Enhanced Surge Capacity & Partnership Effort (ESCAPE ... ccg excerpt from final report.pdf · Emergency Medical Services (EMS), community clinics, Indian health, and a military hospital.

Enhanced Surge Capacity & Partnership Effort (ESCAPE) Grant Project

Crisis Care Guidelines

(Excerpt from the Final Report Section 1.1)

Healthcare Facilities Emergency Care Partnership Program

Grant No. 6 HFPEP070013-01 | CFDA Number 93.889

Surge Capacity Through Technology Innovation

Enhanced Surge Capacity & Partnership Effort (ESCAPE) Grant Project

Principal Investigator, Christian Sandrock, M.D., M.P.H., FCCP Assistant Professor, Pulmonary and Critical Medicine

UC Davis Health System

Page 1 of 35 Healthcare Facilities Emergency Care Partnership Program Grant No. 6 HFPEP07001301 | CFDA Number 93.889 Principal Investigator, Christian Sandrock, M.D., M.P.H., FCCP, Assistant Professor, Pulmonary and Critical Medicine UC Davis Health System

Tables, Attachments and Comments

ESCAPE Project Crisis Care Guidelines Christian Sandrock, MD, MPH (Project Principle Investigator) Ellie Anderson, BS James Marcin, MD, MPH Madan Dharmar Tina Palmieri, MD, FACS Christine Cocanour, MD, FACS, FCCM Joseph Galante, MD Peter Yellowlees, MBBS, MD Kathleen Ayers, PsyD

Introduction The development of crisis care guidelines for delivering critical care to compliment other elements of the ESCAPE (Enhancing Surge Capacity and Preparedness Effort) Partnership is paramount. After a Multi-Casualty Incident (MCI), the early stages of patient surge become evident, and thus adequate planning, preparation, and mitigation are essential in order to develop the best response. In particular, the patient care must be delivered in a uniform manner, with equality to access and level of care at all partnership sites. Failure to implement broad-reaching guidelines for crisis care during a surge event will have negative consequences. Planning and implementing such guidelines may offer legal protection (i.e., prudent practitioners doing the same things within the same environment of care), decrease the likelihood of patients further overwhelming healthcare facilities that may have more perceived resources, and provide for the ethical and consistent treatment of patients. A set of guidelines for crisis care within the ESCAPE Partnership has been established. The Partnership, established by ESCAPE in 2008-2009, includes healthcare sites in California’s Emergency Management Agency (CalEMA) Mutual Aid Regions III and IV. A wide variety of sites ranging throughout the continuum of healthcare were involved for this demonstration project. We included public health, rural hospitals, tertiary care centers, alternate care sites, Emergency Medical Services (EMS), community clinics, Indian health, and a military hospital. By the conclusion of the project, all partnership sites will have been given telemedicine units for communication, consultation, and just-in-time training, and will have participated in at least one exercise and access to just in time training on the crisis care guidelines. Many sites participated with UC Davis Medical Center (the grant awardee) in a medical health exercise in June 2009, although this exercise was scaled back in scope due to the high number of key players involved in the H1N1 response. Because ESCAPE is a demonstration project, Partnership sites are not required to implement these Guidelines in their Emergency Operations Plans (EOPs).

ESCAPE Project Crisis Care Guidelines


For the purpose of this document, we will consider the Partnership to be a microcosm of the Region, spanning the continuum of care, and will contextualize these Crisis Care Guidelines in standard emergency management language (i.e., Local, Operational Area, Region, etc.). This will enable it to more clearly fit into the existing emergency management system of California’s Standardized Incident Management System (SEMS) and National Incident Management System (NIMS). For these Crisis Care Guidelines (in the interest of using a broad geographical area to improve the uniformity of crisis care delivery), the Regional Emergency Operations Center (REOC), particularly the Regional Disaster Medical Health Specialist/Coordinator (RDMHS/C), then becomes the definitive player in the response. However, the Region does not dictate the response; it supports the geographical implementation (in coordination with the SEMS levels of which it is comprised) of the Crisis Care Guidelines at the appropriate time. Some of the suggested guidance below may not, at this point, fit every facility within a given Region; however, this document may serve as a planning tool for those sites. Recommendations for future planning efforts include expanding the ESCAPE Partnership concepts to include all major health facilities in each EMA Mutual Aid Region of California, and implementing standardized crisis care during exercises and actual surge events. For the purpose of this document, it is critical to define what is meant by “healthcare surge.” In California, the consensus document — Standards and Guidelines for Healthcare Surge During Emergencies, produced by the California Department of Public Health working with key stakeholders — defines healthcare surge. This is also the definition utilized by ESCAPE to produce this and other documents.

A healthcare surge is proclaimed in a local jurisdiction when an authorized local official, such as a local health officer or other appropriate designee, using professional judgment determines, subsequent to a significant emergency or circumstances, that the healthcare delivery system has been impacted, resulting in an excess in demand over capacity in hospitals, long-term care facilities, community care clinics, public health departments, other primary and secondary care providers, resources and/or emergency medical services. The local health official uses the situation assessment information provided from the healthcare delivery system partners to determine overall local jurisdiction/ Operational Area medical and health status.

ESCAPE’s Crisis Care Guidelines have been developed as an assistance and guidance tool for when crisis care (and limited resources) may reach a point of inequality across the Region. These guidelines are not intended to set a standard. Each healthcare facility should use this document as a framework for the delivery of care and rationing of resources when needed. In a true healthcare surge, such as a severe pandemic, when circumstances call for care to fall outside of the facility’s ability to support its own response, the activation of SEMS/NIMS levels will commence. The facility should alert the Local (jurisdictional) Emergency Operations Center (EOC). As Local levels become active within a particular geographic area, they will notify the Operational Area, which will activate the Region, on up through the State to the Federal EMA.



In the type of surge we are considering in this document, a minimum level of activation would be multi-regional. Thus, using the existing SEMS/NIMS approach on a regional basis, an “at risk” facility could be easily identified as a potential site where care may be compromised. This framework will thus allow regional bedside care to have some consistency and similarity during a crisis, meeting our core mission of equality of care during a surge event. Additionally, this guide will serve local, regional, and state planners with some suggested areas of potential inequality during a crisis. Healthcare representatives at the Local, Operational Area (OA), as well as the RDMHS/C (working with the REOC) can begin the process of prioritization with regard to unequal care, allowing the logistics and planning branches to target the facilities most likely to have difficulty in delivering crisis care. As mentioned above, this document is not intended to set a “standard” of care for the partnership. The standard of care is determined and managed by local healthcare professionals, and is based on the environment of care. When bedside care appears to fall outside of usual care delivery, a healthcare facility may then receive, through Local, OA, Regional, State (and potentially Federal) resources, assistance to improve delivery and equity of care. When these resources are exhausted, or are scarce, utilizing these Guidelines may serve as a framework for response. The use of this document can be “in-person” at the bedside, over standard communications lines within the Region, and across telemedicine units (where applicable) during consultation and just-in-time education. Reference back to this document and the portion of the framework that is affected will help guide the telemedicine consultation and education process during crisis care. Thus, each facility within a Region will receive equal subspecialty access and when a facility is in danger of delivering care outside of the Regional consensus for crisis care delivery, resources (such as subspecialty access) can be refocused to the facility or facilities with greatest need. Although it is critical to stay within the SEMS and NIMS framework, the creation of these guidelines and the need for a strong Regional response to implement them, does occasionally require a new approach to the existing medical/health response framework. This approach makes the most of SEMS/NIMS; allowing clinical judgment, as well as healthcare facility, Local, and Operational Areas to support the Regional crisis care response. Any Regional decision-making with regard to crisis care will be brought about by consensus of the OAs and Local levels and may include markers such as the amount of patient surge, scarcity of resources, infrastructure damage, etc., as detailed in this document. The Guidelines are divided into two sections. The first section contains a framework that the Region will use to guide patient care delivery. The second section sets a bedside care framework with some minimal “expectations” regarding individual care delivery. Additionally, there are some examples included regarding the use of the framework during a crisis, as tools to guide implementation.

Partnership Framework Tenets This is the basic framework around which emergency response will be delivered across the partnership. These tenets will serve and remain constant at all times, despite the type, level, and



extent of any healthcare surge event. They will apply across all levels of response, from local to regional to state level. Finally, they will apply to all healthcare facilities, from acute health care facilities to alternate care sites to in-home services. Individual bedside care, such as burn, trauma, or critical care decisions, will function under this framework. The tenets will support these bedside patient care decisions.

