysisfluid administrationoptions.
3 . Develop system wide scarceresourcecommunicationplanswith clear lines ofresponsibility andaccountabilityto keep staffawareof
shortagesandconservation strategies.
4. Considercentralizedinventorycontrolof criticalmedicationsand fluids( e. g. proceduralareas, day surgery areasmayhave
separateinventorycontrolof criticalresources) .
Prepare
IV Fluid ConservationStrategies
5. MonitorCDC, FDA and ASHP updateson supply and conservationstrategies.6 . Switch to oraltherapywheneverpossible (e. g. antibiotics, anticoagulants, electrolytereplacements).
7 . Discontinue (Keep vein open ) orders.
8 . Adopt NPO strategies as recommended by the (2 hours for liquids, 4 hours for breast milk , 6 hours for infant formula , lightmeal
ornonhuman milk ) to limit "maintenance IVF .
9 . Review electronic medical record order sets to ensure conservation strategies are being enforced .10. Iforal therapy is not feasible or indicated consider IM or SQ injection .
. IfIV medications must be used, consider alternative compounding strategies to minimize IVF use such as syringe infusion pumps; IVpush administration, following the ISMPSafePracticeGuidelinesfor Adult IV PushMedications”
12. Considerusingalternative fluids ( e. g. dextrose or LR) , or other volumeexpanders( e. g. colloids) depending on clinicalsituation.
13. Repackage smallbags from larger source followingthe Repackagingof certain Human Drug ProductsbyPharmacies and
Outsourcing Facilities 2017, authored by FDA.
SubstituteEmphasize EnteralHydration Instead of IV HydrationProvide oralhydration (ORT ), when possible
14. Provide guidelines for oral rehydration therapy , including indications for hospital referral, to outpatient providers .
UtilizeAppropriate
OralRehydration
Solution
• 15. Oralrehydration solution : 1- literwater ( 5 cups) + 1 tsp salt + 8 tsp sugar , add flavor (e . g .,juice) asneeded.
• 16 . Rehydrationformoderatedehydration50- over 2- 4 hours.
Pediatric
Hydration
Pediatricmaintenancefluids:
17 . Four / kg / for first 10kg of bodyweight (40 / for 1st 10 kg).
18. Two / kg/ h for second 10kg ofbody weight (20 / for 2nd 10kg = 60 / for child ).
19. One / kg/ h for each kg over 20kg (example - 40 kg child = 60 mL/ h plus 20 / 80 mL/ ).
Supplementforeach diarrheaor emesis.
Substitute
Providenasogastric or gastrostomy(NG G -tube) hydrationfor both adults and pediatricpatientswhen applicable.
• 20. For fluid support, 8-12F(pediatric: infant3 . 5F, < 2yrs ) tubes arebettertolerated than standardsizetubes.21. For additionalequipmentsize guidelines, refer to a pediatriclength-based resuscitationtape, e. g. , the Tape
NOTE: Clinical (urine output,etc.) and laboratory (BUN ,urine specific gravity) assessments and electrolyte correction are key components of therapy and are not specifically addressed by these recommendations.
© NorthwestHealthcareResponseNetwork
and Syringe Pumps
22. Ensure IV pumps are charged and battery lifemonitored.
23. Consider stocking alternate emergency equipment for IV administration such as buretrolsand drip counters, other devices such as
the Drip Assist for use in austere environments.
Conserve
Conserve24. Reserve IV pumps, if limited, for use for criticalmedicationssuch as sedatives, analgesics, certain antibiotics and hemodynamic
support
Substitute Epinephrinefor Other VasopressorAgents in Shortage25. Forhemodynamicallyunstable patients> 18 yo who are adequately volume-resuscitated, consider adding epinephrine( of
/ml) to 1000mL onmini-drip tubingand titrate to targetblood pressure.
26 . For children < 18 yrs. add 0 .6 X weight(kg) to equaltotalmgof Epinephrineto add to a 100mlbagofNS. Runonmini-drip tubingstart at 1 / (= 60 drips/ hr or 1drip/minute). This startingepinephrinerate 0. 1mcg/ kg/min , a standardstartingepinephrinedose, assumingthat 1mL60 dripsformini-drip tubing; increasedrip rate to targetbloodpressure.
Substitute
Re-use CVP, NG, and Other SuppliesAfterAppropriateSterilizations/Disinfection27. In crisis situations, when consideringre-use of otherwise single use disposable equipment, alternate sterilization techniques should
be discussed usingavailable expert opinions such as CDC, WHO localpublic health and infection control specialists. When possible ,
consensusrecommendation should bemade. Possible sterilization options during crisis include:
o 27a) High-leveldisinfectionfor at leasttwentyminutesfordevicesin contactwithbodysurfaces( includingmucous
membranes) ; glutaraldehyde , hydrogen peroxide 6 % , or bleach ( 5 .25 % ) diluted 1: 20 (2500 ppm ) may be acceptable solutions.
NOTE: chlorine levels reduced if stored in polyethylene containers - double the bleach concentration to compensate ).
Re- use
Substitute
Intraosseous and Subcutaneous (Hypodermoclysis ) Replacement Fluids28. Consider clysis” as an option when alternative routes of fluid administration are impossible / unavailable .29. Intraosseousadministrationshould beconsideredbeforehypodermoclysis.
Intraosseous30 . Intraosseousinfusion is notgenerallyrecommendedforhydrationpurposes, butmaybeuseduntilalternativeroutesare available.Intraosseousinfusionrequirespumporpressurebag. Rateof fluid delivery is oftenlimitedby pain ofpressurewithin themarrowcavity. Thismaybereducedby pre-medicationwith lidocaine(preservative- free) 0 .5mg/ kg slow IV push.
Hypodermoclysis5,631. Cannotcorrectmore than moderatedehydration via this technique.32.Manymedicationscannotbe administeredsubcutaneously.
33. Commoninfusionsites: pectoralchest, abdomen, thighs, upper arms.34. Commonfluids: normalsaline(NS), , 1/2 NS (Can addup to 20-40mEqpotassiumifneeded.).35 . Insert21/ 24 gaugeneedleinto subcutaneoustissueat a 45 degreeangle, adjustdrip rateto 1-2 perminute(Mayuse 2 sitessimultaneouslyif needed. ).36 . Maximalvolumeabout3 liters/ day; requiressite rotation.
37 . Localswelling can bereducedwith massageto area.38 .Hyaluronidase 150 units / liter facilitatesfluid absorptionbutis notrequired;may not decreaseoccurrenceof localedema.
Consider Use ofVeterinary and OtherAlternativeSources for IntravenousFluidsandAdministrationSets Adapt
AdaptedFrom the MinnesotaDepartmentof Health, Officeof Emergency Preparedness FINAL version: March 19, 2019
Nextreview andupdate due : 2022
1https: / /www.fda.gov/ downloads/DrugsDrugSafety/ DrugShortages/UCM582461.pdf
2http: / anesthesiology. pubs. .org/ article.aspx?articleid= 2596245& = 2. 204142672. 159725813. 1522250986-8516730731522250986
: / /www.ismp.org/ sites/ default/ files/attachments/ -11/ ISMP97-Guidelines-071415 -3. % 20FINAL.pdf
https:/ /www.fda. / downloads/ Drugs/Guidances/UCM434174.
5Caccialanza, R, et al, SubcutaneousInfusionsof Fluids for Hydrationor Nutrition: A Review , JPEN 2018;42:296 -307
Bruno, VG , Hypodermoclysis: a literature review to assist in clinicalpractice, Einstein (Sao Paulo) 2015; 13( 1): 122-8
WashingtonState Departmentof
HealthNORTHWESTHEALTHCARE
ResponseNetwork.
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MECHANICAL VENTILATION / EXTERNAL OXYGENATIONSTRATEGIES FOR SCARCE RESOURCE SITUATIONS
ConventionalCapacity The spaces, staff, andsupplies used are
consistentwith dailypracticeswithin the institution. Thesespaces and
practicesareused during amajormass casualtyincidentthat triggers
activation ofthefacilityemergencyoperationsplan.
ContingencyCapacity - spaces, staff, and suppliesused
arenot consistentwith daily practices,butprovide care to a
standardthat is functionally equivalentto usualpatient care
practices. These spaces or practicesmaybeused temporarilyduringa majormasscasualty incidentor on a moresustainedbasis during adisaster (when thedemandsof the incident exceed community
resources)
Crisis Capacity - Adaptive spaces, staff, andsupplies arenotconsistentwith usualstandardsof care, butprovidesufficiency of care in
the setting of a catastrophicdisaster( i. e. , providethe best possible care
to patients given the circumstancesandresourcesavailable) . Crisis
capacity activation constitutes a significant and adjustmentto standards
of care (Hick et al, 2009) .
RECOMMENDATIONS Strategy Conventional Contingency CrisisPrepare
Substitute
Conserve
IncreaseHospitalStocksofVentilatorsand VentilatorCircuits, ECMO or bypasscircuits
Access AlternativeSources for ventilators / specialized equipmentObtain specializedequipmentfrom vendors, healthcarepartners, regional, state, or Federalstockpilesvia usual emergencymanagement processes and provide just -in -time training and quick reference materials for obtained equipment
Decrease Demand for VentilatorsIncreasethreshold for intubation / ventilation.
Decreaseelective proceduresthat requirepost-operative intubation.
Decreaseelectiveproceduresthat utilize anesthesiamachines.
non-invasive ventilatorysupportwhen possible.
Re-use Ventilator Circuits• Appropriate cleaning must precede sterilization .
If using gas ( ethylene oxide ) sterilization , allow full 12- hour aeration cycle to avoid accumulation of toxic byproducts on surface .
irradiationor othertechniquesasappropriate.
UseAlternativeRespiratorySupportTechnologiestransportventilatorswith appropriatealarms- especiallyforstable patientswithoutcomplexventilationrequirements.
Useanesthesiamachinesformechanicalventilationasappropriate/ capable.Use -level(BiPAP) equipmentto providemechanicalventilation. (ContingencyandCrisis)
bag-valveventilationas temporarymeasurewhileawaitingdefinitivesolution/ equipment(as appropriateto situationextremely labor intensive and may consume large amounts of oxygen ).
