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A New Quantitative Triage System for Hospitalized Neonates to Assist with Decisions of Hospital Evacuation Priorities. Prehosp Disaster Med 2022; 37:343-349. [PMID: 35388784 DOI: 10.1017/s1049023x22000553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Hospitalized neonates are vulnerable to natural and man-made disasters because of their persistent requirement for medical resources and may need to be evacuated to safe locations when electricity and medical gas supply become unreliable. In Japan, a triage system for hospitalized neonates, or the Simple Triage and Rapid Treatment for Neonates, Revised (START-Neo-R), has been used to determine whether neonates are in suitable conditions for transportation. However, this scale is not useful to determine the evacuation order of neonates because a considerable number of evacuees are classified into the same categories. STUDY OBJECTIVE To solve this problem, a novel triage system, Neonatal Extrication Triage (NEXT) was developed. This study tested the validity and reproducibility of both triages and compared them with a standardized prognostic scoring system for hospitalized neonates, the Neonatal Therapeutic Intervention Scoring System (NTISS). METHODS In this retrospective observational study, physicians and nurses independently assessed each neonate hospitalized at a tertiary neonatal intensive care unit (NICU) twice weekly using NEXT and START-Neo-R. The NEXT system comprises six questionnaires regarding medical resources required during transition and transportation, providing composite scores on a 12-point scale. The START-Neo-R classified neonates into five levels based on the severity of disease and dependence on medical care. Inter-rater reliability of both systems was assessed using Cohen's kappa coefficient, whereas the criterion validity with NTISS was assessed using Spearman's correlation coefficient. RESULTS Overall, 162 neonates were assessed for 49 days, resulting in triage data for 1,079 accumulated patients. Both NEXT scores and START-Neo-R ranks were well-dispersed across different levels without excessive accumulation in specific categories. Inter-rater reliability of NEXT (kappa coefficient, 0.973; 95% confidence interval, 0.969-0.976) and START-Neo-R (kappa coefficient, 0.952; 95% confidence interval, 0.946-0.957) between physicians and nurses was sufficiently high. The correlation coefficient of NEXT and START-Neo-R scores with NTISS scores were 0.889 (P <.001) and 0.850 (P <.001), respectively. CONCLUSIONS Both START-Neo-R and NEXT had good reproducibility and correlation with the severity of neonates indicated by NTISS. With its well-dispersed scores across different levels, the NEXT system might be a powerful tool to determine the priority of evacuation objectively.
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Lin A, King MA, McCarthy DC, Eriksson CO, Newton CR, Cohen RS. Universal Level Designations for Hospitalized Pediatric Patients in Evacuation. Hosp Pediatr 2022; 12:333-336. [PMID: 35137099 DOI: 10.1542/hpeds.2021-006356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Children comprise approximately 22% of the population in the United States.1 In a widespread disaster such as a hurricane, pandemic, wildfire or major earthquake, children are at least proportionately affected to their share of the population, if not more so. They also have unique vulnerabilities including physical, mental, and developmental differences from adults, which make them more prone to adverse health effects of disasters.2-4 There are about 5000 pediatric critical care beds and 23 000 neonatal intensive care beds out of 900 000 total hospital beds in the United States.5 While no mechanism exists to consistently track pediatric acute care beds nationally (especially in real time), a previous study6 showed a 7% decline in pediatric medical-surgical beds between 2002 and 2011. This study also estimated there are about 30 000 acute care pediatric beds nationally. Finding appropriate hospital resources for the provision of care for pediatric disaster victims is an important concern for those charged with triaging patients in a major event.
