Scarce Resource Management

& Crisis Standards of Care

Overview & MaterialsCriticalCare Algorithms ScarceResource Cards Triage Team Guidelines & Worksheets

Washington State Department of

HealthNORTHWEST HEALTHCARE

Response Network

Washington State Departmentof

Health Network.NORTHWESTHEALTHCARE

ResponseNetwork.

SCARCE RESOURCEMANAGEMENTand

CRISIS STANDARDS OF CARE

. INTRODUCTION

In the eventof a large-scale disaster, either a no-notice event such as a natural disaster or a prolonged

situation such as a pandemic, there is thepotentialfor an overwhelmingnumber of critically illor

injuredpatients. In these situations, certain medicalresourcesmay becomescarce and prioritization ofcaremay needtobe considered.

Medical surge is a complex multifactorial event, the response to which is equally complex. In an effortto better understand ,measure , discuss best practices andmanage medical surge, itis essential to havean overall guiding framework .

In 2009, the Institute ofMedicine (currently the NationalAcademy ofMedicine) published a landmark

report, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situation : A Letter Report. Inthis report the authors defined Crisis Standards of Care as follows:

“ A substantial change in usual healthcare operations and the level of care it is possible todeliver, which ismade necessary by a pervasive ( e .g . pandemic influenza ) or catastrophic (e . g .

earthquake , hurricane ) disaster . This change in the level of care delivered is justified by specificcircumstances and is formally declared by a state government in recognition that crisis

operations willbe in effect for a sustained period. The formal declaration that crisis standards ofcare are in operation enables specific legal/ regulatory power and protections for healthcare

providers in thenecessary task of allocating and using scarce medical resources and

implementing alternate care facility operations. ”

They outlineda framework forthe discussion ofsurge capacity definingit as a continuum from

conventionalto contingency, and finally crisis. They definedthis “ Continuum ofCare as follows:

Conventional Capacity : The spaces, , and supplies used are consistentwith daily practices

within the institution . These spaces and practices are used during a majormass casualty incident

that triggers activation ofthe facility emergency operations plan.

Contingency Capacity : The spaces, staff, and supplies used are not consistentwith daily

practices butprovide care that is functionally equivalentto usual patientcare . These spacesor

practicesmaybe used temporarily during a majormass casualty incidentoron a more sustained

basisduring a disaster (when the demandsof the incidentexceed community resources).

Crisis Capacity : Adaptive spaces, staff , and supplies are notconsistentwith usualstandardsofcare butprovide sufficiency of care in the context of a catastrophic disaster (i . e., provide the

best possible care to patients given the circumstances and resources available). Crisis capacity

activation constitutes a significantadjustment to standards of care.

1 IOM ( InstituteofMedicine). 2012CrisisStandardsofCare: A SystemsFramework for CatastrophicDisasterResponse.

Washington,DC: The NationalAcademiesPress.

The NationalAcademyofMedicine also stresses the importance of an ethically grounded system to

guide decision makingin crisis to ensure the mostappropriate use of resources. They definethese

ethical principles as:

Fairness standards that are, to the highest degree possible, recognized asfair by all thoseaffected by them including themembers of affected communities, practitioners, and providerorganizations, evidence -based and responsive to specific needs ofindividuals and the

population .

Duty to care standards are focused on the duty ofhealthcare professionals to care for patientsin need ofmedical careDuty to steward resources institutions and public health officials have a duty to

steward scarce resources , reflecting the utilitarian goalof saving the greatest possible numberof lives.

Transparency – in design and decision making

Consistency in application across populations and among individuals regardless of their human

condition ( e . g . race, age disability , ethnicity, ability to pay, socioeconomic status, preexistinghealth conditions, socialworth , perceived obstacles to treatment, pass use of resources)Proportionality - public and individual requirements must be commensurate with the scale of

the emergency and degree of scarce resources

Accountability – individualdecisions and implementation standards, and of governments forensuring appropriate protections and just allocation of available resources

This framework hasbeen nationally accepted and adopted and hasbeen used by King and PlerceCounties and adopted by the Washington State Department of Health Disaster Medical Advisory

Committee.

I. Background :

In 2012, consistentwith recommendationsfrom the InstituteofMedicine(IOM ), theNorthwestHealthcare

ResponseNetwork developeda DisasterClinicalAdvisoryCommittee(DCAC), a group ofmorethan 45cliniciansfrom healthcareorganizationsacross Kingand Piercecounties, representingmorethan 15 clinicalsubspecialties, workingin coordinationwith PublicHealth Seattle & King County and Tacoma-PierceCountyHealth Department. Since thattime, a WA State DisasterMedicalAdvisory Committee(DMAC) has

beendevelopedand alongwith DCAChave focusedon the developmentof clinically focusedtools and

planningformedicalsurge, includingstrategiesfor theimplementationofCrisis Standardsof Care.

The content of this document is based on a thorough review of the literature , guidelines published by

leading nationalhealthcare specialty colleges and societies, recommendations of the National Academy of

Medicine and detailed discussion and deliberation by theWA State DisasterMedical Advisory Committee(DMAC), the Disaster Clinical Advisory Committee (DCAC ) Central District and included input from both

local and state Community Engagement Reports . 3

II. Contents:

All individualScarce Resource Cards and Triage Algorithmsare continually under review and openfor comments as outlined below in Section D .

5 . -Vollmer , M . Health Care Decisions in Disasters : Engaging the Public On MedicalService Prioritization During a Severe Influenza Pandemic . Journal of Participatory

Medicine. Vol 2 . December 14, 2010 .

3 WashingtonStateCrisisStandardsofCareCommunityEngagementReport, June2019, DOH

WashingtonStateDepartmentof

Health NORTHWEST HEALTHCARE

Response Network .

A . Scarce Resource Cards

The Scarce Resource Cards (SRC) are based on work done byMinnesota Public provide specific

strategies which can be used in the conservation , adaptation , substitution , re -use, and re-allocation of acritical resource during an emergency . Additionally , the cards provide recommendations to beimplemented

in preparation as well as response thus covering thewhole continuum of care ( conventional, contingency ,

and crisis ) as described above.

The contentand compositionbetween cardsvaries. Somecardsaredesignedto providespecific clinical

treatmentstrategies( e.g . Mass Casualty Burn TreatmentCard) . Others outline specificpatient populations

forwhich therecommendationsaremade (e. g. in-patientvs out-patientdialysispatients) .

Scarce resource cardshavebeen created for the following potentially limitedresources:

• BehavioralHealth

Blood productsBurn

Hemodynamicsupport and IV fluids

MechanicalventilationMedicationadministration

Nutritionalsupport

Oxygen

Renalreplacementtherapy

RespiratorandGeneralPPE

Staffing

WashingtonStateDepartmentofNORTHWEST HEALTHCARE

Response Network .