Framework 1: Ethical Tenets 1a. Duty to Care: The fundamental obligation to provide care to all patients without preference. All patients should receive fully appropriate care given resource availability, and if a scarce resource is not allocated, the most appropriate care available should be delivered. 1b. Duty to Steward Resources: Health care providers should steward resources in a time of scarcity to the benefit of saving the most number of lives while balancing the optimal care of the individual patient. 1c. Duty to Plan: Healthcare planning and participation is essential to provide optimal support and guidance to frontline providers. This duty includes effective planning in all four emergency management phases: Preparedness, Response, Recovery and Mitigation. 1d. Distributive Justice: The process of crisis care delivery and allocation of scarce resources must be applied broadly, consistently, and equally across the Region with the support of the RDMHS/C and the Regional Emergency Operations Center (REOC). This must be performed in conjunction with the Local (where applicable), OA, and State public health authorities. 1e. Transparency: The process of creation, development, administration, and analysis of any framework for crisis care and allocation of scarce resources must be performed in an open, collaborative, and prospective manner with all healthcare facilities and providers aware of the decision and development process. These Crisis Care Guidelines incorporate and/or address the suggestions made during the comment period when the crisis care guidelines were posted online and notifications sent to partners, advisory group members, and key colleagues for their input.

Framework 2: Command and Control 2a. Management and Command Structure: All partners will use the National Incident Management System (NIMS) and thus the Incident Command System (ICS or HICS, if applicable) and California’s Standardized Incident Management System (SEMS). 2b. Triage—Telemedicine: The role of triage coordination will occur at the healthcare facility, the OA, and the Regional EOC. Depending on the scale of the disaster and the level of activation, the State may also play a role. In tertiary care centers, a new position, the “Hospital Telemedicine Crisis Triage Coordinator” would be a non-HICS position, but have a Job Action Sheet, and would report activities to the patient In-take/Out-take Units in the Operations section



under Medical Care Branch Director. This position acts as a sort of “virtual” triage manager—with the use of telemedicine and appropriate support of subspecialists, the concept is to reduce the need for physical patient transfers. The Hospital Telemedicine Crisis Triage Coordinator is designed to be a clinical position, preferably a physician or mid-level practitioner with experience in triaging patients. According to the process laid out in ESCAPE’s Telemedicine for Crisis Care document, the Hospital Telemedicine Crisis Triage Coordinator, with at least one additional support position under the Coordinator, will field calls from remote sites requesting specialist access. The job of the Coordinator is to decide, based on the current care environment (in crisis mode, the environment of care is equal across the Region), (1) The type of specialty consult needed, (2) whether the specialist is available, and (3), the placement of the request in the queue of other consultation requests. The concept of the Crisis Telemedicine system is to avoid a physical patient surge on tertiary care centers. (Note: not all healthcare sites have telemedicine at this point, although those participating in the ESCAPE project do). Legislation that has already been passed in California will provide funds to increase the number of sites with telemedicine equipment. If a healthcare facility within the Region does not have telemedicine, specialty access could be obtained through telephone calls to specialists— these would also be fielded by the Hospital Telemedicine Crisis Triage Coordinator. The type of triage to be used is detailed later in this document. 2c. Triage—Physical: The role of triage coordination will occur at all healthcare entities in the Region and be in the Operations Section under the Medical Care Branch Director. Again, see specific Guidelines (i.e, Adult Critical Care, Pediatric Critical Care, Burn Care, Trauma) for triage methodology in a surge event. 2d. Patient Coordination: The role of patient coordination will occur at all healthcare facility types. In HICS, this position will be in the Planning Section under the Situation Unit Leader (Patient Tracking Manager and Bed Tracking Manager), and under the Medical Care Branch Director in Operations. The active coordination of patients and communication between all (activated) levels of NIMS will help inform about facility status and location of available beds, while the Operations Section’s In-patient/Out-Patient Units facilitate any patient transfer with the use of the Control Facility as an intermediary at the OA level. 2e. Communication: The In-patient/Out-Patient Unit at the local facility will communicate directly with the Control Facility and the RDMHS/C (or their designee) in order to move patients in and out of the facility. Both the existing Planning and Operations patient coordination roles will participate as discussed in 2d. 2f. Triage Command Communication: Decisions for triage protocol use, initiation, and termination will occur at the Regional level under the direction of the RDMHS/C once certain triggers are activated, as described below. All facilities within the Region are expected to reach consensus by participating in these decisions by telemedicine/direct real time contact. 2g. Subject Matter Experts--Telemedicine: Medical/Technical Specialists (e.g., burn surgeon, intensivist) will be reached by calling the Regional Telemedicine Coordinator (a new position in



the REOC—either the RDMHS/C or their designee), who will in turn pass the call onto Regional tertiary care sites, appropriately distributing calls based on specialty needed and the tertiary care center’s ability to meet that need. Dependent on whether the REOC has telemedicine equipment this call may occur via videoconferencing or telephonically. The Hospital Telemedicine Crisis Triage Coordinator (located in each tertiary care site) will take the call, triage and assign it to an internal specialist based on severity and type of specialty. As tested with the use of a Codian high definition bridge, the Hospital Telemedicine Crisis Triage Coordinator is able to virtually see when a specialist is available to take a consult and will connect them with the requesting site to perform the consultation. If the specialist is unable to provide the consultation, or the wait time will be too long (based on clinical assessment and the current environment of care), the Hospital TM Crisis Triage Coordinator will be notified. With either outcome, the Hospital TM Crisis Triage Coordinator will then notify the Regional Telemedicine Coordinator. Note: this methodology may seem to deviate somewhat from the traditional linkage between designated SEMS/NIMS levels, as it omits the Local and OA levels (the Control Facility) from coordinating telemedicine patients. However, there is a feedback loop built in (as described above), enabling each level to monitor the situation and become actively involved if there is a problem. This system mirrors the Control Facility Operational Area concept—if the OA cannot support the event within its boundaries, the Region handles patient disbursement (this precedent has already been set in actual MCIs). 2h. Subject Matter Experts—Non-Telemedicine: For healthcare sites without telemedicine, the process will be almost identical to the process detailed in 2e. However, instead of receiving a telemedicine consult, consultations will be managed via telephone. While this may not be ideal, it can still function as a method to provide consultation in the interim (many facilities will be included in the California Telehealth Network over the next several years). 2i. Subject Matter Communication—Triage: For decisions regarding equipment and staff substitution, adaptation, conservation, reuse, or allocation and the initiation/termination of the crisis care triage algorithm will be made in coordination with the Medical/Technical Specialists. Tertiary care sites may use their own internal specialists to help determine the above, or request outside assistance from another tertiary care center through the Regional TM Coordinator. All other types of partnership sites should request assistance using the structure outlined in 2g-2h. 2i. Subject Matter Communication—Patient Coordination: The coordination of activating levels of crisis care, minimum level of care based on specialty, and the movement of patients outside of standard minimum levels of care will be made in conjunction with the Medical/ Technical Specialists (in a tertiary care center, these may be the facility’s own subject matter experts—all other types of healthcare sites in the Region should follow the process outlined in 2g-2h). 2j. Situational Awareness: Incident Commanders at all levels must ensure that triage coordinators and patient coordinators have situational awareness of critical resource availability, staff availability, and patient bed/facility status availability. Situational awareness may be maintained through traditional means such as phone, email, radio, and attendance at any briefings. Telemedicine units may also play a role in clinician situational awareness as they are



utilized for specialty care support between a tertiary care center and any other type of health facility.

Framework 3: Distribution of Care 3a. Level of Care: The highest level of patient care includes the following:

1. Mechanical ventilation 2. Vasopressor administration 3. Aggressive IV fluid resuscitation 4. Specialized surgical or medical care limited to ICU monitoring (e.g., burn, trauma,

antidote—for example, atropine/2-PAM). 5. Operating Room facilities

3b. Location of Care: An acute care hospital with a designated Intensive Care Unit (ICU), or a similarly structured facility like a mobile medical unit, will provide the highest level of care in the partnership with additional facilities, such as clinics, alternate care sites, and skilled nursing facilities (SNFs) providing lower levels of care. 3c. Location of Care within the Acute Care Hospital: The ICU will be the initial location for the highest level of care. After ICU, post-anesthesia units and other post procedure units will be used, followed by intermediate care units, telemetry (step-down) units, and standard hospital wards. 3d. Location of Care Outside of an Acute Care Hospital: Regional facilities, alternate care sites, clinics, skilled nursing facilities, and in-home services will absorb those lower level of care patients from the acute care facilities across the partnership as the highest level of care patients surge. In an infectious disease scenario, SNFs (depending on plant design) may choose not to take any potentially infectious patients due to their existing fragile patient population, close quarters, and lower level of medical practitioners. However, they must be prepared to handle higher acuity patients should some of their population become ill or injured, and “shelter in place.” Telemedicine will be used to support these facilities as they either stabilize patients for transport or, when there is no availability of transportation/tertiary care beds, telemedicine specialists at the tertiary care centers will assist in supporting these higher acuity patients in situ. 3e. Non-Medical Facility Use: Non-medical facilities will not provide the highest level of care unless the regional acute care facilities are fully saturated with high-level care patients or in order to aid evacuation of an acute care facility. For non-medical sites with the appropriate network capabilities, telemedicine units may also be brought in to support patient care. 3f. Interfacility Patient Movement: The plans for the physical movement of patients from an acute care facility to a lower level care center (and back to an acute care hospital if needed) have already been defined and implemented within OAs using Control Facilities. In a surge, this will also be coordinated regionally under the command and control of the patient coordinator working with the RDMHS/C and each OA’s Control Facility. These patient coordination activities are separate from telemedicine patient coordination.