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Affiliation(s)
- Anna Lin
- Department of Pediatrics, Division of Pediatric Hospital Medicine, Stanford University School of Medicine, Stanford, California
| | - Mary A King
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Washington, Seattle, Washington
| | - David C McCarthy
- Arizona Coordinator, Western Regional Alliance for Pediatric Emergency Management
| | - Carl O Eriksson
- Department of Pediatrics, Division of Critical Care, Oregon Health and Science University, Portland, Oregon
| | - Christopher R Newton
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Ronald S Cohen
- Department of Pediatrics, Division of Neonatal and Developmental Medicine, Stanford University, Stanford, California
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An Assessment of Pediatric Resident Disaster Preparedness for the Neonatal Intensive Care Unit. Disaster Med Public Health Prep 2021; 17:e62. [PMID: 34789352 DOI: 10.1017/dmp.2021.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To assess the level of neonatal intensive care unit (NICU) disaster preparedness among pediatric residents. METHODS A mixed-methods study including qualitative interviews and quantitative surveys was used. Interviews guided survey development. Surveys were distributed to residents who rotated through Children's National NICU. Questions assessed residents' background in disaster preparedness, disaster protocol knowledge, NICU preparedness, roles during surge and evacuation, and views on training and education. RESULTS Survey response was 62.5% (n = 80) with 51.3% of invited residents completing it. Pediatric residents (PGY-2 and PGY-3) (n = 41) had low levels of individual disaster preparedness, particularly evacuations (86%). None were aware of specific NICU disaster protocols. Patient acuity, role ambiguity, knowledge, and training deficits were major contributors to unpreparedness. Residents viewed their role as system facilitators (eg, performing duties assigned, recruiting other residents, and clerical work like documentation). Resident training requests included disaster preparedness training every NICU rotation (48%) using multidisciplinary simulations (66%), role definition (56%), and written protocols (50%). Despite their unpreparedness, residents (84%) were willing to respond. CONCLUSION Pediatric residents lacked knowledge of NICU disaster response but were willing to respond to disasters. Training should include multi-disciplinary simulations that can be refined iteratively to clarify roles, and residents should be involved in planning and execution.
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Ma AL, Cohen RS, Lee HC. Learning from Wildfire Disaster Experience in California NICUs. CHILDREN-BASEL 2020; 7:children7100155. [PMID: 33019523 PMCID: PMC7599616 DOI: 10.3390/children7100155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/12/2020] [Accepted: 09/27/2020] [Indexed: 11/16/2022]
Abstract
Wildfires have been affecting California greatly, and vulnerable patients in neonatal intensive care units (NICUs) are not exempt. Our aim was to learn how personnel working in NICUs of California hospitals handled issues of neonatal transfer during wildfire disasters in recent years, with an ultimate goal to share lessons learned with healthcare teams on disaster preparedness. We identified California fires through newspaper articles and the CalFire.gov list. We determined which hospitals were affected and contacted members of the healthcare team through connections via the California Perinatal Quality Care Collaborative (CPQCC) database. We audio recorded interviews over phone or remote conferencing software or by written survey. We coded and analyzed transcripts and survey responses. While describing disaster preparedness, equipment (such as bassinets and backpacks), ambulance access/transport and documentation/charting were noted as important and essential. Teamwork, willingness to do other tasks that are not part of typical job descriptions, and unconventional strategies contribute to the success of keeping NICU babies safe when California wildfire strikes. Healthcare teams developed ingenious and surprising ways to evacuate NICU babies.
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Affiliation(s)
- Amy L. Ma
- Department of Pediatrics, Stanford University, Stanford, CA 94305, USA; (R.S.C.); (H.C.L.)
- Correspondence:
| | - Ronald S. Cohen
- Department of Pediatrics, Stanford University, Stanford, CA 94305, USA; (R.S.C.); (H.C.L.)
| | - Henry C. Lee
- Department of Pediatrics, Stanford University, Stanford, CA 94305, USA; (R.S.C.); (H.C.L.)
- California Perinatal Quality Care Collaborative, Stanford, CA 94305, USA
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5
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California NICU disaster preparedness. J Perinatol 2020; 40:1262-1266. [PMID: 32382117 DOI: 10.1038/s41372-020-0676-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/24/2020] [Accepted: 04/24/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE NICU patients are disproportionately affected by any disaster due to their vulnerability and highly specialized care needs that require a multitude of resources. Research in disaster preparedness and its effect on NICU patients is limited. STUDY DESIGN From March to May 2018, NICUs across California participated in a survey designed to assess their preparedness for a disaster. RESULTS Of the 84 responding units, 99% were urban, 73% were nonprofit, and 65% were community NICUs. As for NICU participation in hospital training exercises for disaster preparedness, 10% did not participate in annual drills, 44% did once a year, 36% did twice a year, and 10% did more than two times per year. CONCLUSION We showed that many NICUs had redundant systems in place and plans for various disasters; however, there is not consistent participation by NICUs in hospital training exercises for disaster preparedness.
