e3 92 Robertson MA, Molyneux EM Description of cause of serious ill ness and outcome in patients identified using ETAT guidelines in urban Malawi Arch Dis Child 2001;85 214 217 93 Tamburlini G, Di Mar[.]
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ill-ness and outcome in patients identified using ETAT guidelines in
urban Malawi Arch Dis Child 2001;85:214-217.
93 Tamburlini G, Di Mario S, Maggi RS, Vilarim JN, Gove S
Evalu-ation of guidelines for emergency triage assessment and treatment
in developing countries Arch Dis Child 1999;81:478-482.
94 Tchorz KM, Thomas N, Jesudassan S, et al Teaching trauma care
in India: an educational pilot study from Bangalore J Surg Res
2007;142:373-377.
95 Bergman S, Deckelbaum D, Lett R, et al Assessing the impact of
the trauma team training program in Tanzania J Trauma
2008;65:879-883.
96 Aboutanos MB, Rodas EB, Aboutanos SZ, et al Trauma education
and care in the jungle of Ecuador, where there is no advanced
trauma life support J Trauma 2007;62:714-719.
97 Ali J, Adam RU, Gana TJ, Williams JI Trauma patient outcome
after the Prehospital Trauma Life Support program J Trauma
1997;42:1018-1021; discussion 21-22.
98 Homaifar N, Mwesigye D, Tchwenko S, et al Emergency
obstet-rics knowledge and practical skills retention among medical
stu-dents in Rwanda following a short training course Int J Gynaecol
Obstet 2013;120:195-199.
99 Butler MW, Ozgediz D, Poenaru D, et al The Global Paediatric
Surgery Network: a model of subspecialty collaboration within
global surgery World J Surg 2015;39:335-342.
100 MacLeod JB, Gravelin S, Jones T, et al Assessment of acute trauma
care training in Kenya Am Surg 2009;75:1118-1123.
101 Opiyo N, English M In-service training for health professionals to
improve care of seriously ill newborns and children in low-income
countries Cochrane Database Syst Rev 2015;5:CD007071.
102 Edgcombe H, Paton C, English M Enhancing emergency care in
low-income countries using mobile technology-based training
tools Arch Dis Child 2016;101:1149-1152.
103 Organization WH Telemedicine - Opportunities and Developments
in Member States Report on the Second Global Survey on eHealth
Geneva: WHO Press; 2010.
104 Alirol E, Getaz L, Stoll B, Chappuis F, Loutan L Urbanisation and
infectious diseases in a globalised world Lancet Infect Dis 2011;
11:131-141.
105 Mould-Millman NK, Dixon JM, Sefa N, et al The State of
Emer-gency Medical Services (EMS) Systems in Africa Prehosp Disaster
Med 2017;32:273-283.
106 Leligdowicz A, Bhagwanjee S, Diaz JV, et al Development of an
intensive care unit resource assessment survey for the care of
criti-cally ill patients in resource-limited settings J Crit Care
2017;38:172-176.
107 El-Khatib Z, Shah M, Zallappa SN, et al SMS-based smartphone
application for disease surveillance has doubled completeness and
timeliness in a limited-resource setting - evaluation of a 15-week
pilot program in Central African Republic (CAR) Confl Health
2018;12:42.
108 Geiling J, Burkle Jr FM, Amundson D, et al Resource-poor
set-tings: infrastructure and capacity building: care of the critically ill
and injured during pandemics and disasters: CHEST consensus
statement Chest 2014;146:e156S-e167S.
109 Marston BJ, Dokubo EK, van Steelandt A, et al Ebola Response
Impact on Public Health Programs, West Africa, 2014-2017
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110 Rosenberg DI, Moss MM, American College of Critical Care Medicine of the Society of Critical Care M Guidelines and levels
of care for pediatric intensive care units Crit Care Med 2004;
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111 Rosenberg DI, Moss MM, American Academy of Pediatrics Sec-tion on Critical C, American Academy of Pediatrics Committee on Hospital C Guidelines and levels of care for pediatric intensive care
units Pediatrics 2004;114:1114-1125.
112 Maitland K, Kiguli S, Opoka RO, et al Mortality after fluid bolus
in African children with severe infection N Engl J Med 2011;364:
2483-2495.
113 Seydel KB, Kampondeni SD, Valim C, et al Brain swelling and
death in children with cerebral malaria N Engl J Med 2015;372:
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114 Sarmin M, Ahmed T, Bardhan PK, Chisti MJ Specialist hospital study shows that septic shock and drowsiness predict mortality in
children under five with diarrhoea Acta Paediatr 2014;103:
e306-e311.