B . Scarce Resource Triage AlgorithmsandWorksheets

Adult andPediatric CriticalCare Triage Algorithmswhich should be used when Critical Care resourcesare overwhelmed. The Algorithms are designed to beused side-by-side with the respective Worksheetwhich providesmore in -depth clinicalconsiderations and informationneeded to move through eachstep in the Algorithm . Decisionsmadeusing these algorithmsneed to bemanaged by a Triage Team .

Guidelinesfor the composition, rolesandresponsibilitiesof TriageTeamsandtheir oversightare

includedin the Triage Team Guidelinesmentionedbelow .

C . Crisis StandardsofCare ClinicalTriage Team Guidelines

Allocationofa scarceresourceis a complex task and, in order to maintain the ethicalframeworkoutlined above, it is crucial that the decision-making processbeconsistentandthatoversightand review

mechanismsbe established. The TriageTeam Guidelinesprovideinstitutionalandregional

recommendationsfor this process.

D . Updateand InputProcedures

1 All documents contained in this packet aremaintainedbyNWHRN.

2 . Each document is reviewed every 3 years during scheduled plan review . During a specific

response, itis recognized that the clinical situation may change based on numerousincident-dependentfactors . Therefore , in response, documents are reviewed as outlined in

the Triage Team Guidelines .

3 . At any time, input iswelcomed and can be discussed atthe institutionallevelwith specific

institutional DCAC members (if applicable ) . Input can also bemade directly to the Chair orVice- Chair of the WA State DMAC or to the SeniorMedical Advisor of NWHRN . A full list of

local DCAC and state DMAC members and the Senior Medical Advisor is available fromNWHRN .

http: / / www. health . state.mn. us/ oep /healthcare /crisis / standards.pdf

WashingtonStateDepartmentof

HealthNORTHWEST HEALTHCARE

Response Network .

III. InstitutionalDistribution

The institutionaldistribution of the contentsof thispacket willbedetermined by each institution' sEmergency Manager, DCACmember(s ), ifapplicable, and appropriate administration.

IV . WA State Crisis Standardsof Care Guidance Framework

In anymedical surge , the primary goal is to prevent or limit the timein Crisis ” (as defined above by the

NAM ). It is understood thatmovement within the continuum of care is a fluid process and can vary

depending on the resource in question or the situation at hand.

It is also paramount , when faced with potential scarce resources that the response is coordinated and

communications among all ofhealthcare is maintained to provide accurate and up -to -date situational

awareness . WA State in conjunction with State DMAC, DOH , and state healthcare coalitions havedeveloped the WA State Crisis Standards ofCare Guidance Framework and is available through DOH .

This document outlines regional roles and responsibilities , provide an ethical framework and other tools

which will assist in coordinated planning and response.

. Contacts:

For any questions about this document or contents of this packet please contact:

NorthwestHealthcare Response Network at info @ nwhrn. org.

BEHAVIORAL HEALTH - PATIENT PLANNING and RESPONSE 05- 09-2019 FINALSTRATEGIES FOR SCARCE RESOURCE SITUATIONS

ConventionalCapacity The spaces, staff, andsupplies used are

consistentwith dailypracticeswithin the institution. Thesespaces and

practicesareused during amajormass casualty incidentthat triggersactivation ofthefacilityemergencyoperationsplan.

ContingencyCapacity Thespaces, staff, andsuppliesused

arenot consistentwith daily practices, butprovide care to astandardthat is functionally equivalentto usualpatientcare

practices. These spaces or practicesmaybeused temporarilyduringa majormasscasualty incidentor on a moresustainedbasis during a

disaster (when thedemandsof the incident exceed community

resources)

Crisis Capacity - Adaptivespaces, staff, and supplies are not

consistentwith usualstandards of care, butprovide sufficiency of care in

thesetting of a catastrophicdisaster( i. e. , providethe best possible care

to patientsgiven the circumstancesandresourcesavailable). Crisis

capacity activation constitutes a significant and adjustmentto standards

of care (Hick et al, 2009).

RECOMMENDATIONS Strategy Conventional Crisis

Prepare

Prepare

PLANNING

General

1. Encouragepatients to assemble and maintain a disaster kit, to include an extramonth worth of theirmedications, in

additionto food, water, sanitation, and first aid supplies, should they need to shelterin place.

• 2. Encouragepatientsto discussplanningfordisruption in their care with their currenthealthcareproviders, includingprimary care providersas well as behavioralhealth providers.

• 3 . Encourage BehavioralHealth Providersto develop a disasterplan with the patientaspart of treatmentplanning.

GatheringResources

• 4. Encouragepatients to identify tools and strategiesthey have found helpfulin symptom reliefand write down whatworks. Includea copy ofthe documentin theirdisasterkit.

• 5. Encouragepatientsto exploreotheravenuesforself-help, such as apps to assistwithmedicationandsymptommanagement, and to practicetheseprior to a disaster. Examples:

o 5a) Headspace (meditation andmindfulness) https: / /www .headspace. com

o 5b ) Virtual Hopebox (distraction , coping exercises, relaxation ) https : // psyberguide.org / apps / virtual -hope-box /

• 6 . Encourage patients to identify family members or friends who are helpful to them and include them as part of theirresources. Familyresources can be found at https: / /www.mentalhealth.gov/ talk / friends- family members

Preparinga Team• 7 . Encourage patientsto reach out and identify a specific individualin their liveswho can be a monitor and coach during

disruptive/ stressfulevents.

8 . Family andfriendsshould be encouragedto take advantageoftrainingthrough Red Cross, NationalAllianceonMentalillness (NAMI, or localcommunitymentalhealth clinics, to assist thepatientduringtimesof disaster.

https: / /www .namiwa.org /index .php /programs/ education-training

Response

• 9 . Patients should be encouraged to locate their physical resources, such as food,water, and medications.

10 . Patients should reach out to their pre-identified support system (family , friends), and to their identified disaster

monitor and coach .11. Patients should retrieve anywritten materials and plansto assist them inmonitoringandmanagingsymptoms.

12. Patientsmaywish to reach outto community organizations ( e . g . Red Cross, NationalAlliance on MentalHealth and

localcommunitymentalhealth clinics) for additionalresourcesif available at the timeof the disaster.

Prepare

AdaptedFrom theMinnesotaDepartmentofHealth, Office of EmergencyPreparedness FINAL: May 9 ,2019

WashingtonStateDepartmentof

HealthNORTHWEST HEALTHCARE

Response Network .

©2020NorthwestHealthcareResponseNetwork.

BEHAVIORAL HEALTH STAFF PLANNING and RESPONSE 05 / 09 / 2019 FINALSTRATEGIES FOR SCARCE RESOURCE SITUATIONS

Crisis Capacity - Adaptive spaces, staff, and supplies arenot

consistentwith usualstandardsof carebutprovidesufficiency of care inthe settingof a catastrophicdisaster( i.e. , providethe bestpossible care

to patientsgiven the circumstancesandresourcesavailable) . Crisis

capacity activation constitutes a significantand adjustment to standards

of care (Hick et al, 2009) .