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[Neonatal transport for disasters]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2019; 21:305-311. [PMID: 31014419 PMCID: PMC7389216 DOI: 10.7499/j.issn.1008-8830.2019.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 01/14/2019] [Indexed: 06/09/2023]
Abstract
Neonates are vulnerable to greater damage in disasters and thus have special needs for equipment and medical staff. It is necessary to establish a regional neonatal transport network, in order to provide a platform for effective information communication and resource sharing. Neonatal care centers for critically ill neonates at all levels need to develop a disaster response plan for neonatal transport, and master this plan. In case of disasters, neonatal transport should be directed at the government level, in order to arrange emergency transport resources in a unified, reasonable and efficient way. Meanwhile, the psychological needs of family members and rescue staff should be taken into account.
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Altman RL, Santucci KA, Anderson MR, McDonnell WM, Fanaroff JM, Bondi SA, Narang SK, Oken RL, Rusher JW, Scibilia JP, Scott SM, Sigman LJ. Understanding Liability Risks and Protections for Pediatric Providers During Disasters. Pediatrics 2019; 143:peds.2018-3893. [PMID: 30804075 DOI: 10.1542/peds.2018-3893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Although most health care providers will go through their careers without experiencing a major disaster in their local communities, if one does occur, it can be life and career altering. The American Academy of Pediatrics has been in the forefront of providing education and advocacy on the critical importance of disaster preparedness. From experiences over the past decade, new evidence and analysis have broadened our understanding that the concept of preparedness is also applicable to addressing the unique professional liability risks that can occur when caring for patients and families during a disaster. Concepts explored in this technical report will help to inform pediatric health care providers, advocates, and policy makers about the complexities of how providers are currently protected, with a focus on areas of unappreciated liability. The timeliness of this technical report is emphasized by the fact that during the time of its development (ie, late summer and early fall of 2017), the United States went through an extraordinary period of multiple, successive, and overlapping disasters within a concentrated period of time of both natural and man-made causes. In a companion policy statement (www.pediatrics.org/cgi/doi/10.1542/peds.2018-3892), recommendations are offered on how individuals, institutions, and governments can work together to strengthen the system of liability protections during disasters so that appropriate and timely care can be delivered with minimal fear of legal reprisal or confusion.
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Affiliation(s)
- Robin L. Altman
- Department of Pediatrics, New York Medical College of Touro University and Maria Fareri Children's Hospital of Westchester Medical Center Health Network, Valhalla, New York
| | - Karen A. Santucci
- Department of Pediatrics, School of Medicine, Yale University and Children’s Emergency Department, Yale-New Haven Hospital, New Haven, Connecticut
| | | | - William M. McDonnell
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska
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Triage by Resource Allocation for INpatients: A Novel Disaster Triage Tool for Hospitalized Pediatric Patients. Disaster Med Public Health Prep 2018; 12:692-696. [PMID: 29382399 DOI: 10.1017/dmp.2017.139] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To develop a disaster triage tool for the evacuation of hospitalized neonatal and pediatric populations. METHODS We expanded an existing neonatal disaster triage tool for the evacuation of a children's hospital. We assessed inpatients using bedside visual assessments and chart review to categorize patients transport level based on local emergency medical services protocols and expert opinion. The tool was refined by using multiple Plan Do Study Act cycles. Primary outcome was the number of each level of transport required for hospital evacuation. Secondary outcome was improved efficiency of obtaining information about specific transport needs for evacuation. RESULTS We evaluated 1382 patients both visually and through electronic chart review over 10 random days. Accordance between visual assessment and electronic chart review reached 96.3%. During a 2 hour statewide disaster drill, no hospital units completed self-assessed transport needs for their patients; a single nurse used Triage by Resource Allocation in INpatients to determine transportation needs in less than 1 hour. (Disaster Med Public Health Preparedness. 2018;12:692-696).