115 Ranjit S, Aram G, Kissoon N, et al Multimodal monitoring for hemodynamic categorization and management of pediatric septic
shock: a pilot observational study Pediatr Crit Care Med 2014;
15:e17-e26.
116 Ranjit S, Natraj R, Kandath SK, Kissoon N, Ramakrishnan B, Marik PE Early norepinephrine decreases fluid and ventilatory
requirements in pediatric vasodilatory septic shock Indian J Crit Care Med 2016;20:561-569.
117 Sankar J, Ismail J, Sankar MJ, Meena RS Fluid bolus over 15-20 versus 5-10 minutes each in the first hour of resuscitation in
chil-dren with septic shock: a randomized controlled trial Pediatr Crit Care Med 2017;18:e435-e445.
118 Sankar J, Dhochak N, Kumar K, Singh M, Sankar MJ, Lodha R Comparison of international pediatric sepsis consensus conference versus sepsis-3 definitions for children presenting with septic shock
to a tertiary care center in India: a retrospective study Pediatr Crit Care Med 2019;20:e122-e129.
119 von Saint Andre-von Arnim AO, Attebery J, Kortz TB, et al Chal-lenges and priorities for pediatric critical care clinician-researchers
in low- and middle-income countries Front Pediatr 2017;5:277.
120 English M, Gathara D, Mwinga S, et al Adoption of recom-mended practices and basic technologies in a low-income setting
Arch Dis Child 2014;99:452-456.
121 Wiens MO, Kumbakumba E, Larson CP, et al Postdischarge mor-tality in children with acute infectious diseases: derivation of
post-discharge mortality prediction models BMJ Open 2015;5:e009449.
122 Chisti MJ, Graham SM, Duke T, et al Post-discharge mortality in children with severe malnutrition and pneumonia in Bangladesh
PLoS One 2014;9:e107663.
123 Richardson B, Dol J, Rutledge K, et al Evaluation of mobile apps targeted to parents of infants in the neonatal intensive care unit:
systematic app review JMIR Mhealth Uhealth 2019;7:e11620.
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Trang 2Abstract: Low- and middle-income countries continue to carry
the largest burden of critical illness and pediatric mortality yet
have the least critical care resources Basic low-cost critical care
interventions can be successfully provided in resource-poor
set-tings without an intensive care unit (ICU) However, publicly
funded ICU treatment remains limited in low-income countries,
and its introduction requires careful resource allocation
Health-care systems improvements for the critically ill should involve a
graded approach of strengthening capacity to provide health
maintenance, basic critical care, and then publicly funded inten-sive care services as overall health indices improve Critical care research from low-income countries is sorely needed to guide ef-fective and efficient care and advocate for resources
Key words: Low-resource settings, low- and middle-income countries, resource allocation, pediatric critical care training, cost-effectiveness
Trang 39
Public Health Emergencies and
Emergency Mass Critical Care
KATHERINE L KENNINGHAM AND MEGAN M GRAY
• Emergency mass critical care (EMCC) is limited, essential critical care
during disasters when intensive care demands surpass resources.
• Pediatric, neonatal, and cardiac intensivists must be engaged
with hospital and regional public health emergency (PHE)
plan-ning and preparedness efforts to ensure that they are familiar
with strategies and resources to rapidly increase care capacity.
• Pediatric intensive care units (ICUs) should plan to care for three
times their usual census for 10 days without outside help
dur-ing a severe PHE.
PEARLS
• The surge capacity continuum that spans conventional to con-tingency to crisis capacity should be employed during a PHE in
order to extend resources to meet needs.
• All ICU disaster planning efforts should consider protocols for triage teams to support the emergency department, patient tracking and reunification, victim and staff mental health, and the role of medical learners in EMCC efforts.
During a public health emergency (PHE) such as a natural disaster
or pandemic, a large number of infants, children, and young adults
may need critical care in order to survive During such an event, the
incident command system (ICS) provides a framework to support
decision-making and coordinate efforts across affected sites
Be-cause pediatric critical care is highly specialized and beBe-cause few
nonpediatric providers are comfortable caring for severely ill or
in-jured children, pediatric, neonatal, and cardiac intensive care units
(ICUs) represent an essential aspect of patient management during
a PHE and should be included within a structured response
Planning and preparedness for PHEs can save lives
Unfortu-nately, critical care providers receive little training in disaster
medicine and response and are often underinvolved in hospital
disaster preparedness efforts Recent public health emergencies
have exposed a lack of PHE awareness, training, and preparation
by critical care providers The goal of this chapter is to educate the
pediatric or neonatal ICU provider in the principles and tools of
PHE preparedness and emergency mass critical care (EMCC)
Learning from smaller or more local PHEs and preparing for
critical care during anticipated PHEs may help intensivists better
prepare for future catastrophic events that require EMCC
For-ward consideration of how to scale up response and conserve,
ration, and allocate critical care services can reduce dangerous
uncertainty and save time in the event of a larger-scale PHE
How Many Pediatric Patients Could Be Affected in a Public Health Emergency?