Assign Limited Ventilators to Most Likely to Benefit ifNo Other Options are Available :
Re-use
Adapt
Re-allocate
See Pediatricand/ or Adult CriticalCare Algorithm
Adapted From theMinnesota Department of Health, Office of Emergency Preparedness As ofJune 19 , 2017
WashingtonStateDepartmentof
lealthNORTHWESTHEALTHCARE
ResponseNetwork
©2020NorthwestHealthcareResponseNetwork.
OXYGEN - 03 /29/ 2019 DRAFT REVISIONSTRATEGIES FOR SCARCE RESOURCE SITUATIONS
ConventionalCapacity – The spaces, staff, and supplies
used are consistentwith daily practiceswithin the institution.Thesespacesand practicesareusedduring a majormasscasualty
incidentthat triggers activation ofthefacility emergency
operationsplan.
Contingency Capacity The spaces, staff, andsuppliesused are
not consistentwith daily practices, butprovide care to a standard thatis functionally equivalentto usualpatientcare practices. These spaces
orpracticesmaybeused temporarilyduring a majormass casualtyor on a more sustainedbasis during a disaster (when the
demandsof the incidentexceed community resources)
Crisis Capacity - Adaptive spaces, staff, and supplies are not consistent
with usualstandardsofcare, but provide sufficiency of care in the setting ofa catastrophic disaster (i . e ., provide the best possible care to patients given
the circumstances and resources available) . Crisis capacity activationconstitutes a significant and adjustment to standardsof care (Hick et al,2009) .
Strategy Conventional CrisisRECOMMENDATIONS
Substitute &
Conserve
Conserve
InhaledMedications
• . Use compressed or room air foradministration ofnebulizedmedicationswhen clinically appropriate.• 2 . Restrict the use of Small VolumeNebulizerswhen inhaler substitutes are available .
• 3 .Restrict continuousnebulization therapy.
4 .Minimize frequency throughmedication substitution that results in fewer treatments (6h -12h instead of 4h-6h applications).
• 5. Change children from albuterolcontinuousnebulizers to Albuterol8 puffsMDI Q2 hrs when they are readyto stop continuoustreatments . Only use albuterolnebulizers in continuous form for truly acute status asthmaticus.
High -Flow Applications
• 6 . Assure all resuscitation oxygen bagshave shutoff valves and are shut off when not in use .
7 . Restrict the use ofhigh-flow adult cannula systemsas these can demand 12 to 40 LPM flows.8 . Restrict the use of simple andpartialrebreathingmasks to 10 LPM maximum .
• 9 . Consider intubation or non -invasiveventilation with a well-sealedmask over the use of high flow oxygen delivery systemsfor bothadult and pediatric patients during critical shortages.
Air -Oxygen Blenders10. Eliminate the low -flow reference bleed occurring with any low -flow metered oxygen blender use . This can amount to anadditional 12 LPM . Reserve air -oxygen blender use for mechanical ventilators using high- flow non -metered outlets. (These do not
utilize reference bleeds).11. Disconnectblenderswhen not in use.
Oxygen Conservation Devices• 12. Use reservoir cannulas if available at 1/ 2 the flow setting of standard cannulas.
• 13. Replace simple and partial rebreather mask use with reservoir cannulas or venti-masks at flow rates of - 10 LPM
14. Use High Efficiency nebulizers and use air flow instead of oxygen when clinically possible .
Conserve
Conserve
Substitute&
Adapt
Augment Oxygen Supply
• 15. Use hospital -based or independent homemedical equipment supplier oxygen concentrators if available to provide low - flow
cannula oxygen for patients and preserve the primaryoxygen supply for morecriticalapplications.16 . Consider other source of oxygen such as dentalor veterinary offices.
• 17 . Obtain oxygen supply from industrial sources, such assupplied by welding companies and underwater divingoperations.
• 18 .Reducehospitalwide from 50-40.
Substitute &
Conserve
Conserve
Monitor Use and Revise ClinicalTargets
• 19. Employoxygen titration protocolsto optimize flow or % to match targets for SPO2or20 . Discontinue oxygen at earliest possible time.
Conserve
© 2020 NorthwestHealthcareResponseNetwork.
• 21. Considervariableparameters for initiatingand continuingoxygen therapy:
StartingExample Initiate 02 Target Note: Thesetargetrangesneedtobe continually
NormalLungAdults SPO2 - 90% SPO290 %re-evaluated depending on resources available ,
the patient' s clinicalpresentation, ormeasured
Pediatrics SPO2 90 % SPO2 90 % determination . Ifno pulse oximetry isavailableinitiateoxygen therapybased on
Severe COPD History SPO2 <85 % SPO2 88 - 90 % clinicalassessment(e. g. cyanosis, increasedwork
ofbreathing , valid respiratory scores etc.)
Expendable Oxygen Appliances• 22 . All non -standard disinfection and sterilization procedures should betested and assessed prior to widespread use. Possible options
during crisis include: Use terminal sterilization or high -level disinfection procedures for oxygen appliances, small & large-bore tubing ,and ventilator circuits. Bleach concentrations of 1 :10 , high - levelchemical disinfection , or irradiation maybe suitable . Ethylene oxide
gas sterilization (if available ) is optimal, butrequires a 12- hour aeration cycle to prevent ethylene chlorohydrin formation with
polyvinylchloride plastics .
Oxygen Re-Allocation Implementation23 . For patientprioritization for oxygen administration or re-allocation during severe resource limitationsplease see Adult andPediatricCriticalCare Algorithms.
Re-use
Re-Allocate
Adapted From theMinnesota DepartmentofHealth, OfficeofEmergencyPreparedness DRAFTREVISION As ofMarch 29, 2019
WashingtonStateDepartmentof
HealthNORTHWESTHEALTHCARE
ResponseNetwork.
©2020NorthwestHealthcareResponseNetwork.
RenalReplacementTherapy Card
STRATEGIESFOR SCARCE RESOURCE SITUATIONSContingencyCapacity Thespaces, staff, and suppliesusedarenot
ConventionalCapacity The spaces, staff, andsuppliesusedCrisis Capacity - Adaptivespaces, staff, and supplies are not
consistentwith daily practices, butprovidecare to a standard thatis consistentwithusualstandardsofcare, butprovidesufficiencyofcareareconsistentwithdailypracticeswithintheinstitution. These
functionallyequivalenttousualpatientcarepractices. Thesespacesor in the setting of a catastrophic disaster ( i . e . , provide the best possiblespaces and practices are used during a majormass casualty
practicesmaybeusedtemporarilyduringamajormasscasualtyincidentor caretopatientsgiventhecircumstancesandresourcesavailable) .incidentthat triggersactivationofthefacilityemergency
on amoresustainedbasisduringa disaster(whenthedemandsof the Crisiscapacityactivationconstitutesa significantandadjustmentto
operationsplanincidentexceedcommunityresources) standards ofcare (Hick et al, 2009 ) .
Category RECOMMENDATIONS Inpatient Outpatient Strategy Conventional contingency Crisis
1 . Allorganizations that provide dialysis need to maintain internalemergency plans toprovidecare for the specialneedsofdialysispatientsduringany externalor internalemergencythatmay disruptstandardoperations. These plansshould addressappropriatewaterandpowersupply, equipmentand supplyneedsand staff/ providerconsiderations. (See links to resourcesin # 2 below)
All dialysisprovidersmustadvisetheir patientsin developingtheirownpreparednessplansincludingemergencyand contingencyplansfor food, medications,transportationandemergencycontactresources.
Dialysis patients need to be self-sufficient for up to 96hrs . Note that shelters are
unlikely to have foods appropriate for renal dietary needs (low sodium , etc . ) . PreparePersonalplanning guidance is available at:https:/ /www .kidney.org / sites/default/files /11- 100807 IBD disasterbrochure.pdf
https:/ /www .davita.com / kidney disease overview / living-with -ckd emergencypreparedness-for-people -with -kidney -disease / e /4930
3. Medicalneeds ofre-located renal failure patients from outside our region aresubstantial; themedical leadership ofNorthwest Kidney Center, DaVita and NW Renal
Network need to bemade aware of such incoming patients in order to be able to planfor their medical needs.
A.General
Prepare
Transportation Interruptions
4 . Chronic dialysis patients should coordinate with their service providers / dialysis clinics
first for transportation and other assistance during service / transportationinterruptions.
5 . Ifindividualproviders /dialysis clinics are unable to meet emergent supplementaltransportationneeds, referto the KingCountyWinterWeatherMedicalTransport
Plan and PierceCountyDepartmentof EmergencyManagementfortheirpossible
assistance
Adapt
Water Supply6 . Identify and quantify water -purifying capabilities for dialysis
7 . Identify alternative water source ifcity water is unavailable
Prepare
B.Water
8 . Identify limitationsand specialarrangementsneeded to use water tanker
a ) Availability ofreverse osmosis (RO )machines with carbon tanks
b ) Available means to generate adequate water pressure to units providing dialysis
Prepare
Water Contamination
9. Consider alternate sourcesofhighly purified water ( e. g. NorthwestKidney Centerwater reservetank, individualfacility wells, etc. ) keeping in mindthat potablewater
alone is NOT sufficiently purified for dialysis.
10. Consider transferring stable inpatients to outpatient dialysis centers for dialysis
treatmentsand vice versa dependingon locationof purifiedwatersource
Substitute
Adapt
© NorthwestHealthcareResponseNetwork
11. Consideruseofotherregionalassets forwaterreserves
Adapt
a ) JBLM assets: well, tanker
b ) Navy assets: desalinationandreverseosmosis capabilities(ship dependent)
c ) Commercialvessels
12 . Consider transferring stable inpatients to outpatientdialysis centers for dialysistreatmentsandviceversa
C.
PowerSubstitute
Adapt13. Consider transferring inpatients or outpatients to other hospitals or facilities out of
the affected region untilissueshavebeen resolved.