ConventionalCapacity The spaces, staff, and supplies Contingency Capacity The spaces, staff, and supplies

used are consistent with daily practices within the institution. used are not consistent with daily practices, but provide care to

These spaces and practices are used during a majormass a standardthatisfunctionallyequivalentto usualpatientcare

casualty incidentthattriggersactivationofthe facility practices. These spaces or practicesmaybeusedtemporarily

emergency operationsplan. duringa majormasscasualtyincidentor on a moresustained

basis duringa disaster(when thedemandsofthe incident

exceed communityresources)

RECOMMENDATIONS

GENERAL (For all clinicalsettings: inpatient, outpatient, group homes, specialty care facilities, ACF)1. IncludeStaffmental/behavioralhealth guidance/resourcesin allresponseplansand continue to maintain,

test and updatementalhealth surgeplans.2 . IncludeMentalHealth surgeissuesin trainings and exercisesincludingDe-escalationTraining,Management

of the aggressivepatientand StaffSafety

Strategy Conventional Contingency Crisis

Prepare

PLANNING for PATIENTMental Health Surge

• 3 . Identify all staff with mental health/ behavioralhealth training and appoint key individuals to lead and

organize disastermentalhealth preparedness and response

o 3a ) Recommend specific disaster mentalhealth training for Behavioral Health providers currently

embedded in generalmedicalsettings. These individualswillbekey in providingJust- in - Time( JIT)

training to others in timesofmentalhealth patientsurge.

o 3b) Store resources and JIT disastermentalhealth trainingmaterials. ( e . g . Health Support Team

Curriculum , or Skills for PsychologicalRecovery NationalChild Traumatic StressNetwork) . See

referencesbelow for specificmaterialrecommendations. 3,4,5

Prepare

PLANNINGfor STAFFMentalHealth needs:

4 . Encouragepsychologicalfirst aid trainingto allmedicalstaff especially forkey clinicalleadersand

administrators

5 . Identify and train willing behavioralhealth and non -behavioralhealth providerswith morecomprehensive curricula than PFA , act asmonitors and evaluators for their colleagues. Utilize

based questionnaires as needed to determine current staff functioning. For example, ProQOL is one quickevaluationtool(https: / proqolorg)

6 . Providepsycho-educationfor staff on caregiverfatigue, includingsymptoms, and coping/supporttools4,5,7,8

• 7. Teach appropriate debrief strategies recognizing9,10,11o Group debriefingmay notbeappropriate for all. Prepare andplan to do 1on 1debriefing

o Thepace of the debrief session should be responder driven not agenda driven

o Individuals traumatic situationsat their ownpace. Forcing graphicor stressfuldebriefing can

causeincreasedtrauma.

Prepare

Prepare

PLANNING FOR IN-PATIENT PSYCHIATRIC FACILITIES:

• 8 . Encourage inpatientpsychiatric facilities to develop connectionswith other inpatient psychiatric

facilities to develop planning for potentialpatient transfers, evacuationsand staffing.

• 9. All inpatientpsychiatric facilities should develop generaldisaster planning to includebasic care for

patientse .g. adequatefood/water/ shelter, staffingshortfalls, medications, transportofpatients,methods

oftransport, andmanagementof patientswhomayrepresenta danger to themselvesor others.

© NorthwestHealthcareResponseNetwork.

Substitute/

Adapt

Substitute/

Adapt

RESPONSE

PatientSurge

10 . Notifypre-trainedprovidersto prepareforsurge. ImplementJIT trainingofotherstaff to helpwith

patient surge.

11. Ensure Alternate Care Facilitieshavewritten educationalmaterials to assistwith patients, andaccess

to mentalhealth consultationasneeded.

• 12 . In preparationforpossiblelossofelectronicmedicalrecords, have printedpatientinformationto

include diagnosis, allergies and currentmedications/dosages.

• 13.Modify individual treatment to shorter, symptom focused appointments .14. Utilize - educational, andbrief evidence-based interventions.

15. Use Telehealth mentalhealth providersas off- site resource.

16 . Shift treatment to emphasize coping strategies, interventions to manage symptoms, and identifyingand accessingpersonalresources.

sponse teams as needed to provide Just in Time training for healthcare

providers /organizations , and to provide consultation on Behavioral Health interventions including

medications and crisis management .

18 . Shift from individualtherapyto group intervention.

StaffSelf Care19 . Consider" deliberateCopingand Calming strategiesor "PersonalReflectiveDebrief techniquesover

and prescribed CISD for staff during and after traumatic events. , 10

• 20 . Encourage and support staff self- care .When possiblemaintain schedules , routines and shifts .

21. During an event encourage personal “pauses” for reflection and self -evaluation .

22 . Encourage utilization of organizational support systems, (e . g . employee assistance program , wellness

programs, etc. ).23 . Maintain consistentscheduled communicationbetween administratorsand providers duringand after

acute event. ( e . g . huddles, check - ins, sign outs, etc)

MEDICATIONS RECOMMENDATIONS:

• 24 . Psychiatricmedicationsmay not be available due to supply chain disruptionsduring amajor event .Encourageall facilitieswho careformentalhealthpatients( outpatient, in -patientmedical, longterm care,

grouphomes, orspecialtycarefacilities) to developpsychiatricmedicationsupply strategies. Consider

increasingparlevels, developingstockpiles, and/or planningwith localretailpharmaciesaspotentialpsychiatricmedicationsupply strategies.

Substitute/

Adapt

Prepare

Adapted From theMinnesota DepartmentofHealth, Office of EmergencyPreparedness FINAL: May 9, 2019

:/ /handlewithcare.com / wp-content / uploads/ 2010 08/ -mentalhealth.pdf

https: / /www .crisisprevention .com: / /learn. org / course /index.php ?categoryid = 11

4ContactHealth Support Team directly athttp :/ /healthsupportteam .org for curriculum .

Shttps:/ / www .nctsn.org / resources/ skills-psychological-recovery -spr online. Requires free registration formaterials.https: / / learn . org /course / index.php? categoryid = 11

Killian , K . Helping Till ItHurts? A Multimethod Study of Compassion Fatigue, , and Self-Care in Clinicians Working with TraumaSurvivors. Traumatology . 2008, Vol 14(2) June 32-448Mendenhall, T ., Trauma-Response Teams: Inherent Challenges and PracticalStrategiesin Interdisciplinary Fieldwork . Families Systems, & Health , 2006 , 24(3):357 -362.

, E., Pietrantoni, L., Palestini, L. , & Prati, G . (2009). Emergency workers quality of life: The protectiverole of sense of community, efficacy beliefsand coping strategies. SocialIndicatorsResearch, 94 (3):449

: // www .massey.ac.nz/ trauma/ issues/ 2003 -1/ orner.htm

11Joint Commission: https: //www. jointcommissionjournal. com / article / -7250(08)34066 -5 / fulltext

Washington State Department of

HealthHealth NORTHWESTHEALTHCARE

ResponseNetwork

© 2020NorthwestHealthcareResponseNetwork.