3g. Minimum Level of Care: The minimum level of care (e.g., minimum level of care for a level 1 trauma) will be defined in advance and be a graded response as patient surge increases. These minimum levels will be determined for burn, trauma, adult critical care, pediatric critical care, and mental health. 3h. Minimum Level of Care—Communication and Coordination: Each facility will have a minimum level of care assessed based on definitions determined in advance. Any change in the minimum level of care must be performed at the Regional level in coordination with the Incident Commander, Medical Branch Director, and the Medical/Technical Specialist at each facility. These positions will also be informed on the status of telemedicine activity and its ability to support the surge situation—the Hospital Telemedicine Crisis Triage Coordinator reports activities to the Medical Branch.

Framework 4: Triggers for the Activation of Crisis Care 4a. Emergency Status: A local emergency or public health emergency that is anticipated to require at least a multi-regional response — or state of emergency — must be declared in response to a disaster/healthcare surge prior to the activation of crisis care measures. 4b. Levels of Care: A graded response plan for mass casualty and catastrophic care with delineated modification in care practices at each level must be established for different surge requirements across the Region. 4c. Equipment & Supply Triggers: A graded response based on the availability of critical resources in the partnership will include the following: mechanical ventilators, blood products, antibiotics, antivirals, and operating room capacity. 4d. Staff/Personnel Triggers: A graded response based on critical workforce limitations in the partnership will include the following: security, personal protective equipment, and subspecialty staff (including pediatric intensivist, burn surgeon, adult intensivist, critical care nurse, and minimum level 1 trauma team). 4e. Activation of Crisis Care: Initiation of a trigger to modify healthcare practice will not be granted or applied to an individual facility and will be applied across the Region uniformly and concurrently. 4f. Crisis Care Activation Requests: The Region will first attempt to meet the requests and needs of an individual healthcare facility or alternate care site in an effort to prevent an initiation of Crisis Care (a modified care practice) rather than grant an individual facility a care level change. 4g. Scarce Resource Utilization: Within each Region, Regional Medical/Technical Specialists and healthcare facility Incident Commanders will consult on the utilization of conservation, reuse, adaptation, and substitution prior to initiating a modification in the level of care practiced.



4h. Level Change Consultation: Prior to requesting or consulting on a regional change in the level of care (via conference call, telemedicine unit, etc.), each healthcare facility Incident Commander should internally consult the Medical/Technical Specialists and the Operations, Logistics and Planning Branch Directors. This consultation will take into account information from the telemedicine crisis care system due to the reporting process outlined above. 4i. Triggers for Care Practice Level Changes at the Region: A movement in care practice/level to a modified care practice will be performed on a regional level by consensus of the MHOACs (Medical Health Operational Area Coordinator) and RDMHC/S in consultation with appropriate Medical/Technical Specialists and healthcare facility Incident Commanders (IC). Prior to any discussion of this nature, individual healthcare facility ICs should consult with their own Section Leaders and facility administrators. 4j. Modified Care Practice: The modification of care for particular specialties (these Crisis Care Guidelines include burn care, trauma, and adult and pediatric critical care, including critical resources for each) at each crisis care level will be determined in advance based on the best available medical care and response knowledge. Any additional changes in the practice of care during a healthcare surge event must be done with consensus among healthcare facilities in the Region, and the Regional Medical/Technical Specialists conjointly with the MHOACs and RDMHC/Ss. 4k. Minimum Infrastructure: A minimum amount of infrastructure must be available within a healthcare facility in order to have any form of care delivery. These include the safety of staff, facilities, and affected and non-affected patients. It also includes adequate personal protective equipment and security. If these minimum levels cannot be met after all attempts at management are reached (especially including the use of resource requests through the SEMS/NIMS process), the facility should be evacuated and closed. 4l. Maximal Utilization of Resources: Prior to triggering a level change or prior to the allocation of certain critical scarce resources (such as ventilators), all resource management options at the facility, local, and regional level must be exhausted, including Memoranda of Agreement (MOAs), Vendor Managed Inventory (VMI), inter-facility agreements, and emergency compacts.

Framework 5: Triage 5a. Triage Initiation: The crisis care triage algorithm will not be initiated until the following five criteria have been met:

1. Declaration by “a local health officer or other appropriate designee” (Standards and Guidelines, CDPH) of a local emergency or public health emergency in the local area or OA,

2. Activation of the disaster medical system within at least the Regional level has occurred (could also be an activation of the State or Federal levels),

3. All health care facilities in the Region have their surge response plans employed,



4. Existing MOUs and other agreements are determined or anticipated to provide insufficient resources to meet the incident needs, and

5. Conservation, reuse, adaptation, and substitution measures of anticipated scarce resources are being considered.

5b. Triage Application: The initiation of a triage algorithm will be applied to the Region uniformly and concurrently and will not be applied for a single facility. 5c. Triage Coordination: The initiation of crisis care triage along with triage method, support, and termination will occur at the Regional level. 5d. Triage Command and Control: The initiation of a triage algorithm along with triage method, support, and termination will be performed by a trained clinician at the Regional level (this individual or individuals may be physically located in an acute care facility, but will function under the Regional Unified Command Center* and the RDMHC/S). This triage coordinator will act in consultation with each facility and appropriate Medical/Technical Specialists.

*Again referencing Standards and Guidelines, CDPH: …an authorized local official, or designee, will notify healthcare facilities that the Unified Command has been established and provide a contact within the Operations Section of the Unified Command for coordination of patient movement and requests for resources, services and supplies. (p.11, Foundational Knowledge)

5e. Triage Committee at the Regional Level: A central triage committee will consist of a triage coordinator (acts in coordination with the RDMHC/S and may be a separate position from the Regional Telemedicine Coordinator), Logistics, Planning, and appropriate Medical/Technical Specialists. This committee will maintain situational awareness of the Region, particularly with regard to patient movement, patient volume; anticipated shortages such as supplies, equipment, and personnel; and hospital status (i.e., infrastructure, number of available beds, PPE if applicable, pharmaceuticals, on diversion, etc.). 5f. Triage Committee at the Facility Level: A triage team for the healthcare facility will consist of a triage officer (adult or pediatric intensivist, surgeon, critical care nurse, other experienced clinician), a second clinical expert (nurse, pharmacist, physician, or respiratory therapist), and a healthcare facility administrator. 5g. Triage Algorithm: The method of triage (e.g., Sequential Organ Failure Assessment— SOFA score) will be determined in advance of the healthcare surge event based on the best available medical evidence and will be determined by the regional expert planning committee. 5h. Triage Algorithm for a Healthcare Surge Event: A method of triage will be determined for five specialty areas (e.g., burn, trauma, medical critical care, pediatric critical care and mental health).



5i. Change in Crisis Care Triage Algorithm: The method of triage can change during a surge event if available data and research shows a compelling need. If deemed necessary, this change should occur across the Region in consultation with each facility, the triage coordination expert, and the Medical/Technical Specialist. 5j. Triage method application: All healthcare facilities in the Region will use the same triage method at all sites throughout the process. 5k. Review of Triage Method: A review committee of at least three clinically oriented experts not directly involved in patient care will intermittently review the decision process of the triage team. The make-up of the committee can be the similar to that described in 5f; additionally, it requires an uneven number of members to act as a tie-breaker. Any concerns will be directly relayed to the hospital triage coordinator under the Medical Care Branch and, if appropriate, will be directed toward the regional triage coordination position. No appeals process will be instituted. 5l Palliative and Submaximal Care: The triage method applied across the partnership will include submaximal care as defined by the scarcity of resources. Palliative care must also be included. This will allow for maximal chance of survival (minus the critical resource) or maximal comfort, should expected survival be poor.