Prepare
D.Supplies
Dialysis Catheters , Machines Reverse Osmosis Machines , and / or
Other Supply Shortages14 . Maintain adequate stock of dialysis tubing sets and venous/peritoneal access
catheters (Quinton, etc.) andmedications(e. g. Kayexalate)
15. Identifyother sourcesof suppliesandmachines
16. Transfermachines/ suppliesbetweenoutpatientcentersandhospitals, or betweenhospitals Substitute
17. Consideralternativestaffingassignmentswith thefollowingrecommendations:
Dialysis Techs
1 .FormerDialysis
Techs who arenowtechs in other
specialties
2.GeneralNursewith
prior dialysis
experience .
E.Staff
Alternative Staff Recommendations
( listed in order of consideration )
Dialysis Nurses MDs(Nephrologist)
1. GeneralRN or 1 . Telemedicine
TransplantRN with nephrologist
previousexperience 2 . Retired nephrologist
who hasmaintained2 . Critical Care nurse medical license
with a dialysis
training 3 . trained in
dialysis
3. CriticalCareNurse
with no dialysis 4. CriticalCare MDwithexperienceandJIT experienceddialysis
nurseandJIT training.
4 . Generalnursewith
JIT 5 . Dialysisnurse with
extensive inpatient
dialysis experience
Substitute
Hemodialysis2PeritonealDialysis3Just-in -time Training (i . e. video, written instructions, handbook, etc.)
F.Treatment
Crush Syndrome
18. Initiate normalsaline IV hydration and acidosis prevention protocols immediately
either pre hospital or as soon as possible upon arrival to a healthcare facility toprevent/ treat rhabdomyolysis. Additional treatment recommendations :
a ) avoid nephrotoxic agents such as NSAIDS, aminoglycosides, ACE/ ARB' s alongwith other drugswhich may causehyperkalemia
b ) aggressive monitoring and treatment ofpotentialhyperkalemia
c) close monitoringof fluid status.
Conserve
©2020NorthwestHealthcareResponseNetwork.
Mode ofDialysis19. Optimize the mode of dialysisto providecare for the mostpatientspossible given
resourcesavailable
a ) ifwater is scarce, consider PD and CRRT asmodes of dialysis
b ) ifwater is readily available restrict to HD or PD and discontinue CRRT for staffconsiderations
Substitute
IncreasedDemandon Resources20. Shorten duration ofdialysis for patients that aremore likely to tolerate it safely
21. Patientsto utilize their home“ kits” ofmedication (Kayexalate) and follow dietaryplansto help increase timebetween treatments.
Conserve
Conserve
G.Triage
InsufficientResourcesAvailable For All Patients RequiringDialysis
22. Changedialysis from to needed based on clinical and laboratoryfindings( particularlyhyperkalemiaandimpairedpulmonaryfunction) parameters
may change based on demand for resources
23. Conceivable (but extraordinary) situationsmay occur whereresources areinsufficient to the point that some patients may not be able to receive dialysis (forexample, pandemic when demand nationwide exceeds available resources ).Prioritization should follow the Crisis RRT Triage Algorithm andWorksheet . In multiorgan system failure (MOSF ) refer to the Adult /Pediatric Critical Care TriageAlgorithm and Worksheet .
Re-allocate
Approved : 5 / 10/ 17AdaptedFrom the Minnesota DepartmentofHealth, Officeof Emergency Preparedness
1MedicalLeadership Contact Information: DaVita (253 -733 -4602); Northwest Kidney Centers (206 -720 -8505); NW RenalNetwork (206 -923-0714).
2 Contact PublicHealth Seattle King County Dutyofficer, PierceCounty EmergencyManagement Duty Officer or theNorthwestHealthcareResponseNetwork DutyOfficer formore information.
WashingtonStateDepartmentof
Health1NORTHWESTHEALTHCARE
Response Network.
©2020NorthwestHealthcareResponseNetwork.
Washington State Department ofNORTHWEST HEALTHCARE
Response Network .
PARTICULATE RESPIRATORS AND GENERAL PPE
(N95 , Elastomeric , PAPR , CAPRSTRATEGIES FOR SCARCE RESOURCE SITUATIONS
ConventionalCapacity– Thespaces, staff, andsuppliesusedareconsistentwith daily practiceswithin theinstitution. These spacesandpracticesareused duringamajormasscasualty incidentthattriggersactivation of the facility emergencyoperationsplan.
Contingency Capacity The spaces, staff, and supplies used
are not consistentwith daily practices, butprovide care to a
standard that is functionally equivalentto usualpatient care
practices. These spacesor practicesmaybe used temporarily duringa majormasscasualty incidentor on a more sustained basis during a
disaster (when the demandsof the incident exceed communityresources)
Crisis Capacity Adaptivespaces, staff, and supplies are notconsistentwith usualstandardsof care, butprovidesufficiency of care in
the setting of a catastrophicdisaster ( i. e. ,providethe bestpossible caretopatientsgiven the circumstancesand resourcesavailable). Crisis
capacity activation constitutes a significant and adjustmentto standardsof care (Hick etal, 2009).
RECOMMENDATIONS Strategy Conventional contingency Crisis
GeneralInfection ControlProcedures
• 1. Screen allpatientsforsymptomsspecific to currentsituation andkeepupdatedto anychangingscreeningrecommendations
2. Athealthcarefacilitieswherepatientshavescheduledappointments, considerscreeningprior to arrivalto limitexposureandresources
3. Establish procedures formanagingvisitors and illhealthcare personnel.
4 . Establish triage procedures and separate areas for ill andwellpatients .
• 5 .Assign dedicated staff to minimize exposure.
6 .Require when possible, or strongly encourage vaccination of primarypersonneland first responders, according to vaccinescheduleasrecommendedfor existingcircumstancesbythe CDC andtheAdvisoryCommitteefor ImmunizationPractices(ACIP).
7. Seriouslyconsidercreationof a registryto reflectthe vaccinationstatusofprimarypersonneland first respondersto aid indecisionsregardingservice assignments.
8. Educateandroutinelytrain allstaffregardingappropriateuseandproperdonninganddoffingproceduresofPPEand particulaterespirators.
9.Maintaingoodhandhygieneproceduresincludinggloves, handwashingwith soap andwaterand/oralcoholbasedhandsanitizersdepending on the current recommendations.
10. Maintain plan for N95 Fit Testing
PrepareEngineering Controls
11. When applicable to specific institution consider designing and installing engineering controls to reduce or eliminate exposure byshielding healthcare providers and otherpatients from infection individuals. Examples of engineering controls include physical
barriersor partitions to guidepatients through triage areas , curtainsbetween patients in shared areas, closed suctioning systemsfor
airway suctioning for intubated patients, aswell as appropriate air-handling systems(with appropriate directionality , filtration ,
exchange rate, etc. ) that are installed and properly maintained.
Cache / Increase Supply Levels
12. Clarify currentCDC and OSHA guidelinesforrespiratorand otherPPEuse;monitorfor updatesand recommendations.
13 . CacheadditionalsuppliesofPPE and respiratorsand their functionalcomponents(e. g. fit testing supplies, batteries, cartridges,filters, hoods etc .).
• 14 . Review vendor agreements , contingencies for delivery and production , including alternate vendors .
15 . Consider other NIOSH approved respirators in times of short supply ( . g . These include N99, N100 , P95 P99 P100 , R95 , R99, andR100.)
• 16 . Review current supply of PPE and determinebaseline and surge burn rates to better plan supply needs.17 .Maintain a reserve sufficient to meet estimated needs of PPE for allinfectiousdiseases.18 .Review cached PPE on a regular basis for expirations dates and consider replacing/updating caches by rotating PPE into daily use19. Obtain masks , cartridges and other PPE from alternate sources such as industrial suppliers and companies welding ,
manufacturing , etc. - as indicated .
Substitute
© NorthwestHealthcareResponseNetwork
Substitute
& Conserve
Conserve
Re-use
20 . Request Strategic NationalStockpile ofrespiratorswith theknowledgethat they maybe from differentmanufacturers. They
may notbe functionalin all situations(i. e surgical use ) andtheymay require additionalfit testingbeforedeployment.
21.Donotdiscard unused expired PPE; submit for extension through * ** (?NIOSH ? CDC?)
DecreaseUse ofPPE22. Clarify currentCDC, OSHA and NIOSH guidelines for PPE use;monitor for updatesand recommendations
23 .Medical/ surgicalmasks can bereusedby infected patientsuntilthemasksare no longer useabledueto moistureor damage.
• 24 .When PPE, especially Respirators are in shortsupply, aerosol- generating procedures should only beperformed onpatientswhenmedically necessary and cannotbepostponed
25. Limit the number of healthcarepersonnelwith patientcontact to only those essentialforpatientcare andsupport, especially
during aerosolgenerating procedures.
26 . Consider primary use of PAPRS, Elastomericor other Respirators to conserve on N95masks
27. Ensure staff are educated and understand specific PPE requirementsduring current situations so asnotto overuse PPE28 . Develop specific protocolsfor PPE distribution so asto ensure PPEisbeing used responsibly29 . Cohort patientswith known disease to limitdonningand doffingof PPE
• 30 . Considerlimiting visitors31. Consider changes in staffing (i. e. unimmunized staff given assignments that would not require significant PPE use)
Respirator Extended
• 32. Clarify currentCDC and OSHA guidelinesfor respiratoruse; monitorforupdatesand recommendations.
• 33. Policiesand recommendationsaround extendeduse” or“ re-use respiratorsshouldincludeinputfrom occupationalhealth,
infection control, infectiousdisease specialists, state and localpublichealth and anynationalrecommendationsaroundthe situation
at hand.
34. For N95, considerwearing a loose-fittingbarrierthat doesnot interferewith fit or seal ( e . g., surgicalmask, face shield ) over the
respirator to extend itsuse.
35. In general, wearing an respirator overmultiple serialpatient encounters(while minimizing touching) is favored over
removingandre-donningbetweenencounters(i. e. extendeduse is favoredoverre-useofN95).
36 . Cleaningand filterreplacementproceduresandextendeduse of filters and/ orhoods/shieldson all othermechanicalrespirators( . e. elastomericrespirators, PAPRS .) should be done accordingtomanufacturers protocolsandguidelines.
Re-useRespiratorAfterRemoval
37 . Clarify current CDC and OSHA guidelines for respirator use; monitor for updates and recommendations .