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Shi Y. [Disaster response plans in the neonatal intensive care unit]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:1033-1037. [PMID: 29046196 PMCID: PMC7389272 DOI: 10.7499/j.issn.1008-8830.2017.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/07/2017] [Indexed: 06/07/2023]
Abstract
Newborns in the neonatal intensive care unit (NICU) are highly vulnerable in disasters due to their need for specialized and highly technical support. It is strongly encouraged to prepare for the most likely disaster scenarios for the NICU. During a disaster, neonatal care providers should maintain situational awareness for decision-making, including available equipment, medication, and staffing. Neonatal care providers also should consider the ethical issues and the psychosocial needs of the families and neonatal care staff.
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Affiliation(s)
- Yuan Shi
- Group of Pediatric Disaster, Pediatric Society, Chinese Medical Association; Pediatrics Committee, Medical Association of Chinese People's Liberation Army
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Barfield WD, Krug SE, Watterberg KL, Aucott SW, Benitz WE, Eichenwald EC, Goldsmith JP, Hand IL, Poindexter BB, Puopolo KM, Stewart DL, Krug SE, Chung S, Fagbuyi DB, Fisher MC, Needle SM, Schonfeld DJ. Disaster Preparedness in Neonatal Intensive Care Units. Pediatrics 2017; 139:peds.2017-0507. [PMID: 28557770 DOI: 10.1542/peds.2017-0507] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Disasters disproportionally affect vulnerable, technology-dependent people, including preterm and critically ill newborn infants. It is important for health care providers to be aware of and prepared for the potential consequences of disasters for the NICU. Neonatal intensive care personnel can provide specialized expertise for their hospital, community, and regional emergency preparedness plans and can help develop institutional surge capacity for mass critical care, including equipment, medications, personnel, and facility resources.
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Affiliation(s)
| | - Steven E. Krug
- Northwestern University Feinberg School of Medicine, Evanston, Illinois; and
- Department of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital, Chicago, Illinois
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Iwata O, Kawase A, Iwai M, Wada K. Evacuation of a Tertiary Neonatal Centre: Lessons from the 2016 Kumamoto Earthquakes. Neonatology 2017; 112:92-96. [PMID: 28437783 PMCID: PMC5872557 DOI: 10.1159/000466681] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 02/28/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Newborn infants hospitalised in the neonatal intensive care unit (NICU) are vulnerable to natural disasters. However, publications on evacuation from NICUs are sparse. The 2016 Kumamoto Earthquakes caused serious damage to Kumamoto City Hospital and its level III regional core NICU. Local/neighbour NICU teams and the disaster-communication team of a neonatal academic society cooperated to evacuate 38 newborn infants from the ward. OBJECTIVE The aim of this paper was to highlight potential key factors to improve emergency NICU evacuation and coordination of hospital transportation following natural disasters. METHODS Background variables including clinical risk scores and timing/destination of transportation were compared between infants, who subsequently were transferred to destinations outside of Kumamoto Prefecture, and their peers. RESULTS All but 1 of the infants were successfully evacuated from their NICU within 8 h. One very-low-birth-weight infant developed moderate hypothermia following transportation. Fourteen infants were transferred to NICUs outside of Kumamoto Prefecture, which was associated with the diagnosis of congenital heart disease, dependence on respiratory support, higher risk scores, and longer elapsed time from the decision to departure. There was difficulty in arranging helicopter transportation because the coordination office of the Disaster Medical Assistance Team had requisitioned most air/ground ambulances and only helped arrange ground transportations for 13 low-risk infants. Transportation for all 10 high-risk infants (risk scores greater than or equal to the upper quartile) was arranged by local/neighbour NICUs. CONCLUSIONS Although the overall evacuation process was satisfactory, potential risks of relying on the adult-based emergency transportation system were highlighted. A better system needs to be developed urgently to put appropriate priority on vulnerable infants.