WashingtonState DepartmentofNORTHWESTHEALTHCARE

ResponseNetworkW HealthBlood Products - LastUpdated 2 / 17 /2020STRATEGIES FOR SCARCERESOURCE SITUATIONS Highest relevance: 1) P = pandemic 2 W =weather 3)MCI

.

ConventionalCapacity Thespaces, staff, and suppliesused are consistentwith daily practiceswithin the institution.

These spaces andpracticesare used during a majormasscasualty incidentthat triggersactivation of the facility

emergency operationsplan.

ContingencyCapacity Thespaces, staff, and suppliesused are not

consistentwith dailypractices, butprovidecareto a standard that is functionally

equivalentto usualpatientcare practices. Thesespaces or practicesmay be usedtemporarilyduringa majormasscasualty incidentor on a moresustainedbasis

during a disaster(when the demandsof the incidentexceed community

resources

Crisis Capacity - Adaptivespaces, staff, and suppliesarenot

consistentwith usualstandardsofcare, butprovidesufficiencyofcare

in thesettingofa catastrophicdisaster (i. e., providethebest possible

care to patients given thecircumstancesand resourcesavailable) . Crisiscapacity activation constitutesa significantandadjustmentto standards

ofcare(Hick etal, 2009).

Category RECOMMENDATIONSHealthcareFacility Blood

CenterStrategy Conventional Contingency Crisis

1. Increasedonationsand consider localincreasein frozen reserves P

Increase positivelevels P, W , MCIConsidermaintaining a frozen blood reserve if severe shortage

Increaserecruitment for specific productneeds

Prepare

AllBlood

ProductsAdapt

Prepare

2 . Consider adjustment to donor HGB/HCT eligibility / explore FDAvariance *

3 . • Relax travel deferrals for possible malaria and BSE (bovine spongiformencephalitis )

o 3a . Consider using ABO -type specific whole blood if components

cannotbeproducedMCI, P , W

4 . cell-saverand autotransfusionto degreepossible* * P, W , + / - Re-use

5 . Limit negativeuse to women of child-bearing age P, W , MCI Conserve

Whole

PackedRedBloodCells

Conserve

6 . positive in emergent transfusion in males or females who are nolonger childbearing , to conserve negative * * (Seattle Children ' s and MaryBridge Children 's currently uses in males < 18 yrs )

7 . donations from whole blood to 2x RBC apheresis collection ifspecific shortage of PRBC' s (Cascade has current capability ) Adapt

Conserve8 . • Use aliquots from parentproduct for severalchildren when possible P,W ,MCI

9 . Encourage use of blood sparing protocols for all patients P, W Adapt

Adapt10. Consider use of erythropoietin (EPO) for chronic anemia inappropriate patients

11. Prioritize freshest blood for infants and small children Conserve

12. aggressive crystalloid resuscitation prior to transfusion in

shortage situations (blood substitutesmay play future role) Use RBC :Plasmain 1: 1 ratio in Trauma cases.

P

Conserve

13. Long term shortage, collectautologousbloodpre-operativelyand

considercrossovertransfusion Conserve

14 . Implementlower hemoglobintriggers for transfusion P , W , MCI * Conserve

© 2020 NorthwestHealthcareResponseNetwork.

V* * Conserve

15. Considerlimitinghigh-consumptionelectivesurgeries(selectcardiac,orthopedic, spinal, etc.)* * (procedureslikelyto requireblood transfusions)P , W , +/ -

16 . Consideruse ofEPO in patientswith anticipatedacutebloodlossP ,W , MCI

17 . FurtherlimitPRBCuse, ifneeded, to activebleedingstates, considersubsequentrestrictionsincludingtransfusionfor treatableshockstatesonly * * (modificationof transfusionthresholds) W , P,MCI

* * Re-allocate

18. Consider Minimum Qualificationsfor Survival (MQS) limits on use of

for example , only initiate for patients thatwillrequire < 6 unitsand/ or consider stopping transfusion when > units utilized )

specificMQS limits should reflectavailable resources at facility . * * P , ,MCI

V * * Re-allocate

19. Reduce or waive usual 56 days inter-donation period * based upon

pre- donation hemoglobin / explore FDA variance * , MCI Adapt

20. Reduceweightrestrictionsfor 2x RBC apheresisdonationsaccording

to instrumentsusedandmedicaldirectorguidance* W P , MCI Adapt

21. increase in red cell: Plasmaratio ( 3 : 1) in massive transfusion

protocols in consultation with blood bank medical staff* * W , Conserve

Plasma 22. early use of plasma in trauma with anticipated massive

hemorrhaging and/ or brain injury . Thaw early and use blood warmer. Conserve

23 . Switch community inventory to liquid plasmaP, W , MCI * * Adapt

24 . using Group A Plasma P, W , MCI V * * Adapt

25 . female donors withoutwhite cell antibody testing. P , W , MCI * * Adapt

Substitute

26. Thoughnot true substitute, consideruse of fibrinolysisinhibitorsor

othermodalitiesto reversecoagulopathicstates (tranexamicacid ,

aminocaproicacid, activated coagulationfactor use, fibrinogen

concentrate, prothrombin complexconcentrate, or otherappropriatetherapies)MCI, P , W

27 . FDA variance to exceed24 collectionsper year for critical

types* = - W ( . . GroupAB) P , W , MCI Adapt

28 . Encourage early use of cryo in trauma with anticipated massive

hemorrhaging and/ orbrain injury. Thaw early and use blood warmer. Conserve

Cryoprecipitate29. nottrue substitute, consider useoffibrinolysis inhibitors or

modalities to reverse coagulopathic states ( tranexamic acid,aminocaproicacid , activated coagulation factor use, fibrinogen

concentrate, prothrombin complex concentrate, or other appropriate

therapies). MCI, P , W

Substitute

30 . Obtain FDA varianceto exceed 24 collectionsperyearfor critical

types* = - W ( . . GroupAB). P Adapt

Substitute

Platelets31. Thoughnottrue substitute, consideruse of desmopressin (DDAVP) tostimulateimprovedplateletperformancein renalandhepatic failurepatientsMCI P, W

32. Consideraliquotingfrom apheresisplatelets. For children, considersplitting whole blood platelets formore than onerecipient. P, W ,MCI

© Northwest Healthcare Response Network.