38 . Review manufacturer recommendations for cleaning and re -using and CAPR face shields when appropriate .
• 39 . Policies and recommendations around " extended use" or " re-use of respirators should include input from occupational health ,
infection control, infectious disease specialists, state and localpublic health andany nationalrecommendationsaround the situation
athand.
• 40. Use and storeusedrespirators(hood, mask, shield) individuallyin such a way that thephysicalintegrityandefficacyoftherespirator will notbe compromised
• 41. Label respirator with a user' s name before use to preventinadvertent use by another individual.
• . Practice appropriate hand hygienebefore and afterremovalof the respirator and, ifnecessary and possible, appropriatelydisinfect the object used to store it.
Respirators should be discarded if visibly damaged or contaminated .
44 . The specific number ofsafe reuses for N95' s is very difficult to estimate . In general check the specific N95 manufacturer
recommendations. In generalFive (5 ) is the recommendednumber of donning of a re-usedN95- type respirator
45 . ConsiderN95 decontaminationwith ultravioletgermicidalirradiation (UVGI) , or other testedmethodof decontamination to
extend theuseofrespirators.
Re-allocate/ prioritize
46 . Respiratorsuse shouldbeprioritizedonly to thosehealthcareprovidersidentifiedashighestriskbasedon epidemiologyofcurrentsituation.
. Identifymedicalpersonneland caregiverswith documentedvaccination, immunityafter an illnessor lowerrisk ofcomplicated
infection to provide directpatientcontactwithout a respirator.
Re-use
Re-allocate
Re-use
Re-allocate
©2020 Northwest Healthcare Response Network .
1 to any device such asN95, elastomeric respirators, PoweredAir Purifyingrespirators (PAPRS, ControlledAir PurifyingRespirator ( ) equivalent. NIOSH approved particulaterespiratorscanbe found at:
https: / / www . cdc. gov /niosh / npptl/ topics / respirators / disp part/RespSource html; https: / /www . cdc. gov/ niosh / npptl/ topics / respirators / disp part /default .html
2CDC and NIOSH overview ofrespirators : https: / www . cdc. gov / niosh / topics / respirators default html
eTool: https:/ /www .osha . gov / SLTC / etools/ respiratory / index. html
4 Extendeduse is defined aswearing the samerespirator for repeated close contact encounterswith multiplepatientswithoutremoving the respirator betweenpatients (e. g. triage area, dedicated waiting roomsorwards, etc). "Reuse " is defined as using the same respirator formultiple encounters but removing itafter each encounter https: / www . cdc. gov /niosh / topics recommendedguidanceextuse. html
https: / www . cdc. gov/ niosh / npptl/ topics/ respirators/ disp part / respsource3respreuse. html
researchon the decontaminationofN95Respirators: https: / / . ncbi.nlm . nih. gov/pmc/ articles/ PMC4699414/pdf/ nihms747549.pdfhttps: / academic.oup.com / annweh/ article/ 53/8 /815/ 154763
https: / / academic.oup.com / annweh/ article / 56 / 1/ 92/
5 https:/ / www .cdc. gov /niosh / npptl/ topics / respirators/ disp part/ default html
https: / /www.cdc. gov / niosh/ topics/howcontrols/recommendedguidanceextuse.html
FINAL APPROVED : 2 / 2020
NextRevision due: 2023
©2020NorthwestHealthcareResponseNetwork.
WashingtonState Departmentof
Health NORTHWEST HEALTHCARENORTHWESTHEALTHCAREResponseNetwork
Crisis Capacity Adaptive spaces, staff, and supplies arenotconsistentwith usualstandardsofcare, butprovide sufficiency ofcare in
the settingof a catastrophicdisaster (i.e ., providethebestpossible care
to patients given the circumstancesand resourcesavailable) . Crisis
capacity activation constitutes a significantand adjustmentto standardsof care (Hick etal, 2009).
Strategy Conventional Crisis
Prepare
STAFFING
STRATEGIES FOR SCARCE RESOURCE SITUATIONSContingency Capacity The spaces , staff , and supplies used
Conventional Capacity – The spaces, staff, and supplies used are are notconsistent with daily practices, but provide care to a
standard that is functionally equivalent to usualpatient careconsistentwith daily practices within the institution . These spaces and
practices. These spacesor practicesmaybe used temporarilyduringpracticesare used during a majormasscasualty incident that triggers
a majormasscasualtyincidentoron a more sustainedbasisduringaactivationofthe facility emergencyoperationsplan.
disaster ( when the demands of the incident exceed communityresources
RECOMMENDATIONS
Staff and Supply PlanningAssure facility has process and supporting policies for disaster credentialing and privileging - including degree of supervision required,clinicalscope of practice,mentoringand orientation, and verification of credentials.
Encourage employee personalpreparednessplanning (ready. gov, redcross.org) .Cacheadequatepersonalprotectiveequipment(PPE) and supportsupplies.
Educate staff on facility disaster response andrecommend regularly scheduled HICS training .
• Educate staff on community , regional and state disaster plans and resources .Develop facility plans addressing staff' s family / pets or staff shelter needs ( such as daycare and unaccompanied minor needs ) as well
as transportation plansfor staff to get to and from the facility .
Include a process of staff identification and verification . Recommend photos and hard - copy files.Create Job Cards for essential services and functions.
Pre-identify criticalpositionsand ensureredundantstaffing for these.Recommendredundantstaff communicationsand notificationplans/procedures.
FocusStaffTimeon CoreClinicalDuties• Minimize meetings and relieve administrative responsibilities not related to event.
Cohort inpatients per OSHA /Public Health or CDC guidelines.
Reduce documentationrequirements.
UsingSupplementalStaff• Utilizeadministrativepositions( e.g. nursemanagers) as patientcare extenders.
Adjustpersonnelwork schedules(longerbutless frequentshifts, etc. ) ifthiswillnotresultin skill / PPEcompliancedeterioration.
• Voluntary call-back of staff
• Increaseuse ofagency, perdiem , travelers, floatpools, locumsstaff
Retain staff for extendedhours in accordancewith labor contract andexistingcontracts/ agreementswhen applicable)
Use familymembers/lay volunteers to providebasicpatienthygieneand feeding - releasing staff for other duties.
Postpone andreschedule out-patientnon-acute andpreventative care appointmentsto openmore acutecareout-patientappointments during surge .
Focus Staff Expertise on Core Clinical Needs
Personnelwith specific critical skills (ventilator, burn management ) should concentrate on those skills; specify job duties that can besafely performedby othermedicalprofessionals.
Reduceavailabilityofnon-timesensitivelaboratory, radiographic, and otherstudies.Postponeand rescheduleelectiveproceduresifitwillimprovestaffingand space needsand does notresultin unduepatientinconvenience
Have specialty staff overseelargernumbersofdifferently specializedstaffandpatients( for example, medical/ surgerynursesworking
in criticalcareareoverseen by a criticalcare nurse) .
Conserve
Adapt
Substitute
Adapt
Conserve
Substitute
Conserve
Use AlternativePersonnelto MinimizeChangesto Standardsof Care
• Bringin equally trainedstaff(burnor criticalcarenurses, DisasterMedicalAssistanceTeam [DMAT), otherhealth system or Federalsources).
• Cancelallnon-acute /preventative care appointments,surgeries andprocedures(e.g. endoscopies,etc.) anddivert staff to emergencydutiesincludingin -hospitalor assistingpublichealth at externalclinics/ screening/ dispensingsites.
Adapt
© 2020 Northwest Healthcare Response Network .
• Use less trainedpersonnelfrom outsideinstitutionwith appropriatementoringand just-in-timeeducation(e.g.,healthcaretraineesorotherhealthcare workers,MedicalReserveCorps,retirees).
• Implementalternateconsultationand care techniquessuch as telemedicine.• Providejust-in-timetrainingfor specificskills.
AdaptedFromthe MinnesotaDepartmentof Health,OfficeofEmergencyPreparedness Updated: March21, 2019
©2020NorthwestHealthcareResponseNetwork.
Washington State Department of
HealthNORTHWESTHEALTHCAREResponseNetwork.ADULT Critical Care Triage Algorithm
Crisis Standards of Care
Updated Version:Mar 2020
This Algorithm is intended to be used alongside the attached Worksheet.
Answering each question requires the supplemental information in theWorksheet.
* * * Please use them together * **
Assumptions for use:1. Health Officer has declared a crisis situation requiring scarce resourcemanagement and crisis standards ofcare,
where crisis standardsofcare is defined as “ substantialchange in usualhealthcare operations and the levelof
care it is possible to deliverwhich ismade necessary by a pervasiveor catastrophic disaster”.
2 . Healthcaresystemsare overwhelmed despitemaximizing allpossible surge and mitigation strategies impactingthespace and/or staff and/or suppliesneeded to deliver usuallevels ofcare.
Washington State has adopted and will use the ethical framework developedby the NationalAcademyofMedicine,
which stresses the importance of an ethically grounded system to guide decision -makingin a crisis standards ofcare
situation . Alldecisions and communications willbebased on the ethicalprinciples below . The National Academyof
Medicine defines these ethicalprinciples as:
Fairness – Standards that are, to the highest degree possible , recognized as fair by those affectedby them
including themembers of affected communities , practitioners, and provider organizations, evidence basedand responsive to specific needsof individuals and the population .
Duty to care Standards are focused on the duty ofhealthcareprofessionals to care forpatients in need ofmedicalcare .
Duty to steward resources – healthcare institutions and public health officials have a duty to steward scarceresources, reflectingtheutilitarian goalofsaving the greatest possible numberof lives.
Transparency in design decisionmaking, and informationsharing.
Consistency – in application across populations and among individuals regardless of their human condition
( . g race, age disability, ethnicity, ability to pay, socioeconomic status, preexisting health conditions, socialworth, perceived obstacles to treatment, past use of resources).
Proportionality - public and individualrequirements mustbe commensurate with the scale of the emergencyand degree of scarce resources .
Accountability – of individualdecisions and implementation standards, and of governments for ensuringappropriate protections and just allocation of available resources .
1 . IOM ( InstituteofMedicine2009. Guidancefor EstablishingCrisis StandardsofCarefor in DisasterSituations: A LetterReport.