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Affiliation(s)
- Osuke Iwata
- Centre for Developmental and Cognitive Neuroscience, Department of Paediatrics and Child Health, Kurume University School of Medicine, Fukuoka, Japan
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Shilkofski N, Agueh M, Fonseka M, Tan A, Cembrano JR. Pediatric Emergency Care in Disaster-Affected Areas: A Firsthand Perspective after Typhoons Bopha and Haiyan in the Philippines. J Pediatr Intensive Care 2016; 6:19-27. [PMID: 31073422 DOI: 10.1055/s-0036-1584910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 02/15/2016] [Indexed: 10/21/2022] Open
Abstract
Disasters are defined as man-made or natural causes that disrupt a population and cause widespread human, material, economic, or environmental losses, exceeding that population's capacity to cope using its own resources. This review highlights the epidemiology and disease patterns in disasters, with specific application to the care of children in the austere environments created in the aftermath of disasters. The review also attempts to describe the experience from a firsthand field hospital perspective of a multinational team in caring for patients in the aftermath of two natural disasters in the Philippines, during both Typhoon Bopha and Typhoon Haiyan. In doing so, we will place these experiences in the context of the current literature on the subject of pediatric management during disaster emergencies and describe lessons learned to refine team approaches and patient care methodologies. The review also discusses methods for improvement in emergency preparedness for disasters, with specific mention of the roles of telemedicine and just-in-time simulation training, when feasible. Lastly, it will review the importance of community and military collaboration and planning for aftercare post-departure of foreign medical teams.
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Affiliation(s)
- Nicole Shilkofski
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States.,Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Modupe Agueh
- Department of Obstetrics and Gynecology, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Malini Fonseka
- Sinai Hospital Lifebridge Health, Baltimore, Maryland, United States
| | - Amirah Tan
- Jamaica Hospital Medical Center, New York, New York, United States
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Devereaux AV, Tosh PK, Hick JL, Hanfling D, Geiling J, Reed MJ, Uyeki TM, Shah UA, Fagbuyi DB, Skippen P, Dichter JR, Kissoon N, Christian MD, Upperman JS. Engagement and education: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2015; 146:e118S-33S. [PMID: 25144161 PMCID: PMC4504247 DOI: 10.1378/chest.14-0740] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Engagement and education of ICU clinicians in disaster preparedness is fragmented by time constraints and institutional barriers and frequently occurs during a disaster. We reviewed the existing literature from 2007 to April 2013 and expert opinions about clinician engagement and education for critical care during a pandemic or disaster and offer suggestions for integrating ICU clinicians into planning and response. The suggestions in this article are important for all of those involved in a pandemic or large-scale disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials. METHODS A systematic literature review was performed and suggestions formulated according to the American College of Chest Physicians (CHEST) Consensus Statement development methodology. We assessed articles, documents, reports, and gray literature reported since 2007. Following expert-informed sorting and review of the literature, key priority areas and questions were developed. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. RESULTS Twenty-three suggestions were formulated based on literature-informed consensus opinion. These suggestions are grouped according to the following thematic elements: (1) situational awareness, (2) clinician roles and responsibilities, (3) education, and (4) community engagement. Together, these four elements are considered to form the basis for effective ICU clinician engagement for mass critical care. CONCLUSIONS The optimal engagement of the ICU clinical team in caring for large numbers of critically ill patients due to a pandemic or disaster will require a departure from the routine independent systems operating in hospitals. An effective response will require robust information systems; coordination among clinicians, hospitals, and governmental organizations; pre-event engagement of relevant stakeholders; and standardized core competencies for the education and training of critical care clinicians.
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Affiliation(s)
- Asha V. Devereaux
- Sharp Hospital, Coronado, CA
- 1224 10th Place #205, Coronado, CA 92118
| | | | - John L. Hick
- Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | - Dan Hanfling
- Inova Health System, Falls Church, VA
- George Washington University, Washington, DC
| | - James Geiling
- VA Medical Center, White River Junction, VT
- Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Mary Jane Reed
- Geisinger Medical Center, Temple School of Medicine, Danville, PA
| | | | - Umair A. Shah
- Harris County Public Health and Environmental Services, Houston, TX
| | - Daniel B. Fagbuyi
- The George Washington University, Children's National Medical Center, Washington, DC
| | - Peter Skippen
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | | | - Niranjan Kissoon
- BC Children's Hospital and Sunny Hill Health Centre, University of British Columbia, Vancouver, BC, Canada
| | - Michael D. Christian
- Royal Canadian Medical Service, Canadian Armed Forces and Mount Sinai Hospital, Toronto, ON, Canada
| | - Jeffrey S. Upperman
- Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
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