Suggested Regional Level of Care with Triggers for Deteriorating Environment of Care These triggers are listed as a rough guideline for use at the Regional level. They will be the recommended alerts and subsequent levels that will help guide decisions regarding the use of resources and at which location/facility that the intervention will occur. By using the same standard definitions of the levels, each facility will have standardized definitions and thus prioritization of resources or level of care consensus can occur more rapidly and uniformly across the Region. It is important to note that not all healthcare facilities have all of the following capabilities (i.e., community clinics, skilled nursing, etc.), but all facilities have some of these capabilities. The following suggested levels and triggers include: 1. ICU Utilization Level 1: Healthcare personnel discretion of ICU use Level 2: No admission of observation or for nursing ratio adjustment Level 3: Use of General ICU Principle definition of ICU criteria Level 4: Use of mechanical ventilation only under allocation of scarce resources guidelines Level 5: Allocation of ICU admission and use based on triage algorithm (ICU is scarce resource) Level 6: Evacuation of ICU due to patient/staff safety concerns 2a. Trauma Care – Individual Hospital Level 1: Hospital fully staffed and with normal operations, able to receive patients per local protocols and/or American College of Surgeons (ACS) verification criteria



Level 2: No neurosurgical, orthopedic, or other subspecialty services as required by the ACS verification criteria are available Level 3a: No ICU capability but still has operative capability and ability to transfer Level 3b: No OR capability but still has ICU capability and ability to transfer Level 4: No operative capability but physicians are available that are capable of performing emergency bedside procedures. Both transfer and telemedicine capabilities remain intact. Level 5: No surgeon or a physician facile with procedures available, no telemedicine capability but transfer capability remains intact Level 6: No ER or transfer capability 2b. Trauma Care at Regional Levels (A more global assessment of trauma care) Level 1: All hospitals will be eligible to receive “trauma” patients according to regional critical trauma criteria (Business as usual) Level 2: In mass casualty situations, regional trauma centers will receive immediate and delayed patients. Non-trauma centers will receive minor and expectant patients. Non-trauma centers may consult via telemedicine and transfer to trauma centers within the region. Level 3: When regional trauma centers are overwhelmed and usual patterns of transfer are not feasible, Non-trauma centers may continue to consult via telemedicine with regional trauma centers but will transfer patients to trauma centers outside the region Level 4: Due to infrastructure or loss of hospital personnel, any patient meeting critical trauma criteria are evacuated immediately from the region, while minor and expectant patients will remain Level 5: In the case of catastrophic infrastructure loss, all trauma patients will be evacuated from region 3. Pediatric and Pediatric ICU Care Level 1: Healthcare personnel discretion of Pediatric and Pediatric ICU use Level 2: No admission to the Pediatric ICU for observation or for nursing ratio adjustment Level 3: Use of General Pediatric ICU Principle definition of Pediatric ICU criteria Level 4: Use of mechanical ventilation only under allocation of scarce resources guidelines Level 5: Allocation of Pediatric ICU admission and use based on triage algorithm (Pediatric ICU is scarce resource) Level 6: Evacuation of Pediatric ICU due to patient/staff safety 4. Burn Care Level 1: Verified burn center fully staffed and with normal operations, able to receive patients per local protocols and/or American Burn Association criteria * (listing of verified and non-verified burn centers available from American Burn Association Resource Manual). Level 2: Non-verified burn center fully staffed and with normal operations, able to receive patients per local protocols and/or American Burn Association criteria Level 3a: No Burn center, but has trauma and ICU capability, operative capability, wound care and escharotomy ability, and ability to transfer Level 3b: No OR capability but still has ICU capability, wound care capability, escharotomy capability, and ability to transfer



Level 4: No operative capability or ICU capability, but physicians/nurses are available that are capable of performing emergency bedside procedures and simple dressing changes. Both transfer and telemedicine capability remains intact. Level 5: No physician or nurse facile with procedures or wound care available, no telemedicine capability but transfer capability remains intact Level 6: No Emergency Department or transfer capability

*American Burn Association Burn Center Criteria (for levels 1 and 2). This provides the definitions listed above and thus will provide the regional EOC guidance on transfer needs. :

1. Partial-thickness burns of greater than 10% of the total body surface area 2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints 3. Third-degree burns in any age group 4. Electrical burns, including lightning injury 5. Chemical burns 6. Inhalation injury 7. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality 8. Any patients with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses the greater immediate risk, the patient’s condition may be stabilized initially in a trauma center before transfer to a burn center. Physician judgment will be necessary in such situations and should be in concert with the regional medical control plan and triage protocols. 9. Burned children in hospitals without qualified personnel or equipment for the care of children 10. Burn injury in patients who will require special social, emotional, or rehabilitative intervention

5. Supplies Level 1: Normal use of supplies Level 2: Diminished capacity by 50% based on stock or anticipated delivery delay Level 3: Diminished capacity by 75% based on stock or anticipated delivery delay Level 4: Diminished capacity by 90% based on stock or anticipated delivery delay Level 5: Supply directly impacting patient care. Institution of allocation triage method Level 6: Allocation at high score (e.g., SOFA score >11) Level 7: Allocation at mid-level score (e.g., SOFA score >8 but <=11) Level 8: Allocation at low score (e.g., SOFA score >6 but <=8) Level 9: No availability of equipment and supplies. Palliative care if lifesaving equipment required. Comfort care made available. 6. Consultation/Subspecialist Triggers Level 1: Availability of subspecialist (in person or via telemedicine) or ability to transfer in a reasonable timeframe



Level 2: Delay of subspecialist or transfer beyond comfort of treating facility but not directly impacting patient care Level 3: Delay of subspecialist care/transfer with >24 hours of alternative care by practitioner Level 4: Delay of subspecialist care/transfer with > 48 hours of alternative care by practitioner Level 5: Delay of subspecialist care/transfer with > 72 hours of alternative care by practitioner Level 6: No ability for subspecialist care or transfer available. 7. General Levels of Crisis Care/Triggers to Move to Next Level Level 1: Normal care delivery Level 2: Alerted delivery with limited supply/resource. No impact on care thus far Level 3: Critical delivery with very limited supply/resource. No impact on care thus far Level 4: Pre-crisis care delivery. Critical resource shortage or infrastructure problems imminent in next 24 hours Level 5: Implementation of Crisis care. Allocation of scarce resources algorithm started Level 6: Allocation of scarce resources based on mid-level score Level 7: Allocation of scarce resources based on low-level score Level 8: Comfort care for individuals with need for unavailable lifesaving resource. 8. Staff Ratios and Expertise Per Specialty a. General Adult ICU Levels Level 1: Normal function with critical care experienced RN at maximum 1:2 nurse patient ratio. Critical Care specialist staffs and rounds in ICU regularly. Level 2: Elevation of Nurse Patient Critical Care Ratio to maximum of 1:4. Critical Care specialist sees most critical patients as defined by ICU criteria (e.g., ventilation, etc.) Level 3: Direct patient care delivered by non-ICU specialists. Nurse delivers care directly with supervision by CC trained nurse. Non-critical Care specialist rounds on ICU patients with supervision by Critical Care specialist. Critical Care physician supports difficult cases. Nurse to patient ration is 1:2 with maximum of 4 non-critical care nurses per 1 supervising critical care nurse. Maximum of 6 non-critical care specialists to one critical care physician Level 4: Direct care of critically ill patients by non-critical care trained staff without supervision. Occurs for <25% of all patients in ICU Level 5: Direct care of critically ill patients by non-critical care staff without supervision in <50% of ICU patients Level 6: Direct care of critically ill patients by non-critical care staff without supervision in <75% of ICU patients Level 7: No critical care specialists available in direct care or consultation b. Trauma ICU Levels and Teams Will be the same as listed above outside of the trauma guidelines listed below for trauma specific critical care

c. Pediatric and Pediatric Critical Care Levels Level 1: normal function with pediatric critical care experienced RN at maximum 1:2 nurse patient ratio. Pediatric Critical Care specialist staffs and rounds in ICU regularly.



Level 2: Elevation of Nurse-to-Patient Critical Care Ratio to maximum of 1:4. Pediatric Critical Care specialist sees most critical patients as defined by Pediatric ICU criteria (e.g., ventilation, etc.) Level 3: Direct patient care delivered by non-Pediatric or non-Pediatric ICU specialists. Nurse delivers care directly with supervision by Pediatric Critical Care trained nurse. Non-Pediatric or non-Pediatric Critical Care specialist rounds on pediatric ICU patients with supervision by Pediatric Critical Care specialist. Pediatric critical care physician supports difficult cases. Nurse to patient ration is 1:2 with maximum of 4 non-pediatric or non-pediatric critical care nurses per 1 supervising Pediatric Critical Care nurse. Maximum of 6 non-pediatric or non-pediatric critical care specialists to one pediatric critical care physician Level 4: Direct care of critically ill pediatric patients by non-pediatric or non-pediatric critical care trained staff without supervision. Occurs for <25% of all patients in Pediatric ICU Level 5: Direct care of critically ill pediatric patients by non-pediatric or non-pediatric critical care staff without supervision in <50% of Pediatric ICU patients Level 6: Direct care of critically ill pediatric patients by non-pediatric or non-pediatric critical care staff without supervision in <75% of ICU patients Level 7: No pediatric critical care specialists available in direct care or consultation d. Burn Care Levels and Teams Level 1: Normal function with burn care experienced RN at maximum 1:2 nurse patient ratio. Burn/Critical Care specialist staffs and rounds in Burn ICU regularly. Level 2: Elevation of Nurse-to-Patient Critical Care Ratio to maximum of 1:4. Burn Critical Care specialist sees most critical patients as defined by Burn ICU criteria (e.g., ventilation, etc.) Level 3: Direct patient care delivered by non-burn ICU specialists. Nurse delivers care directly with supervision by Burn wound/critical care trained nurse. Non-burn or non-burn Critical Care specialist rounds on Burn ICU patients with supervision by Burn Critical Care specialist. Burn critical care physician supports difficult cases. Nurse to patient ratio is 1:2 with maximum of 4 pediatric or non-pediatric critical care nurses per 1 supervising Burn Critical Care nurse. Maximum of 6 non-burn or noncritical care specialists to one burn critical care physician Level 4: Direct care of critically ill/major burn patients by non-burn or noncritical care trained staff without supervision in <25% of patients. Level 5: Direct care of critically ill/major burn patients by non-burn or noncritical care staff without supervision in <50% of patients. Level 6: Direct care of critically ill/major burn patients by non-burn or noncritical care staff without supervision in <75% of ICU patients Level 7: No burn critical care specialists available in direct care or consultation