Nonleukoreduced

Adapt Leukoreduced

33. • Convert whole blood donors to apheresis donors . Standard Practice.W , P , MCI

Adapt

34. Transfuse platelets only for active bleeding, further restrict to lifethreatening bleedingifrequired by situation P, W ,MCI Conserve

35 . prophylacticuse of platelets. P, W , MCI Adapt

36 . • Accept female platelet donors regardless of HLA antibody , W , P, MCI Adapt

37 . changingbacterialdetectionstrategy. MCI, P. Potentially Adapt

38. Obtain FDA variance to allow new Pool and Store sites to ship across

state lines* P , W , MCIAdapt

39. for variance of 5 day outdaterequirement* P , MCI Adapt

Adaptedfrom theMinnesotaDepartmentofHealth, OfficeofEmergencyPreparednessFDA approval/ variancerequiredvia Associationof BloodBanks(AABB)

* *Education and/orexperienceisnecessary in thesettingof a community-widecriticalshortage

UPDATED: Feb 17, 2020

Next Revision Due: 2023

© 2020 Northwest Healthcare Response Network .

MASS CASUALTY BURN TREATMENT – 2 / 24 / 2020 FINALREGIONAL RESOURCE CARD

Harborview MedicalCenter (HMC)

Transfer Center 1-888-731-

INITIALASSESSMENT PRIMARY ASSESSMENT & INTERVENTIONS SECONDARY ASSESSMENT & INTERVENTIONS

CallUW Transfer Center to talk with a Burn

Fellow / Attending, who can assist with triage, care ofburninjured patients and transfer

Mass Casualty Burn ConsultationGuide:

1. TBSA adults, > 15 peds( 2nd/ 3rd degree)

2 . Circumferential3rddegreeburnYES

3 . Respiratoryinjury/ inhalation

4 . Burn plustraumaor other comorbidities

5. High- voltageelectrical( 1000V) or chemicalinjury

NO

OUTPATIENTMANAGEMENT< 20 % TBSA adults, < 15 % TBSA pediatrics

• Oral fluid ( sports drinks, electrolyte solution )PO painmanagement

• Refer to burn dressing guide and supply listElevate extremity burns

6 . Protect yourself using body substance isolation. Stop the burning

process, cover with loose linen, keep warm

7. Perform standard primary and secondary survey for any trauma

patient. Donotbedistractedby burn tissue

8 . Airway/Breathing- Assess for altered LOC, obstruction, respirat

compromise, burnsto face or oropharynx

• 8a. Administer 100 % oxygen via non rebreather/ETT, if suspected

inhalation injury (enclosed space, carbonaceous sputum , 10%

• 8b Carbon monoxide (CO ) exposure signsandsymptoms:

and nausea (20 % -30 % )(30 % -40 %

Coma (40 % -60 % )

Death ( >60 % )

• 8c. Consider intubation for GCS < TBSA , direct upper

airway injury , deep facial burns

9 . Circulation - Assess vital signs. Hypovolemic shock signs including

tachycardia are common > 20 % TBSA

. large bore /

9b . InitialfluidsLR /NS if estimated TBSA 20 adults and > 15

pediatrics : (See secondary assessment for nextsteps in fluidresuscitation # 12c)

years: 125 /

years: 250 /years 500 /

• 9c. Treatadult SBP < 90 and pediatric SBP < (2x age in years) ]

with IV / bolus. Avoid extra fluid when possible

10. Disability – Assess neurologic status: GCS/ AVPU , check pupils,cervical spine protection , if trauma, high -voltage > 1000 V ) injury11. Expose / Estimate - Brush away loose material if concern for chemical

exposure , remove clothing, jewelry , and contact lens. Protect from heat

loss; hypothermia occurs quickly. Circumferential trunk or extremity burn : elevate extremities ,

check pulses. Full- thicknessescharmayneed surgicalrelease

12. Adjuncts

• 12a.Nasogastric or orogastric – Intubatedpatients

12b . EstimateTBSA usingRule of Nineschart

12c. Consensusformula LR / NS: 3 x % TBSA =

fluids in 24 hrs. Give in first 8 hrs and next 16 hrs.

Increase/decrease fluidsby 20 % hourly to targetYES

12d . Pediatrics , addmaintenance fluid (below )

using in addition to Consensus formula in # 12c

1st 10 kg

o 2 m 2nd 10 kg

1 remainingkg = total /

• 12e. Foley – Target urineoutput( uo) 30 / hradultsor

/kg/ in pediatrics < 30 kg.• 12f. Pain control - small doses of opioids

13. History AMPLET or SAMPLE mnemonic

14. Head to Assessment

YES

CRITICAL BURN FEATURES9 % RULEOFNINES

for adult and child

18 %front

15 . TBSA > 25 % partial thickness or > 10 % full - thickness burns

16. Circumferential full thickness burns

17 . Burn plus trauma or other comorbidities

18 . Hemodynamic instability despite ongoing fluid

resuscitationas outlinedin 9b and

18 %

back

18 %front

18 %

back18 % 18 %

CRITICAL: High priority fortransferto Burn Center. YES NO

1114% 14%

SERIOUS BURN FEATURES

DO NOTCOUNT DEGREE BURNSwhen calculating the

RuleofNinesTBSA (TotalBodySurfaceArea)

AdditionalBurn Center ConsultsCyanidePoisoning - Consider ifseveremetabolicacidosis despite adequatefluid resuscitation as outlined in 12c .

Electrical- myoglobin in urine (red pigment) there is a risk of rhabdomyolysis

Chemical and radiologic - consider need for antidote or specific therapies .

Consult Poison Control

19. Secondary priority for transfer-may have to manage in

place awaiting transfer (up to 72 hours)

• 20. Referto burn dressingguideandsupply list

• 21. Infectioncontrol provider gown, glove, andmaskwhen wounds exposed . No prophylactic antibiotics

• 22. Intubated : Consider tube feeds

22a . Non- intubated: encouragehigh calorie PO

1st degree : red intact skin no blisters

2nd degree : red/ pink ,moist, sensate , blisters , blanches

• 3rd degree: dry, leathery, insensate , non- blanching

( see photos below for reference )

NorthwestHealthcareResponseNetwork. Burn TriageSRC.

Resource and Recommendations Strategy Conventional Contingency Crisis

CommandandControl,Communication,

Coordination

GeneralPreparednessInformation

• 23 . HMCBurn Center is an ABA/ACS verifiedburn centerin theWAMIregionwith 18 ICU and 23 acutecarebeds.24. Massburn incidentsare unusualbutdo occur. Theabilityofnon-burn hospitalsto triage and initially treat

victimsis criticalto successfulresponseand should be a planninggoalofallhospitalswithnumbersofvictims

depending on the facility size and role in the community .

• 25. In amajor incident, victimsmay require care at the initialreceivinghospitalfor up to 72 hoursuntiltransfer

to definitive burn care.26 . The role of the DisasterMedical Control Center (DMCC ) in anymajor event is to distribute patients from the

scene to area hospitals . There are different DMCC s in the region . HMCis the DMCC for King County . Patientdistribution is often done by the DMCC with limited information from the field. In an event involvingmany burn

patients it is highly probable that multiple ED' s will receive patients and be responsible for their initial

triage/stabilization.