Washington, DC: NationalAcademies Press
Northwest Healthcare Response Network . CriticalCare Adult Algorithm 1
WashingtonStateDepartmentofADULT Critical Care Triage AlgorithmCrisis Standards of CareUpdated Version :Mar 2020
HealthNORTHWESTHEALTHCARE
ResponseNetwork.
Discharge to
palliativecareNO
STEP
Screen Patient for ICU Care after
reviewingpatient's end oflife directive/POLST or similar livingwill agreements
Reassessdaily to
determine continued
priority for
hospitalization
- -
STEP 2
A . Doespatientmeet ICU inclusioncriteria? and
B . Willpatientbenefitfrom ICU care?
Consider
discharge topalliativecare
- - - - - -
YES NO
Admit to floor
STEP 3
ICU Resource available ?NO
STEP 4
Compelling reason forreallocation ofresource ?
NO
STEP 5
Add patienttoICU waitinglist
YES YES
Re -evaluate
STEP 6 ADMIT TO ICU
Data Collection
1. Expected duration ofneed 2. Prognosis
3 . Response to treatment 4 .MSOFA 5 . Baseline functional status
UNCHANGED
WORSENING
Considerdischarge fromcritical care , provide
appropriate palliative care .
Consider continued ICU care
or consider moving to floorwith oxygen or NIPPV (as
appropriate ) . Reassess dailyto determine continuedneed
for hospitalization.
IMPROVING
ConsidercontinuedICUcare. Ifextubatedwithnosignificantorganfailure,
transfer to flood and
reassess daily to determine
continuedneed for
hospitalization.
© 2020NorthwestHealthcareResponseNetwork. CriticalCare Adult Algorithm
ADULT Critical Care Triage WorksheetCriticalCareGuidelines During Crisis Capacity
Washington State Department of
HealthNORTHWESTHEALTHCAREResponseNetwork.
This Worksheet , alongwith the corresponding Adult Critical Care Algorithm , are to be usedby “ Triage Teams” duringa declared emergency eventwhereby an appropriate healthcare official has implemented crisis standards of care. It isrecommended that a “ Triage Team comprised of seniormedicalpersonnel, preferably not those primarily takingcare of the individualpatient under consideration . Please see “ Scarce Resource Triage Team Guidelines” for furtherinformation
STEP 1: Screen adult patients for ICU care during scarce resources
Proceed to following after reviewingpatient' s end of life directives/ POLSTor similar livingwill documents. For the
following conditions consider available staffing and resources. If resources are inadequate, considertransferringthe following patients to out-patientor palliative care with appropriate resources and support as
can be provided .
1. Pre -existing or Persistent coma orvegetative state
2 . Severe acute trauma ( e. g.non -survivable head injury)
3. Severeburnswith Low Survivalburn scoresbasedon the TriageDecisionfor Burn Victimstable (See Table A
below ). See Burn Scarce Resource Card for managementofcriticalburn patientoutside of a Burn Center.
4. Significant underlying disease process that predict poor short term survival*
* Examples of underlyingdiseasesthat predict poor short-term survival, despite standard treatment, includebut
are notlimited to :
Severe congestive heart failure
Severe chronic lung disease• Centralnervous system , solid organ orhematopoietic malignancy with prognosis for recovery
Severe cirrhotic liver disease with multi-organ dysfunction
5. Baseline functional status (consider loss ofreserves in energy , physicalability , cognition and general health )
© 2020NorthwestHealthcareResponseNetwork. CriticalCare Adult Algorithm 3
STEP 2: Determineifpatientmeets ICU Inclusion Criteria
2A : Patientsmusthave at least one of the following INCLUSION CRITERIA :
1. Requiresventilatory support, either invasiveornon- invasive
Clinicalevidenceofimpendingrespiratoryfailure
• Refractoryhypoxemia (SpO2< 90 % on 0.85)• Respiratoryacidosis (pH<7.2)
Inability to protect ormaintain airway
2 . Hypotension(SBP < 90) secondary to eitheran acute medicalor traumacondition, with clinical
evidenceof shock (alteredleveloff consciousnessdecreasedurineoutput, or other evidenceof end
stage organ failure ) refractory to volume resuscitation that cannotbemanaged in a non-ICU setting .
2B : To determine critical care resource allocation the following should be considered :
• Expected durationofneedof criticalcareresource
• Prognosiswith consideration to both currentepidemiology and underlyingillness
• Response to currenttreatment
• DegreeofOrgan Dysfunction as measuredby theMSOFA (ModifiedSequentialOrgan FailureAssessmentScore) Please see Step 6 regardinguse of scoring system
• Baseline functionalstatus (consider loss of reserves in energy , physical ability, cognition and generalhealth )
* Examples ofunderlying diseases that predictpoor short- term survival, despite standard treatment,include but are not limited to :
Severe congestiveheartfailure
Severe chronic lung disease
Centralnervous system , solid organ or hematopoietic malignancy with poorprognosis for recovery
Severe cirrhotic liverdisease withmulti-organ dysfunction
STEP 4 : Assess forre-allocationofCriticalCare Resource
To determinecriticalcare resourceallocation thefollowingshould beconsidered:
• Expected duration need of criticalcareresource
• Prognosis with consideration to both currentepidemiology and underlyingillness
• Response to currenttreatment• DegreeofOrgan Dysfunction asmeasuredby theMSOFA (Modified SequentialOrgan Failure Assessment
Score) Please see Step 6 regarding use ofscoring systems
• Baselinefunctionalstatus (considerloss ofreserves in energy,physical ability , cognition and generalhealth )
* Examples ofunderlying diseasesthat predictpoorshort- term survival, despite standard treatment,includebut are notlimited to :• Severe congestive heartfailure
Severe chronic lung disease• Centralnervous system , solid organ or hematopoieticmalignancy with poor prognosis for recovery
Severe cirrhotic liverdisease with multi-organ dysfunction
©2020 NorthwestHealthcareResponseNetwork. CriticalCare Adult Algorithm 4
STEP 5 : Critical care waiting list
If a patient meets ICU inclusion criteria and resources are not available , patientwill be placed on an ICU waitinglist. As resources become available their clinical situation willbe re- assessed and they will be re-triaged based
on criteria outlined in Step 6 . If a clear distinction cannot be made between patients of similar triage priority ,
the resource willbe allocated to thepatient who has been waiting the longest.
STEP 6 : Admit to ICU
Patient data collection outlined on Step 6 of the Algorithm willbe continuous and ongoing. It isrecommendedthat every 24 hours of a patient's ICU stay, their clinicalcondition willbe reviewed and they willbe determinedtobe “ Improving” “Unchanged or “Worsening” . This determination must not only take into account data pointsas outlinedin Step 6 butmustalso include updated epidemiology , criticalcare resource availability and censusdemands.
Previously, recommendationshad been madeto use MSOFA score aloneto determine triagecategories.However, based onmore recentdata2,3itis current consensus that a specific SOFA orMSOFA score cannot
accurately define clinical categories alone, and therefore all criteria outlined in Step 6 including currentepidemiologymust be taken into accountwhen deciding if patients are “ Improving,” “Unchanged,
Worsening”
Other Adult Considerations
All patients receiving critical care before the onset of crisis standards will be re-assessed based on the samecriteria as all incoming critical care patients . The same Data as outlined in Step 6 should be obtained andresources re-allocated ifneeded dependent on the Triage Team assessment and decisions.
The use of ECMO should be decided on an individual basis by the ICU attending, nursing supervisor and ECMOrepresentative based on prognosis, suspected duration of ECMO, availability of staff and other resources .
1 . CrisisCapacity: Adaptive spaces, staffand supplies arenot consistentwith usualstandardsofcare, butprovidesufficiencyofcare in the setting
of a catastrophic disaster ( i . . provide thebest possible care to patients given the circumstancesand resources available) . Crisis capacity
activation constitutes a significant adjustmentto standardsof care. (Hick et al,2009, IOM
2 . Grissom ,Colin K DisasterMed Public Health Preparedness 4(4 ):277 -284 , 2011
3. Shahpori, R ; Crit CareMed 39( 4):827-832, 2011
© 2020NorthwestHealthcareResponseNetwork. CriticalCare Adult Algorithm 5
Percent TBSA burn size
20 -29 30- 39 40 -49 50 -59 60 -69 70 -79 80 -890 - 9 10 - 19 90
0 - 1. 9
2 - 4
5 - 19
20- 29 Outpatient Delayed Immediate
Age,inyears
30- 39
40 -49
50-59
60 -69 Low survival,mayoptforexpectantmanagement
Table A
al the of outcomes to resources forSaffle, JR etal. Definingtheratioofoutcomesto resourcesfor triageofburnpatientsinmasscasualties. J burnCareRehabil
2005 ( 6) :478
© 2020NorthwestHealthcareResponseNetwork. CriticalCare Adult Algorithm 6
Washington State Department ofPediatric Critical Care Triage AlgorithmCrisis Standards ofCareUpdated Version :Mar 2020
HealthNORTHWESTHEALTHCAREResponseNetwork.
This Algorithm is intendedtobeused alongsidethe attachedWorksheet.
Answeringeach questionrequiresthesupplementalinformationin theWorksheet.
* * * Please use them together. * *
Assumptions for use:
1. Health Officer has declared a crisis situation requiring scarce resourcemanagementand crisis standardsofcare,where crisis standardsofcare is defined as “ substantialchange in usualhealthcare operations and the levelof
care it ispossible to deliverwhich ismadenecessary by a pervasive or catastrophic disaster” .
2 . Healthcaresystemsare overwhelmed despitemaximizing allpossible surge and mitigation strategies impacting
thespace and/orstaff and/orsuppliesneededto deliverusuallevelsofcare.
Washington Statehas adopted and willuse the ethicalframework developedby theNationalAcademy ofMedicine,which stressesthe importanceofan ethically grounded system to guide decision -makingin a crisis standards ofcaresituation. Alldecisionsand communicationswillbe based on the ethical principlesbelow . The NationalAcademyof
Medicine defines these ethicalprinciplesas:
Fairness – Standards that are, to the highestdegree possible, recognized as fair by those affectedby them
including themembers ofaffected communities, practitioners , and providerorganizations , evidence based andresponsive to specific needs of individuals and the population .