Bedside Guidelines to Function under the Larger Framework

Adult Critical Care Guidelines This section of the Guidelines will assist with the delivery of specific and modified care for critical care. These concepts will guide acute care facilities in delivery of bedside care, and when care extends outside of this framework, contact and prioritization within the Local, Operational Area and Regional EOCs will occur. Thus, by using this guide, patient care will be delivered in the most equitable manner possible across a wide region. Adult Critical Care Framework 1: General ICU Principles: 1a. All hospitals with an ICU should prepare to administer ICU level care with a maximal surge limit of triple the usual ICU capacity. 1b. Hospitals should be able to provide surge capacity critical care for 10 days without sufficient external assistance from the region (e.g., supplies, staff, etc.). 1c. The following should be provided within ICUs during a surge event:

1) Mechanical ventilation 2) IV fluids, including resuscitation 3) Vasopressor administration 4) Antibiotic or antidote administration 5) Sedation and pain control 6) Nutritional support 7) Preventative measures including pneumonia reduction, thrombosis

prophylaxis, skin breakdown prevention, stress ulcer/GI prophylaxis, and catheter prophylaxis should be continued during surge capacity,

8) Renal replacement therapy 9) Invasive monitoring capabilities

1d. Criteria for admission to the ICU during surge capacity must include the need for mechanical ventilation, vasopressor administration, and/or IV fluid resuscitation. General observation or admission outside of these criteria should be avoided. 1e. Palliative, end of life care and comfort should be administered outside of the ICU.

Adult Critical Care Framework 2: Mechanical Ventilation 2a. Only one mechanical ventilator per patient currently receiving sustained ventilatory support will be administered. 2b. A ventilator should be able to provide positive pressure ventilation with a minimum of:

1) Oxygenate and ventilate most pediatric and adult patients with airflow obstruction or acute lung injury,

2) Able to function with low flow oxygen and without high pressure medical gas, 3) Be able to prescribe a set minute ventilation in patients without spontaneous respirations,



4) Have basic alarms to alert for apnea, circuit disconnect, peak airway pressures, and low gas source.

2c. Non-invasive positive pressure ventilation and alternative ventilator strategies (APRV, oscillatory) should not be a part of critical care surge capacity mechanical ventilation plans. 2d. Ancillary consumable respiratory equipment for airway care should be available in a ratio or 1.5 per 1 mechanical ventilator at maximal surge capacity (e.g., endotracheal tube, suction catheter, suction trap, vacuum source, filters) (e.g., if 30 ICU beds at baseline, 90 will be maximal with ancillary respiratory support at 135 ventilators). 2e. A single pulse oximeter with cardiac monitoring should be available per 1 mechanical ventilator with an additional 3 probes per pulse oximeter. 2f. Oxygen supply sources must be available and on site for the duration of mechanical ventilation during surge capacity, with permanent preferred over finite quantities (compressed air on site or compressed/liquid oxygen if no compressed air).

Adult Critical Care Framework 3: General equipment 3a. Central venous access supplies should be available in a ratio of 1.5 per 1 ICU patient, including central venous catheters, IV tubing and supplies, and peripheral IV catheters. 3b. A multi-channel pump should be available per ICU patient at maximal surge capacity (e.g., if 30 ICU beds at baseline, 90 pumps needed). 3c. Gastrointestinal, cardiac monitoring, EKG equipment, and urology equipment should be available at the ratio of 1.5 to 1 ICU bed at maximal surge capacity. 3d. A single bed will be administered per patient across the partnership. Specialized beds for prolonged immobilization will be triaged to the ICU.

Adult Critical Care Framework 4: Sedation and Analgesia 4a. Sedation and analgesia will be offered as an integral part of ICU care across the partnership at all times when clinically indicated. 4b. Non-continuous sedation and analgesia will be avoided unless clinically indicated during maximal patient surge. 4c. Interruption of daily sedation will be continued and administered during the patient surge. 4d. Sedation and analgesia substitution should occur at the local facility based on local formulary and pharmacy practices.



4e. Plans to withhold or diminish sedation or analgesia at a healthcare site should not be performed alone and requires consultation at the regional level. 4f. Comfort Care: End of life care and any withdrawal of mechanical ventilation plans must have sedation and/or analgesia.

Adult Critical Care Framework 5: Antimicrobials and Microbiology 5a. Antimicrobial choices should reflect the local susceptibility patterns and formulary choices. 5b. Antibiotic class changes or choices are at the discretion of the local practitioner but should provide adequate coverage based on susceptibilities and disease state (if susceptibilities not known). 5c. If a site becomes limited in a class of antibiotics (e.g., carbopenems), consultation with at least the RDMHC/S, the Regional Medical/Technical Specialist and Planning Chief is required. 5d. Regionally, treatment with antibiotics will reflect current best practices and treatment dose or length will not be altered unless antibiotics become a scarce resource, and measures for their allocation are put in effect. 5e. Limitations on antibiotic dose and length will not be performed at the local facility without consultation with the MHOAC, the RDMHC/S, the Regional or OA Medical/Technical Specialist and the Regional Planning Chief. 5f. The microbiology laboratory at each acute care site is expected to provide routine culture and susceptibility data unless limited by scarce resources within the lab. Unless unsafe conditions are present, no laboratory should be on diversion. 5g. Routine surveillance cultures will be discontinued when microbiology resources become scarce.

Adult Critical Care Framework 6: Patient Safety and Prevention 6a. The following forms of prevention and patient safety are to be considered during critical care at all levels of surge capacity:

1) venous thrombosis prophylaxis (VTE), 2) hospital acquired infection (HAI) prevention, including ventilator associated pneumonia,

central venous catheter blood stream infections (CRBSI), and urinary tract infections (UTI),

3) stress ulcer prophylaxis, 4) medication safety and reporting, 5) early nutrition program, 6) skin breakdown prevention.



6b. VTE prevention should include: 1) pharmacologic intervention 2) early mobilization 3) compression stockings or SCDs 4) continued facility recording and tacking during crisis care.

6c. HAI prevention includes:

a) VAP with bundle requirements to include oral care program, teeth brushing program, elevation of the head of bed >30 degrees, stress ulcer prophylaxis, avoidance on nasogastric tube, daily interruption of sedation,

b) CRBSI prevention includes scheduled dressing changes, daily line evaluation, sterile insertion technique in non-emergent placement, early termination,

c) UTI prevention includes sterile site insertion, early discontinuance program, and daily function assessment.

6d. Stress ulcer prophylaxis included any one of the following:

a) Use of PPI, H2 blocker, or sucralfate, b) Early use of enteral feeding, c) Use of post pyloric feeding tube, d) Oral tube placement when possible.

6e. Medication safety program includes continuance of staff-pharmacy review and reporting under current institution plans. 6f. Nutrition program includes any or all of the following:

a) Institution of feeding within 48 hours of admission, b) Daily enteral feeding evaluation if indicated, c) Caloric needs evaluation within 7 days of admission, d) Use of post pyloric feeding tube, if indicated.

6g. Skin breakdown prevention includes the following:

a) Turning of patient per protocol or q2hrs, b) Early OOB (out of bed) daily if tolerated and required if post operatively, c) Use of specialized beds for patients that are unable to be moved or turned regularly

(e.g., ARDS/critical care), d) Use of protective boots for foot drop (and other orthotic devices) and skin breakdown.

6h. If any of the above safety measures cannot be met, this triggers contact with Regional EOC.

Pediatric Critical Care Guidelines This section is to function in addition to the adult critical care guidelines above. If not otherwise stated, then the adult guidelines are followed.



Pediatric Critical Care Framework 1: General Pediatric ICU Principles General Pediatric ICU Principles should be the same as the Adult Critical Care General ICU Principles.

Pediatric Critical Care Framework 2: Mechanical Ventilation Mechanical ventilation principles should be the same as the Adult Critical Care mechanical ventilation principles with the following considerations: 2a. Ventilators must be able to provide low positive pressure settings and low volume settings. Appropriate size ventilator tubing (pediatric and neonatal) should be available as well.

Pediatric Critical Care Framework 3: General Equipment General equipment principles should be the same as the Adult Critical Care general principles with the following consideration: 3a. Special pediatric beds, cribs, and infant ICU beds should be available for every pediatric patient to receive an appropriate size bed.

Pediatric Critical Care Framework 4: Sedation and Analgesia Sedation and analgesia principles should be the same as the Adult Critical Care Sedation and Analgesia Principles.

Pediatric Critical Care Framework 5: Antimicrobials and Microbiology Antimicrobial and microbiology principles should be the same as the Adult antimicrobial and microbiology principles.

Pediatric Critical Care Framework 6: Patient Safety and Prevention Patient safety and prevention principles should be the same as the Adult patient safety and prevention principles with the following considerations: 6a. The incidence of VTE is rare and there should not be the requirement for VTE prevention for pediatric patients. 6b. Age-appropriate beds/cribs should be available and used for each patient to provide safety from falls and unauthorized bed departure.