• 27. Notification: In a majorburn incident, HMC,DMCC, NWHRN, Publichealth and area EOC'swillbenotified.

• 28. IfHMCisunableto accommodatecasualtiesorrequireassistancewith transportation/resourceissues,communicationwillneedto occurbetween areahospitals, DMCC, Healthcare

coalitions, PublicHealth, area EOC' s andpotentiallyotherregionalburn centersdependingon themagnitudeof

the eventand extentofinjuries. (See Burn Surge Annex, pending 2021)

Prepare

Capacity

• 29. Each facility is encouraged to activate its own internal contingency / disaster plan ifneeded to manage

multipleburn patients.

• 30. In a majorevent, someburn ICU patientsmayneedtobe cared for in non-burn centeracute care units.

31. In coordination with HMC Burn Center, forwardmovementto other burn centers in adjoining statesmaybe

needed .

Adapt

Space

• 32. NationalDisasterMedicalSystem (NDMS) patientmovementmayneedto beutilized. Adapt

© 2020 NorthwestHealthcareResponseNetwork .

ResourceandRecommendations Strategy Conventional Contingency Crisis

Outpatient/ Supplies Planning

• 33. Institutions should prepare based on role in community. Outpatientclinics andurgentcare centersmay alsocacheappropriatesupplies for their locationandpatientpopulation. Suggestedburn dressingsupplies(per

patient) (seebelow) Prepare

Supplies(for72hours)

Inpatient Supplies Planning

34. Institutionsshould prepare based on rolein community . In contingency or crisis situationsnon-burn centers

maybe asked to stabilize or potentialprovide extended care to burn patients.

Suggested burn dressingsupplies(per patient) (see below )

Increase

Supply

Adapt

Adapt

Staffing

Staff

• 35. Strongconsideration shouldbe given to trainingphysician and nursingstaffon care ofmajorburnspreincidentandhavingquick-referencecards/materialsavailableforburn stabilization.

36 . Level & IIITraumaCentersshould considerhavinga cohortofproviderstrainedin the ABA Advanced

Life Support(ABLS) and ACS DisasterManagementEmergencyPreparedness( DMEP) .

37. Identify staff with priorburn treatment experience (i. e .military ).

• 38 . See Staffing Scarce Resource Card for further staffing considerations .

• 39. Staff should have access to just- in -timetraining provided to non -burn nursing and physician staff reinforcing

key pointsofburn patient care (including importance of adequate fluid resuscitation, urineoutputparameters,principlesofanalgesia, dressing changes, wound care andmonitoring

• 40. In a Mass casualty event, call the HMC Transfer Center 1-888 -731-4791for consultation in caring for burn

patients.

41. NDMSpersonnelandothersupplementalstaffmayberequired.

Conserve

Adapt

Subst

Prepare

SpecialSpecial Considerations

Consider availability ofresources for:. Pediatrics: age-and size appropriate equipment: intravenous, intraosseous access devices,medication dosing

guides. Consider using color - coding pediatric guides.

© 2020 NorthwestHealthcareResponseNetwork .

ResourceandRecommendations Strategy Conventional Contingency Crisis

CriticalBurn Features : Survivability Grid

• . The following grid provides an example of triage decisions thatmay become necessary in the setting ofoverwhelmed resources or in austere conditionswhere crisis standards of caremay be instituted. The

survivability grid utilizesthe same 4 color scheme used for EMS personal. Survivability will differ if the patient hassustained an inhalation injury .

44 . Use of the survivability table should be done in close collaboration with the Burn Center but should NOTsubstitute for amore globalassessment of thepatient. (See ABLS 2018 update) http ://ameriburn .org /wpcontent/uploads/2019 /08 / 2018 -abls -providermanual.pdf

45 . IfBurn Center resources are limited , critical burn patientsmay need to be cared for in non-burn centers. Justin Time training and on -line resources are available to non -burn centers in these situations. Please refer to

https://crisisstandardsofcare utah.edu /Pages/ home.aspx; This website requires registration and login password .please consider planning ahead and gaining access before an event occurs.

Re

Triage Allocate

© 2020 NorthwestHealthcareResponseNetwork .

UW MedicineHARBORVIEW

MEDICALCENTER

REGIONALBURNCENTER

(

Jar)

SSD9 % RULE OF

for adult and child

ElasticAdult

Greasygauze(

roll)

(

tubes) Antibiotic

ointment

Kerlixroll(6

in)

4x4

Gauze

(

Boator

package)

4x8Gauze

18x18Gauze

netting(

inch)

drg Silver

Impregnated18 %

front

18 %back

18 %

Head 1 / 418 %

front 10 inch

18 %

back face18 % 18 % /

Arm Three 8x

8 1- 2 6 inch

One 8x 20

Hand/ Fingers

Hand4 in

1 4 1/ 4 1 12 1Fingers1 in

Torso Four 8 x2 each

side2 16 12 inch

(ant/ post) Two 8x

Burn DressingGuideandSupply Estimates:Goalforpartialthicknessburnhealingis to keep

the woundmoist and free from infection

• degreeburn :o degreeburnsdonot countwhen

calculating the TBSA using the Rule ofNines

burn chart. Apply lotion or ointment and

leave open to air . No dressings needed

• 2nd degree burn :

o Apply a greasy gauze dressing with thin layer

ofantibioticointment. Changeevery 1-2 days

o Or applysilver impregnateddressingto moistburns on flat surfaces. Dressingmust lay flat

againsttheburn . Secure in placewith elastic,

netting etc . Change every 7 days3rd degree burn :

o Apply SSD and cover with thin layer of gauze

Change every 1- 2 days

Perineal

1/ 2

( ant/post) 1/4 1 12 inch Two 8x

each side

Six 8x

2 3-4 10 inch

Four 20

Foot/ Toes400 gm jar : 1jar per 9 % tbsa

o Antibiotic ointment: 1 tubeper 9 % tbsa

o Greasy gauze 4 in 9 yard roll: 1 roll per 9 % tbsa

o Gauze 6 inch x 3 yd roll: 1roll per 9 % tbsa

gauze : ( 1box or boat)per 4 % tbsa

1 / 2 each 1/4 1 1/2 1-2 6 inch

©2020 Northwest HealthcareResponse Network .

2 / 2020

References:

• i . American Burn Association. Advanced Burn Life SupportProvider Manual2018Update. http :/ / ameriburn. org /wp-content/uploads/ 2019/ 08/ 2018- ablsprovidermanual.pdf

• ii. AmericanBurn Association. 2013 Burn Care Resourcesin North America USBurn Centersavailablefrom http: / / ameriburn. org/ BCRDPublic.pdf

• iii. American CollegeofSurgeons, ATLS: AdvancedTraumaLife Support , Chapter9, Pgs 169- 185

iv . DMEP: DisasterManagementandEmergencyCourse, AmericanCollegeof SurgeonsCommitteeon Trauma, Subcommitteeon DisasterAndMass Causalities2016

112 - 120

v . Buidelines for Burn Care Under Austere Conditions: Introduction to Burn Disaster, Airway and Ventilator Management, and Fluid Resuscitation ; ABA , BurnCare & Res; Sep Oct Kearns, Randy D .

