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[.]
e3 92 Robertson MA, Molyneux EM Description of cause of serious illness 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 Evaluation 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 obstetrics knowledge and practical skills retention among medical students 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 Emergency 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 critically 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 settings: 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 Emerg Infect Dis 2017;23:S25-S32 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; 32:2117-2127 111 Rosenberg DI, Moss MM, American Academy of Pediatrics Section 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: 1126-1137 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 children 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 Challenges 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 recommended 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 mortality in children with acute infectious diseases: derivation of postdischarge 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 124 Metelmann B, Metelmann C, Schuffert L, Hahnenkamp K, Brinkrolf P Medical Correctness and user friendliness of available apps for cardiopulmonary resuscitation: systematic search combined with guideline adherence and usability evaluation JMIR Mhealth Uhealth 2018;6:e190 e4 Abstract: 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 settings without an intensive care unit (ICU) However, publicly funded ICU treatment remains limited in low-income countries, and its introduction requires careful resource allocation Healthcare 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 intensive care services as overall health indices improve Critical care research from low-income countries is sorely needed to guide effective and efficient care and advocate for resources Key words: Low-resource settings, low- and middle-income countries, resource allocation, pediatric critical care training, costeffectiveness Public Health Emergencies and Emergency Mass Critical Care KATHERINE L KENNINGHAM AND MEGAN M GRAY “Keep your eye on the ball.” Bob Kanter, Trailblazer for Children in the World of Disaster Medicine • • 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) planning 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 during a severe PHE 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 Because pediatric critical care is highly specialized and because few nonpediatric providers are comfortable caring for severely ill or injured 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 Unfortunately, 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 Forward 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 • • • PEARLS The surge capacity continuum that spans conventional to contingency 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 How Many Pediatric Patients Could Be Affected in a Public Health Emergency? If a PHE affected persons of all ages equally, children aged to 14 years would account for 20% of all patients.1 However, younger patients may be more vulnerable to infections, dehydration, 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 pediatric 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 population.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 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, 59 60 S E C T I O N I Pediatric Critical Care: The Discipline with 6% of low-risk term infants and 97% of very-low-birthweight 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, control 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 telemedicine to connect available pediatric critical care and subspecialty physicians to facilities unaccustomed to caring for pediatric patients may significantly extend the reach of pediatric EMCC during a PHE Incident commander Operations chief Medical director Public info officer Safety officer Planning chief Logistics chief Labor pool Finance and admin chief Materials & supplies ICU leader • Fig 9.1 Incident command system diagram admin, Administrative; ICU, intensive care unit; info, information What Are the Most Likely Public Health Emergencies? What Is the Expected Timeline of a Public Health Emergency? Public health emergency risks vary depending on hospital location, 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 electronic medical record (EMR) outages are experienced nearly universally in healthcare settings and are included in HVAs Primary planning for IT/EMR outages should include protocols for downtime procedures, paper charting, and nonelectronic communication Hospitals should engage in drills, tabletop 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 When a sudden-impact PHE occurs, the hospital’s ICS is activated The initial priority is to perform an assessment of the current state of the hospital; units rapidly assess their bed capacity, including potential beds that could be mobilized Patients potentially 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 structure 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 assessment 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 commander 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 reassigning 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 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 possible, usually at the city or county level, until those resources are outpaced The hospital ICS further provides a leadership framework within and among organizations responding to an emergency, representing a simplified and clear chain of command in order to speed decision-making A hospital ICS includes clinical and nonclinical representation, provides flexible logistical 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 available 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 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 normal standards of critical care to all who need it in this scenario.23 Conventional critical care surge needs can be met by canceling CHAPTER 9 Public Health Emergencies and Emergency Mass Critical Care 61 Maximum ICU capacity Level of care available Crisis standards of Major surge: crisis response care Functionally equivalent Moderate surge: contingency response care Minor surge: conventional response Expanding ICU capacity Usual care Usual volume Usual ICU capacity # of patients • Fig 9.2 Surge volume, expansion of intensive care unit (ICU) capacity, and the effect on standards of care Conventional strategies Conserve resources Utilize on-call staff Substitute for equivalent items Utilize supply caches Contingency strategies Adapt other ICUs and similar care areas Crisis strategies Extend usual staff Adapt non-ICU and noncare areas Reuse select supplies Utilize non-ICU staff Substitute where reasonable Reallocate resources • Fig 9.3 Conventional, contingency, and crisis strategies to extend critical care resources ICU, intensive care unit elective 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, necessitating a contingency response to most effectively use limited resources Contingency surge methods include all elements of the conventional response with additional strategies to expand coverage 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 providers 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 increase 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 emergency 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 attempt to maximize the number of survivors by reallocating lifesaving 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 hospital 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 critical care However, no historical 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 temporary or sustained, should attempt to provide these five priority ... 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... 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... (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 Unfortunately, critical