If a PHE affected persons of all ages equally, children aged 0 to
14 years would account for 20% of all patients.1 However, younger patients may be more vulnerable to infections, dehydra-tion, toxins, and trauma Therefore, they may be overrepresented
in the patient population during a PHE.2 Events involving a child-specific location, such as school, may result in a patient population predominantly made up of children
Under usual circumstances, survival rates from high-risk pedi-atric conditions tend to be higher when children receive care at pediatric hospitals.3–6 A national survey estimated a pediatric ICU (PICU) peak capacity of 54 beds per million pediatric popula-tion.7 Typical PICU occupancy in excess of 50% leaves fewer than
30 vacant PICU beds per million age-specific population, with even fewer cardiac ICU (CICU) beds generally available The younger the patient, the more age-specific and specialized the treatment requirements become, culminating in the extremely preterm neonate who requires equipment unavailable outside of a regional neonatal ICU (NICU) There are approximately 4 million newborns born in the United States annually and 5700 total NICU beds per million age-specific population In contrast to PICU capacity, occupancy of NICU beds is higher at baseline,
“Keep your eye on the ball.”
Bob Kanter, Trailblazer for Children
in the World of Disaster Medicine
Trang 460 SECTION I Pediatric Critical Care: The Discipline
with 6% of low-risk term infants and 97% of
very-low-birth-weight infants requiring NICU care.8 Because each region may be
served by only a few or even a single pediatric-capable hospital,
events that disable one hospital may disproportionately degrade
regional pediatric and neonatal care
Quantitative models indicate that survival during a PHE
would improve if a pediatric patient surge is distributed to pediatric
beds throughout a larger geographic area rather than overwhelming
facilities near the epicenter of an emergency.9 Unfortunately,
con-trol of patient distribution may be limited in a severe PHE As a
result, all hospitals must be prepared to care for some children for
an extended period of time.10–12 Whether or not patients are
distributed optimally, outcomes from a large PHE are likely to
improve with EMCC approaches.9 , 14 Additionally, using
tele-medicine to connect available pediatric critical care and
subspe-cialty physicians to facilities unaccustomed to caring for pediatric
patients may significantly extend the reach of pediatric EMCC
during a PHE
What Are the Most Likely Public Health
Emergencies?
Public health emergency risks vary depending on hospital
loca-tion, population demographics, and local resources Each
hospital is tasked with maintaining emergency plans for its
most likely PHEs This list is usually generated via a hazards
vulnerability analysis (HVA), which leverages local expertise in
medical management and infrastructure risks, and combines
this with frequency and severity data on past and potential
events.15 Events such as information technology (IT) and
elec-tronic medical record (EMR) outages are experienced nearly
universally in healthcare settings and are included in HVAs
Primary planning for IT/EMR outages should include
proto-cols for downtime procedures, paper charting, and
nonelec-tronic communication Hospitals should engage in drills,
ta-bletop exercises, and simulations targeted to address issues
identified by their HVA Smaller and less severe events, such
as planned EMR downtimes and routine adverse weather
should be used as opportunities to clarify and test protocols
for larger PHEs
Who Will Make Decisions During
an Emergency?
Responses to major public health emergencies are organized
within a National Response Framework, as outlined by the
federal US Department of Homeland Security.16 Emergency
responses are coordinated at the most local jurisdiction
possi-ble, usually at the city or county level, until those resources are
outpaced The hospital ICS further provides a leadership
frame-work within and among organizations responding to an
emer-gency, representing a simplified and clear chain of command in
order to speed decision-making A hospital ICS includes
clini-cal and noncliniclini-cal representation, provides flexible logisticlini-cal
support, and helps to prioritize key functions Disaster plans at
every hospital should incorporate ICS principles, regardless of
the size of the hospital; ICS planning guides are widely
avail-able to aid in plan development Identifying the ICU role
within the local ICS framework is an essential part of PHE
preparedness (Fig 9.1)
What Is the Expected Timeline of a Public Health Emergency?