• v1: Guidelines for Burn Care Under Austere Conditions: Special Etioloiges: Blast, Radiation, and Chemical Injuries; ABA , JBurn Care& Res 38 ( 1) e482 ; Cancio , LeopoldoC; Jan - Feb, 2017

viii. https: / / crisisstandardsofcare .hsc.utah.edu /_ Requires login and password , recommend obtaining during planning not response .

1st degree Superficial 2nd degree Partial Thickness 3rd degree Full Thickness

FINALAPPROVED : 2 24 /2020

NextRevision due: 2023

WashingtonStateDepartmentof

HealthNORTHWEST HEALTHCARE

ResponseNetwork.© 2020 NorthwestHealthcareResponseNetwork .

HEMODYNAMIC SUPPORT AND IV FLUIDS March 19, 2019 FINALSTRATEGIES FOR SCARCE RESOURCE SITUATIONS

ConventionalCapacity– The spaces, staff, and suppliesused areconsistentwith daily practiceswithin theinstitution. These spacesandpracticesareusedduringa majormass casualtyincidentthattriggersactivationof the facility emergencyoperationsplan.

ContingencyCapacity – Thespaces, staff, andsuppliesusedare notconsistentwith daily practices, butprovide care to a

standard that is functionally equivalentto usualpatient care

practices. These spacesor practicesmaybeused temporarily during

a majormass casualtyincidentor on a more sustainedbasisduringa disaster(when thedemandsof the incidentexceedcommunity

resources)

Crisis Capacity Adaptivespaces, staff, and suppliesarenotconsistentwith usualstandardsof care, butprovidesufficiencyof care inthesettingof a catastrophicdisaster (i .e ., providethebestpossiblecareto patientsgiven thecircumstancesand resourcesavailable). Crisiscapacityactivationconstitutesa significantandadjustmentto standardsofcare (Hick et al, 2009).

RECOMMENDATIONS Strategy Conventional Crisis

Equipmentand Suppliesand Training1. Cacheintravenous(IV ) cannulas, tubing, fluids, medications, andadministrationsupplies, oralrehydrationpackets(ORS) and

intraosseous( 10 ) equipment, includingdrillandmanualplacementneedles.

2. Conduct training and education re: oraland enteralhydration, andhypodermoclysisfluid administrationoptions.

3 . Develop system wide scarceresourcecommunicationplanswith clear lines ofresponsibility andaccountabilityto keep staffawareof

shortagesandconservation strategies.

4. Considercentralizedinventorycontrolof criticalmedicationsand fluids( e. g. proceduralareas, day surgery areasmayhave

separateinventorycontrolof criticalresources) .

Prepare

IV Fluid ConservationStrategies

5. MonitorCDC, FDA and ASHP updateson supply and conservationstrategies.6 . Switch to oraltherapywheneverpossible (e. g. antibiotics, anticoagulants, electrolytereplacements).

7 . Discontinue (Keep vein open ) orders.

8 . Adopt NPO strategies as recommended by the (2 hours for liquids, 4 hours for breast milk , 6 hours for infant formula , lightmeal

ornonhuman milk ) to limit "maintenance IVF .

9 . Review electronic medical record order sets to ensure conservation strategies are being enforced .10. Iforal therapy is not feasible or indicated consider IM or SQ injection .

. IfIV medications must be used, consider alternative compounding strategies to minimize IVF use such as syringe infusion pumps; IVpush administration, following the ISMPSafePracticeGuidelinesfor Adult IV PushMedications”

12. Considerusingalternative fluids ( e. g. dextrose or LR) , or other volumeexpanders( e. g. colloids) depending on clinicalsituation.

13. Repackage smallbags from larger source followingthe Repackagingof certain Human Drug ProductsbyPharmacies and

Outsourcing Facilities 2017, authored by FDA.

SubstituteEmphasize EnteralHydration Instead of IV HydrationProvide oralhydration (ORT ), when possible

14. Provide guidelines for oral rehydration therapy , including indications for hospital referral, to outpatient providers .

UtilizeAppropriate

OralRehydration

Solution

• 15. Oralrehydration solution : 1- literwater ( 5 cups) + 1 tsp salt + 8 tsp sugar , add flavor (e . g .,juice) asneeded.

• 16 . Rehydrationformoderatedehydration50- over 2- 4 hours.

Pediatric

Hydration

Pediatricmaintenancefluids:

17 . Four / kg / for first 10kg of bodyweight (40 / for 1st 10 kg).

18. Two / kg/ h for second 10kg ofbody weight (20 / for 2nd 10kg = 60 / for child ).

19. One / kg/ h for each kg over 20kg (example - 40 kg child = 60 mL/ h plus 20 / 80 mL/ ).

Supplementforeach diarrheaor emesis.

Substitute

Providenasogastric or gastrostomy(NG G -tube) hydrationfor both adults and pediatricpatientswhen applicable.

• 20. For fluid support, 8-12F(pediatric: infant3 . 5F, < 2yrs ) tubes arebettertolerated than standardsizetubes.21. For additionalequipmentsize guidelines, refer to a pediatriclength-based resuscitationtape, e. g. , the Tape

NOTE: Clinical (urine output,etc.) and laboratory (BUN ,urine specific gravity) assessments and electrolyte correction are key components of therapy and are not specifically addressed by these recommendations.

© NorthwestHealthcareResponseNetwork

and Syringe Pumps

22. Ensure IV pumps are charged and battery lifemonitored.

23. Consider stocking alternate emergency equipment for IV administration such as buretrolsand drip counters, other devices such as

the Drip Assist for use in austere environments.

Conserve

Conserve24. Reserve IV pumps, if limited, for use for criticalmedicationssuch as sedatives, analgesics, certain antibiotics and hemodynamic

support

Substitute Epinephrinefor Other VasopressorAgents in Shortage25. Forhemodynamicallyunstable patients> 18 yo who are adequately volume-resuscitated, consider adding epinephrine( of

/ml) to 1000mL onmini-drip tubingand titrate to targetblood pressure.

26 . For children < 18 yrs. add 0 .6 X weight(kg) to equaltotalmgof Epinephrineto add to a 100mlbagofNS. Runonmini-drip tubingstart at 1 / (= 60 drips/ hr or 1drip/minute). This startingepinephrinerate 0. 1mcg/ kg/min , a standardstartingepinephrinedose, assumingthat 1mL60 dripsformini-drip tubing; increasedrip rate to targetbloodpressure.