Duty to care Standards are focused on the duty of healthcare professionals to care for patients in need ofmedical care.
Duty to steward resources – healthcare institutions and public health officials have a duty to steward scarceresources,reflecting the utilitarian goalof saving the greatest possible number of lives.
• Transparency in design decision making, and information sharing.
Consistency – in application across populationsand among individuals regardless of their human condition
(e g. race, age disability, ethnicity, ability to pay, socioeconomic status, preexisting health conditions, socialworth , perceivedobstacles to treatment, past use of resources) .
Proportionality and individualrequirementsmustbe commensurate with the scale of the emergencyand degree of scarce resources.
Accountability individualdecisions and implementation standards, and of governments for ensuringappropriate protections and just allocation of available resources.
1 , 2 IOM ( InstituteofMedicine) 2009 .Guidance for EstablishingCrisis Standardsof Care for in DisasterSituations: A Letter
Report. Washington, DC:NationalAcademiesPress.
© 2020NorthwestHealthcareResponseNetwork. CriticalCare Pediatric Algorithm | 1
Washington State Department ofPediatric Critical Care Triage AlgorithmCrisis Standards of CareUpdated Version :Mar 2020
HealthNORTHWESTHEALTHCAREResponseNetwork.
STEP 1
Discharge to
palliative careNO Screen Patient for ICU Care after
reviewing goals of care with patient and
family
Reassess daily to
determine continued
priority for
hospitalization
-
STEP 2
A . DoespatientmeetICU inclusioncriteria and
B. Willpatientbenefit from ICU care? dischargetopalliativecare
- - - - -
YES
NO
- - - -
Admit to floor
i
Consult adult ICU partners to
discuss extendingthe definition
of adult criticalcareto
accommodateolder children
STEP 3
ICU Resourceavailable?
STEP 4
Compellingreason forreallocationof resource?
NO
STEP 5
Add patientto
ICU waitinglist
YES YES
Re-evaluate
STEP 6 ADMIT TO ICU
Data Collection
1. Expected duration of need 2 . Prognosis
3. Responseto treatment4 . PELOD
IMPROVINGUNCHANGED
WORSENING
Consider discharge fromcriticalcare, provide
appropriate palliative care.
Consider continued ICU care
or considermovingto floorwith oxygen or NIPPV (as
appropriate). Reassess dailyto determine continued need
for hospitalization.
Consider continued ICUcare. Ifextubated with no
significant organ failure ,
transferto flood and
reassessdaily todetermine
continuedneedfor
hospitalization.
© 2020NorthwestHealthcareResponseNetwork. Critical Care Pediatric Algorithm
Washington State Department ofPediatric CriticalCare TriageWorksheetCriticalCareGuidelinesDuring Crisis CapacityUpdated Version: Mar 2020
HealthNORTHWESTHEALTHCAREResponseNetwork.
This Worksheet , along with the corresponding Pediatric Critical Care Algorithm , are to be used by TriageTeams” during a declared emergency eventwhereby an appropriate healthcare official has implemented crisis
standards ofcare . Itis recommended that a “ Triage Team comprised of seniormedicalpersonnelpreferably not those primarily taking care of the individualpatient under consideration . Please see Scarce
Resource Triage Team Guidelines” for further information .
STEP 1: Screen PediatricPatientsfor ICU care DuringScarceResources
Proceed to the following after reviewing goals of care with patient and family ( .g . limited code status ). The
goals of care should reflect the best interest of thepatient.
For the followingconditionsconsideravailablestaffingandresources. Ifresourcesareinadequate, consider
transferringthe followingpatientsto out-patientorpalliativecare with appropriateresourcesand supportas canbeprovided.
1. Pre-existingor Persistent encephalopathy, comaor vegetative state
2 . Severe acute trauma( e . g . non -survivable head injury)
3 . Severeburnswith Low Survivalburn scoresbased on the Triage Decision for Burn Victimstable
( See Table A . See Burn Scarce Resource Card formanagement of critical burn patient outside of aBurn Center .
4. Significant underlying disease process that predictpoorshort term survival*
* Examplesofunderlyingdiseasesthatpredictpoorshort- term survival, despitestandardtreatment, include
butare notlimitedto:•Knownsevere chromosomalabnormalities with poorprognosis
•Knownsevere metabolic, neuromuscular, cardiac, oncologic or pulmonary disease with poor
prognosis
•Extreme prematurity at the limitsof viability
© 2020NorthwestHealthcareResponseNetwork. CriticalCare Pediatric Algorithm 3
STEP 2 :Determine ifpatient meets ICU Inclusion Criteria
2A : Patients must have at least one of the following INCLUSION CRITERIA :
1. Requires ventilatory support , either invasive or non -invasive
Clinicalevidence of impendingrespiratoryfailure• Refractoryhypoxemia( 90 % on > .85)
• Respiratoryacidosis (pH < 7 .2)Age
InabilitytoprotectormaintainairwaySBP (mmHG)
0-28 days <602. Hypotension(seetable A ) or clinicalevidenceof
shock ( defined as an alteredlevelof consciousness, 1month 1year <70
decreased urineoutput, or other evidence end 1year 10 years (age in years x 2) + 70stage organ failure) refractory to volume
> 10 years < 90resuscitation secondary to either an acutemedical
or trauma condition that cannotbemanaged in a Table A
non - setting.2B : To determine critical care resource allocation the following should be considered :
Expected duration ofneed of critical care resource
• Prognosis with consideration to both current epidemiology and underlying illness *
• Response to current treatment
• Degree of Organ Dysfunction asmeasured by the Pediatric Logistic Organ Dysfunction (PELOD 2) score.
(Table C) see Step 6 regardinguseofscoring systems.
*Examples ofunderlying diseases thatpredictpoor short-term survival, despite standard treatment,includebutare not limited to :
•Known severe chromosomal abnormalities with poor prognosis•Known severe metabolic , neuromuscular , cardiac , oncologic orpulmonary disease with poor
prognosis
• Extreme prematurity at the limits of viability
STEP 4 : Assess for re-allocation ofCritical Care Resource
To determine critical care resource allocation the following should beconsidered :• Expected duration ofneed of criticalcareresource
• Prognosiswith consideration to both currentepidemiology and underlying
• Response to currenttreatment• Degree ofOrgan Dysfunction asmeasuredby the Pediatric Logistic Organ Dysfunction (PELOD 2 ) score.
(Table C) Pleasesee Step 6 regardinguse ofscoringsystems.
* Examplesof underlyingdiseases that predictpoorshort-term survival, despite standard treatment,includebutare notlimitedto :
severe chromosomalabnormalities with poor prognosis
•Knownseveremetabolic, neuromuscular, cardiac, oncologic or pulmonary disease with poorprognosis
• Extreme prematurity at the limits of viability
© 2020NorthwestHealthcareResponseNetwork. Critical CarePediatricAlgorithm 4
STEP 5 : Critical carewaiting list
If a patientmeets ICU inclusion criteria and resourcesare notavailable, patientwillbe placed on an ICUwaiting list. As resourcesbecomeavailable their clinical situation willbere-assessed and they willbe retriaged based on criteria outlined in Step 6 . If a clear distinction cannotbemadebetween patientsofsimilartriage priority, theresource will be allocated to the patientwho has been waiting the longest.
STEP 6 : Admit to ICU
Patient data collection outlined on Step 6 of the Algorithm willbe continuous and ongoing. Itisrecommended that every 24 hours of a patient' s ICU stay , their clinical condition will be reviewed and they
will be determined to be “ Improving ” “Unchanged “Worsening ” . This determination must not only
take into account data points as outlined in Step 6 butmust also include updated epidemiology , criticalcare resource availability and census demands .
Pediatric prognostic scoring systems currently available ( e . g . PELOD2) are unable to accurately predictpatient outcomes and thus should notbe used as a sole indicator ofprognosis especially in a disaster
situation . When considering critical care resource allocation in a crisis , it is recommended that decisions be
made by a Triage Team . Decisions should be made based on best clinical judgment with full knowledge ofregional resource availability . (Ped Crit Care 2011)
Other Pediatric Considerations
All patients receiving critical care before the onset of crisis standards willbere-assessed based on the same criteriaas all incoming critical care patients. The sameData as outlined in Step 2 should be obtained and resources reallocated if needed dependent on the Triage Team assessment and decisions .
The use of ECMO should be decided on an individual basis by the PICU and/or NICU attending,nursing supervisorand ECMO representative based on prognosis , suspected duration of ECMO , availability of staff and otherresources
Percent TBSA burn size
10-19 20- 29 30- 39 40 -49 50-59 60 - 70 -79 80 -890 - 9 90
0 - 1. 9
2- 4
5 - 19
20 - 29 Outpatient Delayed Immediate
Age,inyears
30-39
40 -49
50-59
60-69 Low survival,may optforexpectantmanagement
Table B
Saffle, JR , etal. Definingtheratio of outcomesto resourcesfor triageofburn patientsinmasscasualties. J burn Care Rehabil200526 (6 ):478
© 2020NorthwestHealthcareResponseNetwork. CriticalCare Pediatric Algorithm 5
Table C. PELOD2Scoring System
Points bySeverityLevels
4 5 6
10 3 4Both fixed
5.0 - 10. 9 . 0
31- 45 17- 30
25 - 38
31-43
39 -54
44 -59
OrganDysfunctions
andVariables
NeurologicGlasgow Coma Score 211Pupillary reaction Both reactive
Cardiovascular
Lactatemia (mmol/ L < 5. 0
Mean arterial pressure (mm Hg)
O 1mo
1- 11mo
12-23 mo
24 -59mo60 - 143 mo
144 mo
Renal
Creatinine ( L
mo
1 - 11mo
12-23 mo
24 mo
60 - 143 mo
144mo
262 46 -61 32- 44
49-64
52- 66
36 - 48
38 -51
No
Respiratory
Pao, (mm Hg) /
Paco, (mm Hg) 59 - 94
Invasive ventilation Yes
Hematologic
WBC count( > 2
Platelets ( 10°/ L ) 77 - 141
variablesmustbecollected butmeasurementscan be doneonly if justified by thepatient' s clinicalstatus. If a variable isnotmeasured, it shouldbeconsiderednormal. If a variable is measuredmore than once in 24hr the worstvalue is used in calculatingthe score fraction ofinspired oxygen.Neurologicdysfunction: Glasgow ComaScore: usethe lowest value. If the patientis sedated, record the estimatedGlasgow ComaScore before sedation.