Pediatric Critical Care Framework 7: Family-Centered Care Because care of the ill and/or injured child requires more communication and support of family members (e.g., parents), ancillary support for parents/family should be available, including space for bedside presence, open visiting hours to assist in the comfort of the child, a plan for room and board for the parents/family, and social support (e.g., social services) for parents/family. Consider cohorting or other accommodations when multiple family members are concurrent inpatients in the same or varied facilities.

Trauma Guidelines This section of the Guidelines will assist with the delivery of specific and modified trauma care. Trauma care includes initial assessment and resuscitation, operative interventions including neurosurgery, orthopedic surgery, oral-maxillo-facial surgery and general surgery, surgical critical care, and medical surgical ward care. These concepts will guide the healthcare facility in



delivery of bedside care, and when care extends outside of this framework, contact and prioritization within the Regional EOC will occur. Thus, by using this guide, patient care will be delivered in the most equitable manner possible across a wide region. Agreed upon ESCAPE trauma consensus statements, formulated during ESCAPE Advisory Committee retreats, from which many of the principles are derived.

- During a mass casualty incident, all hospitals in the region will be expected to provide some level of trauma care.

- When regional trauma resources are overwhelmed, trauma patients will be transferred out of the region.

- When trauma centers are unable to provide 24/7 care because of a lack of required manpower, resources will be allocated to provide 24/7 trauma care within EMS Regions III and IV.

Trauma Framework 1: General Trauma Principles (applicable to all incidents): 1a. All hospitals with an Emergency Department within the Region should prepare to administer some type of emergency trauma care, which may be supported by telemedicine. 1b. Trauma Consultation via telemedicine requires the ability to view the patient, radiographic studies and laboratory data (if available). 1c. Trauma Centers within the Region should be able to provide surge capacity trauma care for 10 days without sufficient external assistance from the region (e.g., supplies, staff, etc.). This includes critical care. 1d. Non-trauma centers within the Region should consult with trauma centers in the Region to identify patients who require transfer to higher levels of care. If patient transfer is unfeasible, partnership trauma centers should provide trauma specialists and equipment as needed to provide adequate resources and/or otherwise provide support for care. 1e. When medical resources are limited, trauma patients will be triaged according to trauma triage protocols and then will additionally be triaged under the medical triage algorithm. 1f. If level I or II trauma centers across the Region close due to a shortage of staff (nurses or surgeons), the emergency department or ICU has reached its patient surge limit, or there are resource shortages for treating trauma patients, trauma will divert to a central trauma hospital. 1g. If 50% or more of Level I or II trauma centers go on diversion to a central trauma center and that trauma center becomes overwhelmed, all hospitals will reopen to trauma, and critical patients will be diverted/transferred out of the region 1h. Criteria for admission to the trauma center during a surge event must include the need for mechanical ventilation, vasopressor administration, and/or IV fluid resuscitation, injuries requiring surgery, potentially life-threatening or severely disabling injuries requiring observation. Admission outside of these criteria should be avoided.



1i. Palliative and/or end of life care should be administered at non-trauma centers and/or ad hoc facilities outside of the ICU or med/surg beds. 1j. Pandemic Flu (based on decreased travel and decreased levels of crime per Mexico City experience) Non-designated trauma centers may close or divert any trauma patients as necessary to designated trauma centers.

Trauma Framework 2 (Applicable to incidents that are traumatic in nature) 2a. Minimal requirements for non-trauma center personnel dedicated to trauma care when the inciting event is traumatic in nature: Personnel 20 General Surgeons 3 Orthopaedic Surgeon 1 Nurse Anesthetist 2 Registered Nurse 3 OR Tech 2 Medic / NP 8 Administrator 1 OR Rooms 2 PRBC’s 20-50 units FFP 20-50 units OR trays 3 abdominal/chest/ortho 2 vascular 2b. Patients treated at non-trauma centers should be stabilized and transferred to centers capable of providing definitive care within or outside of the region 2c. Damage control general surgery and orthopedic surgery should be provided as needed prior to transfer 2d. Ultrasound is preferred radiological study 2e. Trauma center receiving patients requires the minimal personnel dedicated to trauma: Total Personnel 250-500 General Surgeons 3-7 Orthopaedic Surgeons 3-5 Urologist 1 OB/GYN 1 Neurosurgeon 1-2 ENT 2 Medicine 1-5 Anesthesiology 1-2 Nurse Anesthetist 1-2 RN 5-12 ORs 3-5 rooms



PRBCs 110-150 units FFP 110-150 units Platelets 110-150 units 2f. May transfer patients requiring more definitive care out of region.

Trauma Framework 3: Mechanical Ventilation Mechanical ventilation principles should be the same as the Adult Critical Care mechanical ventilation principles.

Trauma Framework 4: General Equipment General equipment requirements and principles are the same as Adult Critical Care general equipment requirements/principles.

Trauma Framework 5: Sedation and Analgesia Sedation and analgesia principles are the same as Adult Critical Care sedation and analgesia principles.

Trauma Framework 6: Antimicrobials and Microbiology Antimicrobials and microbiology principles are the same as Adult Critical Care antimicrobial and microbiology principles.

Trauma Framework 7: Patient Safety and Prevention Patient safety and prevention principles are the same as Adult Critical Care patient safety considerations.

Burn Care Guidelines Individual medical center care for burn patients will be determined by burn extent and depth, personnel available, and resources available. Unless otherwise stated, the general principles of adult critical care are followed, followed by these additions/alterations.

Burn Care Framework 1: General Burn ICU Principles General Burn ICU Principles should be the same as the Adult Critical Care General ICU Principles.

Burn Care Framework 2: Mechanical Ventilation Mechanical ventilation principles should be the same as the adult mechanical ventilation principles with the following considerations: 2a. Ventilators must be able to provide low positive pressure settings and low volume settings. Appropriate size ventilator tubing (pediatric and neonatal) should be available as well. Specialized mechanical ventilatory support, such as volumetric diffusive ventilation, may need to be available. Appropriate methods for securing and maintaining endotracheal tubes on faces with burn injury should be available.



Burn Care Framework 3: General Equipment General equipment principles should be the same as the adult general principles with the following considerations: 3a. Special burn beds should be available for every patient to receive an appropriate size bed. 3b. Maintenance of a warm room/environment (room temperature 80-85 degrees Fahrenheit) for burns >20% total body surface area should be provided.

Burn Care Framework 4: Sedation and Analgesia Sedation and analgesia should be administered intermittently during burn shock (first 24 hours after injury). Other principles should be the same as the Adult Critical Care Sedation and Analgesia Principles. Increased doses of narcotics and benzodiazepines may be necessary.

Burn Care Framework 5: Antimicrobials and Microbiology Antimicrobial and microbiology principles should be the same as the Adult Critical Care antimicrobial and microbiology principles, with a few specific considerations. Prophylactic intravenous antimicrobial therapy should NOT be used, as it increases multidrug resistance. Topical antimicrobials (silver sulfadiazine, mafenide acetate, bacitracin) need to be available for wound care. Wounds should be cleansed with an antimicrobial, devitalized tissue debrided, and topical antimicrobials reapplied twice daily if wound greater than 20% total body surface area. For burns <20% total body surface area, wounds should be cleansed and dressings changed at least daily.

Burn Care Framework 6: Patient Safety and Prevention Patient safety and prevention principles should be the same as the Adult Critical Care patient safety and prevention principles.

Burn Care Framework 7: Wound Care Level 1 centers are capable of critical care and wound care for all types and extent of burn injuries. Level 2 centers are capable of providing for wound care for all types of injuries. Level 3 centers are capable providing wound care and resuscitation for patients with second degree burns (partial thickness) <30% TBSA; and third degree (full thickness) burns requiring excision and grafting <15% TBSA that do NOT involve the hands, face, feet, perineum, or major joints. Level 4 centers are capable of providing daily wound care for second degree burns <20% TBSA and for third degree burns <10% TBSA needing excision and grafting. Level 5 centers are capable of providing wound care to patients with second degree burns <10% TBSA. Level 6 centers are not capable of caring for patients with burns. Children with burn injuries >20% TBSA need to be cared for in a level 1 or 2 center or a pediatric intensive care unit. Burns—Case Examples A brush fire occurs in a campground, resulting in the following injuries. Where should they be cared for? This assumes a normal healthcare system, with no surge a. 45-year-old man with 45% TBSA third degree burns to his arms and legs. i. Care at level 1or 2 center b. 30-year-old man with 25% TBSA second degree burns to chest, back.



i. Care at level 3 center c. 20-year-old woman with 13% TBSA third degree burn of thigh, abdomen. i. Care at level 4 center d. 18-year-old woman with 8% TBSA second degree burn to chest. i. Care at level 5 center

Mental Health Guidelines Types of Patients

1. Chronically mentally ill/homeless and impoverished who need referrals and are resource intensive

2. Worried well/distressed citizen who need to be triaged out of the system and given information to decrease distress

3. Those who are ill as a consequence of the situation and need practical help 4. Providers at greatly increased risk of suicide/depression/worry about family