When a sudden-impact PHE occurs, the hospital’s ICS is acti-vated The initial priority is to perform an assessment of the cur-rent state of the hospital; units rapidly assess their bed capacity, including potential beds that could be mobilized Patients poten-tially no longer requiring ICU care should be identified for rapid transfer or discharge, and on-site staff able to be redirected to patient care should be tallied If the PHE directly affects the struc-ture or function of the hospital building, the initial assessment should also include numbers of newly injured staff, visitors, and patients, as well as any damage to the unit These initial assess-ment numbers are collected from each unit, and a rough estimate
of potential incoming patients is, in turn, shared with area leaders Based on initial assessment and estimates, the incident com-mander will direct the response to ensure adequate staff supplies, equipment, and clinical space, and will communicate decisions regarding whether to mobilize potential bed capacity identified
in the initial assessment Information from the ICS should be communicated to front-line staff early on to reduce uncertainty and ensure a clear and united message to patients and families ICS-directed response may include assigning and sometimes re-assigning current staff, calling in additional staff, ordering and distributing additional supplies, and identifying when standards
of care should change Area leaders should be called in as soon as possible to aid in coordinating the response and offload clinical staff of administrative duties As information about the event becomes available, ICU leaders and educators may need to provide incident-specific just-in-time teaching to staff
What Is a Surge and What Can Be Done to Meet Surge Needs?
Critical care responses to PHEs are scaled according to the size and severity of the emergency (Fig 9.2).17 , 18 Emergency surges are categorized as minor, moderate, or major A minor event would require up to 20% increase above usual peak hospital capacity; conventional surge methods would likely suffice to provide nor-mal standards of critical care to all who need it in this scenario.23 Conventional critical care surge needs can be met by canceling
Labor pool
Incident commander
Safety officer
Public info officer
Operations chief
Medical director
Planning
Materials &
supplies
ICU leader
• Fig. 9.1 Incident command system diagram. admin, Administrative;
ICU, intensivecareunit;info,information.
Trang 5elective admissions, quickly discharging all patients who can safely
leave the ICU, mobilizing staff, and adding bed space (Fig 9.3)
Moderate emergency surges result in an increased patient
population of between 20% and 100% of usual capacity,
neces-sitating a contingency response to most effectively use limited
resources Contingency surge methods include all elements of the
conventional response with additional strategies to expand
cover-age Non-ICU patient care areas may be repurposed for ICU-level
care Staff are leveraged by changing provider-to-patient ratios or
by using non-ICU staff in a tiered approach whereby non-ICU
providers provide care and are, in turn, supervised by ICU
provid-ers Supplies and equipment are conserved when possible; some
substitutions, adaptations, and reuse may be necessary when safe
The goal of the contingency surge response is to significantly
in-crease capacity while minimally affecting patient care practices
EMCC and crisis standards of care (CSC) are required when a
large PHE threatens to overwhelm critical care resources despite
fully deployed conventional and contingency surge responses
Following a sudden-impact PHE, there may be an initial
emer-gency department (ED) surge lasting a few hours and a subsequent
ICU phase of weeks, while prolonged events such as pandemics
could require both EDs and ICUs to sustain contingency or crisis strategies for months It is recommended that hospitals with PICUs be able to care for up to three times the usual number of critically ill pediatric patients for up to 10 days without outside help.19 In these circumstances, population-based goals will at-tempt to maximize the number of survivors by reallocating life-saving interventions to persons who are more likely to benefit from them This represents an escalation from usual standards of care to CSC PHE powers are defined on a state-by-state basis; thus, ICU leaders must be familiar with their own state and hos-pital incident command process for determining when CSC should be activated.20
Sudden-impact events that stress the resources of a community may require the implementation of temporary reactive mass criti-cal care However, no historicriti-cal precedents exist for sustained mass critical care such as might occur with major regional damage
or severe pandemic.21 During the initial wave of COVID-19 in New York City, temporary mass critical care via rapid expansion
of COVID-19 units and staff was utilized as a means to address the overwhelming care needs of patients EMCC, whether tempo-rary or sustained, should attempt to provide these five priority
Major surge: crisis response
Maximum ICU capacity
Usual ICU capacity
# of patients
Usual care
Functionally equivalent care
Crisis standards of care
Moderate surge: contingency response
Minor surge: conventional response
Usual volume
Expanding ICU capacity
• Fig. 9.2 Surgevolume,expansionofintensivecareunit(ICU)capacity,andtheeffectonstandards
ofcare.
Conventional strategies
Conserve resources Utilize on-call staff Substitute for equivalent items Utilize supply caches
Contingency strategies Adapt other ICUs and similar care areas Extend usual staff Reuse select supplies Substitute where reasonable
Adapt non-ICU and noncare areas Utilize non-ICU staff Reallocate resources Crisis strategies
• Fig. 9.3 Conventional,contingency,andcrisisstrategiestoextendcriticalcareresources.ICU, intensive
careunit.