Assess only patients with known or suspected acute centralnervous system disease. Pupillary reactions: nonreactivepupilsmust be > 3mm.Donotassessafter iatrogenicpupillary dilatationCardiovasculardysfunction: Heartrate and mean arterial pressure: do notassessduring cryingor iatrogenicagitation.Respiratorydysfunction: Pao arterialmeasurementonly. Pao / ratio is considerednormal in children with cyanotic heartdisease. Paco, canbe
measuredfrom arterial, capillary, orvenous samples. Invasiveventilation the useofmask ventilation is notconsideredinvasiveventilation.Logit(mortality) = - 6 .61 + PELOD- 2 score.
Probabilityofdeath = 1/( 1 + exp logit(mortality) . CRITICAL CARE MEDICINE
1. Crisis Capacity : Adaptive spaces, staff and supplies are not consistent with usual standards of care, but provide sufficiency of care in
thesettingof a catastrophic disaster ( i . e . provide thebestpossible care to patients given the circumstancesandresourcesavailable) .
Crisis capacity activation constitutes a significant adjustment to standards of care. (Hick et al, 2009 )
2 . ECCGuidelines 2010 , Circulation 2010; 122 Suppl3: -
3 . Leteurtre, Stéphane; Duhamel, Alain ; Salleron , Julia ; Grandbastien , Bruno; Lacroix, Jacques ; Leclerc, Francis; on behalf of theGroupe Francophone de Réanimation et d Urgences Pédiatriques ( ; Critical Care Medicine41 7 ): 1761- 1773, July2013 . doi: 10 .1097 / CCM .Ob013e31828a2bbd
© 2020NorthwestHealthcareResponseNetwork. CriticalCare Pediatric Algorithm 6
Washington State Department of
HealthNORTHWESTHEALTHCARE
ResponseNetwork.
Scarce Resource Triage Team GuidelinesTo be used in conjunction with Scarce ResourceAlgorithmsduring Crisis Standards ofCareUpdated:Mar 2020
IntroductionIn the event of a large scale disaster - either a no notice eventsuch as a naturaldisaster or a prolonged situationsuch as a pandemic there is the potentialfor an overwhelmingnumberof critically illor injured patients. In thesesituations, certain medicalresourcesmay becomescarce and prioritizationofcaremayneed to be considered.
In 2009 the Institute ofMedicine ( currently the NationalAcademyof Medicine )published a landmark report,
Guidance for Establishing Crisis Standards of Care for use in Disaster Situation : A Letter Report. In this report theauthors defined surge capacity as a continuum from conventional to contingency and finally crisis. This framework
hasbeen nationally accepted and adopted . The definition of Crisis Capacity ” as set by the NAM , is a situationwhere space, staff and supplies “ are notconsistentwith usual standardsof care ,butprovide sufficiency of care inthe context of a catastrophic disaster (i. . , provide thebest possible care to patients given the circumstances and
resources available ).
The content of this document is based on a thorough review of the literature , guidelines published by leadingnationalhealthcare specialty colleges and societies, recommendationsofthe NationalAcademy ofMedicine anddetailed discussion and deliberation by theWA State Disaster MedicalAdvisory Committee (DMAC ), the DisasterClinical Advisory Committee (DCAC ) Central District and included input from both local and state CommunityEngagement Reports. ,3
This document is to be used in conjunction with the DOH ScarceResource Triage Algorithmswhich were developedby regional workgroups of Subject Matter Experts (SME), and approved by the Disaster Clinical Advisory Committee(DCAC) Central District . Implementation of these algorithms depends upon the development of individual CrisisStandards of Care Hospital, HospitalSystem , and Regional Triage Teams as outlined below .
Purpose
To provide a transparent, fair, equitable , and consistent approach to allocation of scarce resources during a declaredemergency in which Crisis Standards of Care (CSC)has been implemented .
Scope
Allhealthcareorganizationsandproviderswithin theaffectedregion ofthe CSC declaration.
Assumptions• A Health Officerhas declared a crisis situation and crisis standards ofcare has been activated.
• Healthcare systemsare overwhelmed despitemaximizingall possible surge andmitigation strategiesimpactingthe space and/ or staff and /or supplies needed to deliver usual levels of care
• Federal assets have been requested butmay bedelayed .
1. IOM ( InstituteofMedicine) 2009. Guidance forEstablishingCrisis StandardsofCare for in Disaster Situations: A LetterReport
Washington, DC:NationalAcademiesPress
2. 2 Washington StateCrisisStandardsof CareCommunityEngagementReport, June2019,WADOH.
3 . 3 Li-Vollmer, M .Health Care Decisionsin Disasters: EngagingthePublicOnMedicalService PrioritizationDuringa Severe InfluenzaPandemic.JournalofParticipatoryMedicine. Vol2 . December14, 2010 .
©2020 Northwest Healthcare Response Network . ScarceResource Triage Team Guidelines 1
Implementation Recommendations
A . General
All healthcare organizations within the affected region agree to implement a uniform triage process asoutlined in this document to be used along with the DOH Scarce Resource Triage Algorithms to include : AdultCritical Care , Pediatric Critical Care and RenalReplacement Therapy (pending) Algorithms.
B . CSC Triage Teams: Identification and Composition
1. CSC HospitalClinicalTriage Team
It is recommended that every in patient healthcare institution have a CSC Hospital ClinicalTriage Team
which will report to the Medical Care Branch Director (or equivalent position within organization' scommand structure during activation ofHICS.
a . It is recommended the CSC HospitalClinical Triage Team
• At least 2 -3 senior clinicianswith experiencein tertiary triage (e. g. CriticalCare, EmergencyMedicine,
TraumaSurgery, etc.), with one designatedas LeadTriage Officerwho oversees all Triageprocesses.• 1medicalethicist
• When possibleclinicianson the Triage Team willnotbe primary providersof the patientsunderconsideration
• When patients requiring a scarce resource fall under a specific specialty such asburn , trauma, pediatrics , etc.then all attemptswillbemadeto consultthatspecialtyeitherin person or remotelyduringconsideration
b . Allpatientspresentedto the CSC HospitalClinicalTriage Team willberecorded in a CSC Hospital
Clinical Triage Team Log, which will include:
• Date andtimeofreferral
Nameof referringclinician andcontact information
Patientidentifiers: These shouldinclude only date of birth and sex. Patient' s nameandotherdemographic data should notbe considered by the Triage Team . Hospital specific MRN should be
notated to confirm patient identification butshould notbemade available to the Triage Team
All clinical information presented to the Triage Team at the timeof decision
Triage Team decision, date andtime of thedecision, and all supporting documentation reviewed andproduced for the decision
Ifpatient isreferred , date and time of referral and contact information of receiving Clinical Triage Team
• Patientoutcome(ifknown)
C . If the patientrequiresreferraloutsidean individualhospitaland the hospitalis partof a widerhospitalsystem please see Section 2 . Ifthehospital is not part of a larger hospitalsystem thenplease refer to Section 3 .
d . It is recommended the CSC HospitalClinical Triage Team follow the communication guidelinesoutlined in this document in order to maintain accurate and up to date situationalawareness.
2. Hospital systemsduring CSC
It is recommendedeveryHospitalSystem maintain goodcommunicationsbetweenindividualhospitalsin
their system to assistin situationalawarenessfor thescarceresourcein question. It is recommendedthat
everyhospitalsystem havea mechanism bywhich a criticalresourcecan bemaximizedanddistributed
throughouttheir system and thatall appropriatechannelshavebeen exhaustedto obtain additionalresources. When a specifichealthcarefacilitywithin a hospitalsystem lacksa specificresource, identifying
thatresourcewithin their system shouldbethe firststep in patientplacement. This wouldbemanagedbythe CSCHospitalSystem TriageTeam .
©2020 Northwest Healthcare Response Network . Scarce Resource Triage Team Guidelines
a . All patientspresented to the CSC HospitalSystem Triage Team willbe recorded in a CSC Hospital
System Triage Team Log, which will include:
Date and timeofreferral
Nameof referring clinician andcontact information• Patientidentifiers : These should include only date ofbirth and sex. Patient' s name and other
demographicdata should notbeconsideredby the Triage Team . HospitalspecificMRNshould be
notated to confirm patient identification butshould notbemade available to Triage Team .
All clinical information presented to the Triage Team at the timeofdecision
Triage Team decision , date and time of the decision , and allsupporting documentation reviewed and
produced for the decision
• Ifpatient is referred to the Regional Triage Team , date and time of referraland contact information ofreceiving RegionalTriage Team
Patient outcome ( ifknown)
b Those patients who cannot bemanaged within their system will need to bepresented to the CSCRegionalClinicalTriage Team for consideration and prioritization within a differenthospitalsystem .
3 . CSC Regional Clinical Triage Team
It is recommended a CSC RegionalClinicalTriageTeam manageprioritizationandplacementofpatients in
need of a scarce resource in the affected geographic region who cannotbemanaged within a specifichospitalsystem .
It is recommendedthe CSC RegionalClinicalTriage Team fairly representthe healthcarefacilities andsystemswithin the region. If a region hasdeveloped a healthcare coalitionDCACthen itis recommendedthatmembersof theCSC Regional Triage team bedetermined in coordinationwith localDCAC, StateDMAC LHO , other Public Health experts, outside SMEs, etc and can consist ofmembersfrom thelocalDCAC, healthcareexecutivesor the clinicalcommunityatlarge.
If a regiondoesnothave a localDCAC then CSC RegionalClinicalTriageTeam memberswillbedeterminedby the State DMAC in coordinationwith the SHO, LHO, other Public Health experts, outsideSME' s, etc. and
can consist ofmembersfrom the DMAC, healthcareexecutivesor the clinicalcommunity atlarge.Recommendedmembersof the CSC RegionalClinical TriageTeam are as follows:
• Seniorclinicianswith experiencein tertiary triage (e. g. CriticalCare, EmergencyMedicine, TraumaSurgery,etc. ), with one designated as Lead TriageOfficerwho oversees all Triage processes .