Department of Mental Health Services—Hierarchy of Needs Basic needs/concerns first:

• Survival • Safety and security

Then: • Food, clothing and shelter, meds as needed • Health and well being

DMH Services—non-traditional settings

• Temporary shelters • Food distribution centers • Waiting in lines • Medical triage areas • Ad hoc healthcare locations

Key Intervention Strategies

• Provide human contact and basic information to assist in problem-solving • Build rapport through supportive listening; validate experiences • Perform rapid assessment and triage • Build trust through multiple brief contacts • Focus on strengths, existing resources, and natural support systems • Address crisis in manageable doses • Avoid psychological or psychiatric jargon and the concept of pathology • Assist with everyday tasks



• Be a hopeful presence, but don’t offer false assurances Assessment Considerations

• An informal process of noticing needs and responding appropriately • Start with practical information and supportive interventions or refer as appropriate • When unsure of the proper response:

o Support: Provide support to the victim o Consult: Review the situation with team members o Return: Frequent brief contacts builds a relationship and provides more accurate

understanding of needs Differentiate 4 general groups:

1. Those in need of practical information only 2. Those who may benefit from a return visit for further contact, support, and

monitoring 3. Those who need immediate crisis counseling (supporting listening, debriefing,

comfort 4. Those who require referrals for severe reactions or chronic mental health conditions 5. Consider a separate group for response personnel with critical incident stress or

support needs Assess with

a. Alertness and Awareness b. Actions c. Speech d. Emotions

Alertness and Awareness You can probably handle the situation if the client:

• Is aware who they are, where they are, and what has happened • Is only slightly confused or dazed, or shows slight difficulty in thinking clearly or

concentrating on a subject Consider referral to mental health agency if the client:

• Is unable to give own name or names of people with whom they are living • Cannot give date or state where they are or tell what they do • Cannot recall events of past 24 hours • Complains of, or demonstrates, memory gaps

Actions You can probably handle the situation if the client:

• Wrings hands or sits motionless for several minutes • Is restless, mildly agitated, and excited • Has sleep difficulty



• Has rapid or halting speech Consider referral to mental health agency if the client:

• Is depressed and shows agitation, restlessness, and paces • Is apathetic, immobile, unable to arouse self to movement • Is incontinent • Mutilates self • Uses alcohol or drugs excessively • Is unable to care for self (doesn’t eat, drink, bathe, or change clothes, endangers self • Repeats ritualistic acts

Speech You can probably handle the situation if the client:

• Expresses appropriate feelings of depression, despair, discouragement • Expresses doubts of their ability to recover • Is overly concerned with small things, neglecting more pressing problems • Denies problems or states that they can take care of everything themselves • Blames their problems on others, is vague in their planning, and bitter in their feelings of

anger that they are a victim Consider referral to mental health agency if the client:

• Hallucinates—hears voices, sees visions, or has unverified bodily sensations • States that their body feels unreal and fears they are losing their mind • Is excessively preoccupied with one idea or thought • Has the delusion that someone or something is out to get them and their family • Is afraid they will kill self or another • Is unable to make simple decisions or carry out everyday functions • Shows extreme pressure of speech—talk overflows

Emotions You can probably handle the situation if the client:

• Is crying, weeping, with continuous retelling of disaster • Has blunted emotions, little reaction to what is going on around them right now • Shows high spirits, laughs excessively • Is easily irritated and angered on trifles

Consider referral to mental health agency if the client:

• Is excessively flat, unable to be aroused, completely withdrawn • Is excessively emotional and shown inappropriate emotional reactions

Relating to Victims



• Recognize that a victim’s life may have changed immeasurably, and “returning to normal” may not be possible

• Feelings may be intense, and it may be difficult for victims to “get down to business” or “be practical”

• An outsider’s view of the situation may be less emotion-laden, but isn’t necessarily more “objective” or “reasonable”

• Offer information and encouragement; avoid advice or directives • Opportunities to review or process feelings come naturally; pushing victims to move too

quickly may be harmful • Recognize and accept your own tolerance for others’ pain; being aloof, condescending, or

telling your own story is rarely helpful Psychological Reactions to Disasters

• Personal assets and vulnerabilities mitigate and/or exacerbate disaster stress • Disasters affect survivors both psychologically and socially • Pre-existing community structures for social support and resources for recovery vary • Engagement with survivors and the overall community is key to promoting recovery • Program planners, administrators, and providers must appreciate “macro” view of

interacting factors Responses to Trauma Individual--Initial--Normal Emotional

• Emotional numbing • Depression, anxiety, guilt, fear • Clinginess, dependency Behavioral • Withdrawal, hypervigilance

Fatigue

• Increased substance abuse • Shock • Reduced sleep and appetite • Worsening health Spiritual • Resolve/ Despair • Altruism/Isolation • Questioning/Reaffirming

Individual--Delayed--Normal Emotional

• Distancing through denial, intellectualization, compartmentalization, blaming, or inappropriate use of humor

Cognitive • Slowed thought, disorientation



• Hallucinations, flashbacks • Decreased performance at school or work

Physical • Chronic low energy • Stress-related problems • Frequent injuries

Spiritual • Changes in relationships, promiscuity • Social withdrawal • Fatalism, cynicism

Specific Problem Areas Related to a Pandemic • Pandemic trauma may be both individual and collective • Disruptions to daily living • Personal loss (severity will vary) • Loss of equilibrium to individuals, communities, and geographic regions • Economic devastation on the personal and community level • Ripple effect of multiple losses • Anniversary of pandemic may be a vulnerable point and retraumatization • While there is a clearly defined beginning, there is no clearly defined endpoint and the

virus may return again the next year • Prolonged impact period will impede the recovery process • People will be concerned about not infecting family members and other loved ones • Quarantine and isolation will lead to lack of social support • Infectious disease process may prevent human contact • Some services will have to be delivered in non-traditional ways, due to isolation and

quarantine issues • The death toll could be much higher than anticipated, depending on a variety of factors • Massive surge on medical system is likely • Adherence to public health recommendations will be low • Fear of their own risk can cause providers to avoid caring for patients • Individual and community factors will influence behavioral and emotional consequences • Information about the pandemic needs to be available and accessible • People will look for instances of unequal treatment • What is the public’s perceived trust in institutions? • Key personnel in critical infrastructure functions will need support • Public wants to be involved and wants to help out as best as they can • Public may not want to accept quarantine, isolation restrictions • Public may ignore restrictions on social gatherings • Long term psychological problems may ensue (depression, anxiety, PTSD, feelings of

guilt, increased substance abuse, violence in interpersonal relationships, risk of suicide) • Some professions more vulnerable to psychological problems (health care workers,

mortuary workers, funeral home workers, nursing home employees)



Conclusion The development of the ESCAPE Crisis Care Guidelines is an important step in developing a Regional solution to the myriad problems caused by a patient surge during a healthcare emergency. Particularly for disasters that require a sustained state of emergency (such as a severe pandemic), it is critical that the healthcare system maintain a systematic and coordinated response. It is especially challenging for the wide variety of types of healthcare providers spanning the continuum of care; public and private; for profit and non-profit, to agree to manage resources and patients with the high level of synchronization necessary for an ethical, transparent, effective response. As a demonstration project planning for a potential widespread healthcare surge, through the ESCAPE project, healthcare facilities such as the US military, Kaiser, Indian Health, community clinics, public health, alternate care, and rural and urban hospitals have come together to demonstrate the strength of a broad-based healthcare coalition. ESCAPE partners are not required to utilize the telemedicine network this project has provided them, nor are they required to adhere to these Crisis Care Guidelines in an actual disaster. However, by providing partners with highly effective tools for surge emergency management, many partners have become interested in implementing the ESCAPE concepts and equipment networks. In addition, we have already witnessed one partner’s usage of their telemedicine equipment for emergency response when Shriner’s Hospital for Children remotely assisted with the victims of the Hermosillo, Mexico, daycare fire in early June 2009. Partnerships like the ESCAPE coalition help to bring healthcare planning entities together, increasing the ability of these healthcare facilities to work in concert in a surge situation. Local and State government support (legislative, regulatory, public health, and pre-hospital arenas) is also critical to the success of any surge planning or response, particularly with regard to events requiring a sustained healthcare response. These Guidelines, along with other documents produced by the ESCAPE project, can serve as a template for developing a Regional or Statewide broad-based healthcare coalition with the ability to work in concert to benefit the population in both exercises and actual healthcare emergency response.

Theme Leaders Aaron E. Bair, MD, MSc Dr. Bair completed his training and chief residency in emergency medicine at UC Davis in 1997. He joined the EM faculty at UC Davis in 1998. His areas of research focus are related to procedural competency (airway management and emergency ultrasound use) as well as computational modeling of ED workflow. He has authored multiple textbook chapters and contributions to UpToDate Emergency Medicine. He lectures frequently on topics related to difficult airway management and



has taught the subject internationally. He serves as a reviewer for multiple emergency medicine journals and is an associate editor for Journal Watch Emergency Medicine. Dr. Bair is the medical director, Editor-in-Chief, for the TheAirwaySite.com. Dr. Bair is currently on sabbatical and working with the Department of Homeland Security as a research scholar.

Aaron E. Bair, MD, MSc Associate Professor Director of Emergency Medicine Disaster Preparedness and Simulation Training Department of Emergency Medicine University of California, Davis (916) 734-1137 [email protected]

Christine Cocanour, MD, FACS, FCCM Dr. Cocanour is a board-certified surgeon in Surgical Critical Care. Her research interests focus on trauma resuscitation, nosocomial infections in the ICU, gastric function following severe trauma and computerized decision support in the ICU. Dr. Cocanour served as the Medical Director for the North Channel EMS (Houston, TC) for 4 years and is currently the Program Director for the Surgical Critical Care Fellowship. She has also served on the Western Trauma Association Board of Directors and on the editorial board for Archives of Surgery and The Journal of Trauma.

Christine S. Cocanour, MD, FACS, FCCM Professor of Surgery Division of Trauma & Critical Care UC Davis Medical Center (916) 734-7330 [email protected]

Glynis Foulk, CIH, MS American Board of Industrial Hygiene Certified; MS in Occupational Safety and Health; Glynis Foulk is the Emergency Preparedness and Security Administrator for UCDHS. She led the efforts to integrate the revised Hospital Incident Command System (HICS) and National Incident Management System (NIMS) into the Health System’s emergency management program. She conducted training on the concepts and application of HICS to over 150 employees from the hospital leadership to HICS unit leaders. Glynis coordinated preparation of the Health System’s Influenza Pandemic Business Continuity Plan and was co-chair of the Emergency Response and Business Continuity Workgroup. She has developed and conducted health and safety and

Glynis Foulk, CIH, MS Emergency Preparedness & Security Administrator UC Davis Health Systems (916) 734-8261 [email protected]



emergency preparedness training for 17 years. She is an active member of the Sacramento Region Emergency Preparedness Committee. As the Training and Coordination Theme Leader, Glynis Foulk, will work with the NIMS Coordi-nator at the Calif. Hospital Association (CHA) to assist and ensure hospitals in the Emergency Care Partnership become and maintain NIMS com-pliance; work with the CHA coordinator on training modules and advise CHA NIMS coordina-tor; manager relationship and distribution of infor-mation between organizational partners; ensure that proposed activities follow NIMS guidelines. James P Marcin, MD, MPH Dr. Marcin is Associate Professor of Pediatrics and Pediatric Critical Care Medicine at the University of California, Davis. He works in the Pediatric Intensive Care Unit at the UC Davis Children’s Hospital and is the Director of the UC Davis Children’s Hospital Pediatric Telemedicine Program. He is a faculty member of the UC Davis Center for Health Services Research in Primary Care, a Major Professor in the Graduate Group in Epidemiology, and a member of the Health Informatics Program at UC Davis. His research interests are in prognostic indicators, severity of illness measures, and quality of care for pediatric patients. His expertise and research interests include pediatric critical care and emergency medicine telemedicine and quality of care measures. He is currently investigating telemedicine in rural and underserved Emergency Departments, Clinics and Inpatient Wards. With these projects and grants he is researching the impact of telemedicine on the quality of care delivered to acutely ill and injured children all over Northern California.

James P Marcin, MD, MPH Associate Professor of Pediatric Critical Care Medicine Director, Pediatric Telemedicine Center for Health and Technology UC Davis Children's Hospital (916) 734-4726 [email protected]

Tina Palmieri, MD Dr. Palmieri began her medical training at Northwestern University Medical School. She subsequently completed surgery residency at the



University of Iowa Hospitals and Clinics and a critical care and burn fellowship at the University of Missouri Hospitals and Clinics. She served in the Air Force at Keesler Air Force Base as Director of the Intensive Care Unit, assistant general surgery residency program director, and Critical Care Air Transport Team member for 4 years. For the past 9 years she has been the Director of the University of California Davis Burn Center and Assistant Chief of Burns at Shriners Hospital for Children Northern California.

Tina L. Palmieri, MD, FACS Associate Professor and Director Regional Burn Center University of California, Davis (916) 453-2050 [email protected]

Christian Sandrock, MD, MPH Christian Sandrock, a physician and an expert in infectious diseases, and pulmonary and critical care medicine at the UC Davis Medical Center, specializes in disaster preparedness, emerging infectious diseases, terrorism and other threats to public health. As medical director of the California Preparedness Education Network, he develops educational materials, primarily for providers in rural, border, inner-city and underserved areas of the state. He was medical director of the Hospital Bioterrorism Preparedness Program for the state of California and currently, as medical adviser to the state Emergency Medical Services Authority, he contributes his expertise to the U.S. Centers for Disease Control and Prevention, Hospital Bioterrorism Preparedness Program, and many other Homeland Security projects. He is working with the California Department of Health Services and the Emergency Medical Services Authority in pandemic influenza and other infectious disease outbreak planning, disease surveillance and hospital infection-control preparedness.

Christian Sandrock, MD,MPH Assistant Professor of Clinical Medicine Division of Pulmonary and Critical Care Medicine Division of Infectious Diseases UC Davis School of Medicine Deputy Health Officer, Yolo County (916)-734-3564 [email protected]



Javeed Siddiqui, MD, MPH Javeed Siddiqui is the Associate Medical Director at the Center for Health and Technology and an Assistant Clinical Professor of Medicine, Division of Infectious and Immunologic Diseases, School of Medicine, University of California, Davis At the Center for Health and Technology Dr. Siddiqui serves as medical director for the telemedicine program and has been actively involved in HIV/AIDS and Infectious Diseases telemedicine since 2002. In addition, Dr. Siddiqui has currently embarking in what we believe is the first in-patient infectious diseases telemedicine program in the United States. Dr. Siddiqui is board certified in Infectious Diseases and Internal Medicine. Dr. Siddiqui’s clinical practice includes treatment of HIV/AIDS and general in-patient infectious diseases both at the medical center and through telemedicine. Dr. Siddiqui is a co-investigator in a number of clinical trials primarily in the field of HIV/AIDS. He has written several articles in peer reviewed journals, published manuscripts and presented abstracts at national and International Conferences.

Javeed Siddiqui, MD,MPH Assistant Professor of Clinical Medicine Division of Infectious and Immunologic Diseases Associate Medical Director Center for Health and Technology School of Medicine University of California, Davis (916) 734-3742 [email protected]

R. Steven Tharratt, MD, MPVM Dr. Tharratt is Professor of Medicine and Anesthesiology and Vice Chief, Division of Pul-monary and Critical Care Medicine at the Univer-sity of California Davis. Dr. Tharratt has research interests in emergency management and the integration of health issues into public policy and emergency decision making in both natural and technological disasters. He has published widely on emergency management issues and in the relationship between the medical and veterinary medical disciplines in response to biodefense and emerging zoonotic diseases, including avian influenza. He currently serves as Vice Chair of the California Commission on Emergency Medical Services.

R. Steven Tharratt, MD, MPVM Professor of Medicine & Anesthesiology Vice Chief, Division of Pulmonary & Critical Care Medicine



Dr. Tharratt is formerly medical science Advisor to the California Governor’s Office of Emergency Services and the Emergency Medical Services Authority. He is currently Medical Director for Sacramento County Emergency Medical Services and all Sacramento City and County Fire Agencies. Dr. Tharratt was one of two physicians deployed to the World Trade Center Collapse on September 11, 2001 with the Sacramento Urban Search and Rescue Team. Dr. Tharratt received his MD degree from the University of California Los Angeles and his Master of Preventative Veterinary Medicine Degree (Public Health) from the University of California Davis. He is Board certified in Internal Medicine, Emergency Medicine, Pulmonary Diseases, Critical Care Medicine and Medical Toxicology.

University of California, Davis 916-734-3564 [email protected]

Peter Yellowlees, MBBS, MD Dr. Yellowlees is Professor of Psychiatry and Director of Academic Information Systems at UC Davis, where he also chairs the Graduate Group in Health Informatics and is responsible for the Health Informatics Program. Dr. Yellowlees undertook his medical training in London and then worked in Australia for 18 years before moving to UC Davis three years ago to continue his research in telemedicine and eHealth. He has an international reputation in telemedicine and long distance health and education delivery and is much in demand as a speaker having given over 100 presentations in 20 countries in the past five years. He has consulted to governments and private sector companies in several countries, and has published three books and over 100 scientific articles. Dr. Yellowlees has a number of research interests and is presently working on projects involving data mining and disease management protocols, internet email and video consultation services, and the use of virtual reality and other online platforms for health education on the internet.

Peter Yellowlees, MBBS, MD Professor of Psychiatry and Director of Academic Information Systems University of California, Davis (916) 734-8581 [email protected]

Enhanced Surge Capacity & Partnership Effort (ESCAPE ... ccg excerpt from final report.pdf · Emergency Medical Services (EMS), community clinics, Indian health, and a military hospital.

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