• 1medicalethicist
• When possible, clinicians on the CSC RegionalClinical Triage Team willnotbe primary providers ofthepatients under consideration,normembers of the referring CSC Hospitalor HospitalSystem ClinicalTriage Team (s ).
When patients requiring a scarce resourcefall under a specific specialty such asburn , trauma, pediatrics,
etc . then all attemptswillbemade to consult thatspecialty eitherinperson or remotelyduringconsideration .
a. Allpatientspresentedto the CSC RegionalClinical Triage Team willbe recordedin a CSC RegionalClinical Triage Team Log which will include:
• Date and timeof referral
Nameofreferring clinician and contact information
Patient identifiers : These should include only date ofbirth and sex. Patient's name and otherdemographic data should not be considered by the Triage Team . Hospital specific MRN should be
notated to confirm patient identification ,butshould notbe made available to Triage Team .
All clinical information presented to the Triage Team at the time of decision Triage Team decision dateand time and all supporting documentation
Patientoutcome (ifknown)
©2020 Northwest Healthcare Response Network . Scarce Resource Triage Team Guidelines
b Itis recommended the CSC Regional Clinical Triage Team follow the communication guidelines below in
order to maintain accurate and up to date situationalawareness .
The CSC Regional Clinical Triage Team is under the sameOversight and Re-evaluation processes asthe CSC Hospital and HospitalSystem Triage Teamsoutlinedbelow .
. Oversight
In order to maintain transparency and ensure a fair, equitable andconsistentapproachto allocation of ascarceresourcesit is importantthatall triageteamshave an oversightprocessfor decisionsmadeduring
an event
1. CSC HospitalandHospitalSystemsOversightCommittee
When an event occurs which requires activation of the CSC Hospitalor HospitalSystem ClinicalTriageTeam the following documentationwillberequiredand should bemaintainedand reviewedby the CSCOversightCommittee designated by theMedicalOperations Branch DirectorunderHICS.
a . It is recommended the CSC Triage Team OversightCommittee consistoftheSenior clinicians with experience in tertiary triage (e .g. Critical Care, Emergency Medicine, Trauma Surgery,etc.) ,with one designated as Chair who oversees all processes
When possible clinicians on the CSC Triage Team Oversight Committee will not be primary providers ofthe patientsunderconsideration
• When patientsrequiringa scarceresourcefallundera specificspecialty such asburn, trauma,pediatrics, etc.then all attempts willbemade to consult that specialty either in person orremotely during consideration
At least one medicalethicist
b Allpatientspresentedto theCSCHospitalor HospitalSystem Triage Team willbe reviewedbyan
CSC Oversight Committee and will be recorded in an CSC Oversight Triage Team Log, which will
• All patient demographicsDate and time of the case consideration
• Allpatientinformation presented to theClinicalTriage Team at the timeof consideration
Triage Team decision, date and timeof the decision , and all supporting documentation reviewed and
produced for the decision
• Ifpatientwas referred, date and timeof referral and contact informationofreceiving ClinicalTriage Team
• Patientoutcome
C. It is recommendedthat at agreed upon intervalsthe CSC OversightCommitteewill review all
cases presented to the CSC Hospitalor HospitalSystem Triage Team to ensure the following:
• All appropriate clinical information was considered• Accurate documentation was recorded
• Significantvariancesbe reviewed and addressed
d . Depending on thenature of the incident oversightreview may be in real time(e. g. in a prolongedeventsuch as a pandemic) . Howeverin no notice, sudden or briefevents, this review may be
retrospective.
©2020 Northwest Healthcare Response Network . Scarce Resource Triage Team Guidelines
2 . CSC Regional Oversight Committee
When an event occurs which requires activation of the CSC Regional Clinical Triage Team the following
documentation willberequired and willbemaintained and reviewed by the CSC RegionalOversight
Committee. If a region has developed a healthcare coalition DCAC then it is recommended thatmembersof the CSC RegionalOversight team be determined in coordination with localDCAC, State DMAC LHO
other Public Health experts , outside SME s , etc. and can consist ofmembers from the localDCAC,
healthcare executives or the clinical community at large.
If a region does not have a local DCAC then the CSC RegionalOversight Team memberswill bedetermined by the State DMAC in coordination with the SHO, LHO , other Public Health experts, outsideSME s, etc . and can consist ofmembers from the DMAC (or their designees), healthcare executives or the
clinical community at large. Recommendedmembers of the CSC Regional ClinicalTriage Team are asfollows:
Senior clinicianswith experience in tertiary triage (e.g. CriticalCare, EmergencyMedicine, Trauma Surgery ,etc.), with one designated as Chair who oversees all processes.
When possible clinicianson the RegionalTriage Team Oversight Committeewill notbe primary providers ofthe patientsunder considerationnormembersof the RegionalTriage Team .
When patientsrequiring a scarceresourcefall under a specificspecialty such asburn, trauma,pediatrics, etc.then allattemptswillbemadeto consult that specialty either in person or remotely during consideration.
• At leastonemedicalethicist
a. Allpatients presented to the CSC RegionalOversight Committee will berecorded in a CSC RegionalOversight CommitteeLog, which will include:
All patientdemographics• Date andtime of the case consideration
• Allpatient information presented to the CSC Regional Clinical Triage Team at the timeof consideration.
• The CSC Regional Clinical Triage Team decision date, time and supporting documentation reviewed andproduced for the decision
Patientoutcome
b It isrecommendedthatat agreed uponintervals the CSC RegionalOversightCommittee willreview all casespresented to the Regional Triage Team to ensure the following:
All appropriate clinicalinformationwas considered
• Accurate documentation wasrecorded
Extremevariances bereviewedand addressed
C. Dependingon thenatureof the incidentoversightreview maybein realtime(i . e . in a prolonged
eventsuch as a pandemic). However in no notice, sudden orbriefevents, this review may be
retrospective.
©2020 Northwest Healthcare Response Network . Scarce Resource Triage Team Guidelines
D . Re- evaluationProcess DuringResponse
1. Request to change process
a. During an event individual clinicians may request a specific change to the Scarce Resource Cards,Triage Algorithmsorprotocolsbased on new clinicalinformationsuch as changesin prognosticindicatorsor outcomemeasure. These requestsshouldbemade in writingto the Chairand ViceChairof theWAStateDMAC(or theirdesignee) .
b . WA State DMACwillkeep a log andrecord of every CSC Reevaluation ProcessRequest, date and
timeofrequest , and all the supporting documentation presented during therequest and evaluation .
• Each request willbe reviewed by the DMAC Chair and Vice Chair or their designee alongwith allrelevant partners including additional inputfrom SME' s
All request decisions will be made in a timely fashion and will be based on consensus of all relevantpartners
Finaldecisions for all CSC Reevaluation Process Requestswillbein writing, dated and timed , andinclude all supporting documentation
2 . Requestto reevaluate specific case
a . Any clinician may bring a CSC Request for Patient Reevaluation of a specific case to the respectiveMedicalCare BranchDirectorand designatedethicist. TheMedicalCare Branch Directorhas
authorityover therespectiveCSC ClinicalTriage Team whomadetheinitialdecisionunder
consideration( . e . individualCSChospital, hospitalsystem , orregionalClinicalTriageTeam ).
At the individualhospital andhospital system , theMedicalBranch Directorwillbedeterminedbystandards HICS designations within the organization
• At the Regional level, theMedical Branch Director will theChair or Vice Chair of the State DMAC (or
their designee)
At all levels, a CSC Requestfor PatientReevaluationwillbe reviewedby theMedicalBranchDirector, a
designatedethicist and any other relevantpartners.
b A logwillbemaintainedof every RequestforReevaluation, date andtimeofrequest, and allsupportingdocumentation presented during therequest andreevaluation.
C. Every case broughtto theMedicalCare Branch Director and designated ethicistwillbe reviewed in
a timely fashion to ensure the Triage Team documentationwas completeand thedecisionprocess
was consistentwith Scarce Resource Cards, Triage algorithms, protocols or any other clinical
documentationrelated to the case thatwas available atthe timethe originaldecisionwasmade.
d Depending on the event ( i . . no notice vs prolonged ) it is understood that this process may be
retrospective. However, if theevent ismore prolonged and thepotentialoutcomesof thepatient
may be affected, then processesshould be in place to allow a sufficiently rapid decision.
e Finaldecisionsfor CSC RequestforPatientReevaluationof a specificcasewillbe in writing, dated andtimed, and includeall supportingdocumentation.
f . Decisionmadeby therespectiveMedicalCare Branch Director and designated ethicistwillbe final.
©2020 Northwest Healthcare Response Network . Scarce Resource Triage Team Guidelines 6
E . ResourceUpdate Protocols
1 Duringresponse
It is understood that during an event, the clinical situation may change depending on resource availability ,
new epidemiologic information , new treatment protocols and guidelines, etc. Itwillbe the responsibility
of the entire healthcare community to maintain close communication with the Local and State Health
Officer and all relevant partners to maintain accurate situational awareness and consensus regarding local
triage recommendations .
2 . Duringpreparedness
AllScarce Resource Cards and algorithmsand any supporting documentation willbe reviewed and updatedevery 3 years.
3 . Communicationsa. Duringresponse,NWHRN in conjunction with DMACwillbe responsible for identifying all
pertinentpartners during an activation of the Scarce ResourceTriage Team Guidelines to includebutnot limited to : LHO , SMEs , DOH and Federalpartners.
Depending on the situation , clinical updates may be required at various frequencies , and willbedetermined by DMAC Chair and Vice Chair , SHO , LHO and all other pertinent partners . State Health
officer ( SHO ) in conjunction with NWHRN will be responsible for disseminating this information in atimely fashion to all appropriate clinical entities.
. Communicationswillbe electronically, but if circumstancesare such that electronic
communication isnot possible , secondary communication processes will include FAX , phone andcourier.
©2020 Northwest Healthcare Response Network . Scarce Resource Triage Team Guidelines