Substitute

Re-use CVP, NG, and Other SuppliesAfterAppropriateSterilizations/Disinfection27. In crisis situations, when consideringre-use of otherwise single use disposable equipment, alternate sterilization techniques should

be discussed usingavailable expert opinions such as CDC, WHO localpublic health and infection control specialists. When possible ,

consensusrecommendation should bemade. Possible sterilization options during crisis include:

o 27a) High-leveldisinfectionfor at leasttwentyminutesfordevicesin contactwithbodysurfaces( includingmucous

membranes) ; glutaraldehyde , hydrogen peroxide 6 % , or bleach ( 5 .25 % ) diluted 1: 20 (2500 ppm ) may be acceptable solutions.

NOTE: chlorine levels reduced if stored in polyethylene containers - double the bleach concentration to compensate ).

Re- use

Substitute

Intraosseous and Subcutaneous (Hypodermoclysis ) Replacement Fluids28. Consider clysis” as an option when alternative routes of fluid administration are impossible / unavailable .29. Intraosseousadministrationshould beconsideredbeforehypodermoclysis.

Intraosseous30 . Intraosseousinfusion is notgenerallyrecommendedforhydrationpurposes, butmaybeuseduntilalternativeroutesare available.Intraosseousinfusionrequirespumporpressurebag. Rateof fluid delivery is oftenlimitedby pain ofpressurewithin themarrowcavity. Thismaybereducedby pre-medicationwith lidocaine(preservative- free) 0 .5mg/ kg slow IV push.

Hypodermoclysis5,631. Cannotcorrectmore than moderatedehydration via this technique.32.Manymedicationscannotbe administeredsubcutaneously.

33. Commoninfusionsites: pectoralchest, abdomen, thighs, upper arms.34. Commonfluids: normalsaline(NS), , 1/2 NS (Can addup to 20-40mEqpotassiumifneeded.).35 . Insert21/ 24 gaugeneedleinto subcutaneoustissueat a 45 degreeangle, adjustdrip rateto 1-2 perminute(Mayuse 2 sitessimultaneouslyif needed. ).36 . Maximalvolumeabout3 liters/ day; requiressite rotation.

37 . Localswelling can bereducedwith massageto area.38 .Hyaluronidase 150 units / liter facilitatesfluid absorptionbutis notrequired;may not decreaseoccurrenceof localedema.

Consider Use ofVeterinary and OtherAlternativeSources for IntravenousFluidsandAdministrationSets Adapt

AdaptedFrom the MinnesotaDepartmentof Health, Officeof Emergency Preparedness FINAL version: March 19, 2019

Nextreview andupdate due : 2022

1https: / /www.fda.gov/ downloads/DrugsDrugSafety/ DrugShortages/UCM582461.pdf

2http: / anesthesiology. pubs. .org/ article.aspx?articleid= 2596245& = 2. 204142672. 159725813. 1522250986-8516730731522250986

: / /www.ismp.org/ sites/ default/ files/attachments/ -11/ ISMP97-Guidelines-071415 -3. % 20FINAL.pdf

https:/ /www.fda. / downloads/ Drugs/Guidances/UCM434174.

5Caccialanza, R, et al, SubcutaneousInfusionsof Fluids for Hydrationor Nutrition: A Review , JPEN 2018;42:296 -307

Bruno, VG , Hypodermoclysis: a literature review to assist in clinicalpractice, Einstein (Sao Paulo) 2015; 13( 1): 122-8

WashingtonState Departmentof

HealthNORTHWESTHEALTHCARE

ResponseNetwork.

©2020NorthwestHealthcareResponseNetwork.

MECHANICAL VENTILATION / EXTERNAL OXYGENATIONSTRATEGIES FOR SCARCE RESOURCE SITUATIONS

ConventionalCapacity The spaces, staff, andsupplies used are

consistentwith dailypracticeswithin the institution. Thesespaces and

practicesareused during amajormass casualtyincidentthat triggers

activation ofthefacilityemergencyoperationsplan.

ContingencyCapacity - spaces, staff, and suppliesused

arenot consistentwith daily practices,butprovide care to a

standardthat is functionally equivalentto usualpatient care

practices. These spaces or practicesmaybeused temporarilyduringa majormasscasualty incidentor on a moresustainedbasis during adisaster (when thedemandsof the incident exceed community

resources)

Crisis Capacity - Adaptive spaces, staff, andsupplies arenotconsistentwith usualstandardsof care, butprovidesufficiency of care in

the setting of a catastrophicdisaster( i. e. , providethe best possible care

to patients given the circumstancesandresourcesavailable) . Crisis

capacity activation constitutes a significant and adjustmentto standards

of care (Hick et al, 2009) .

RECOMMENDATIONS Strategy Conventional Contingency CrisisPrepare

Substitute

Conserve

IncreaseHospitalStocksofVentilatorsand VentilatorCircuits, ECMO or bypasscircuits

Access AlternativeSources for ventilators / specialized equipmentObtain specializedequipmentfrom vendors, healthcarepartners, regional, state, or Federalstockpilesvia usual emergencymanagement processes and provide just -in -time training and quick reference materials for obtained equipment

Decrease Demand for VentilatorsIncreasethreshold for intubation / ventilation.

Decreaseelective proceduresthat requirepost-operative intubation.

Decreaseelectiveproceduresthat utilize anesthesiamachines.

non-invasive ventilatorysupportwhen possible.

Re-use Ventilator Circuits• Appropriate cleaning must precede sterilization .

If using gas ( ethylene oxide ) sterilization , allow full 12- hour aeration cycle to avoid accumulation of toxic byproducts on surface .

irradiationor othertechniquesasappropriate.

UseAlternativeRespiratorySupportTechnologiestransportventilatorswith appropriatealarms- especiallyforstable patientswithoutcomplexventilationrequirements.

Useanesthesiamachinesformechanicalventilationasappropriate/ capable.Use -level(BiPAP) equipmentto providemechanicalventilation. (ContingencyandCrisis)

bag-valveventilationas temporarymeasurewhileawaitingdefinitivesolution/ equipment(as appropriateto situationextremely labor intensive and may consume large amounts of oxygen ).

Assign Limited Ventilators to Most Likely to Benefit ifNo Other Options are Available :

Re-use

Adapt

Re-allocate

See Pediatricand/ or Adult CriticalCare Algorithm

Adapted From theMinnesota Department of Health, Office of Emergency Preparedness As ofJune 19 , 2017

WashingtonStateDepartmentof

lealthNORTHWESTHEALTHCARE

ResponseNetwork

©2020NorthwestHealthcareResponseNetwork.

OXYGEN - 03 /29/ 2019 DRAFT REVISIONSTRATEGIES FOR SCARCE RESOURCE SITUATIONS

ConventionalCapacity – The spaces, staff, and supplies

used are consistentwith daily practiceswithin the institution.Thesespacesand practicesareusedduring a majormasscasualty

incidentthat triggers activation ofthefacility emergency

operationsplan.

Contingency Capacity The spaces, staff, andsuppliesused are

not consistentwith daily practices, butprovide care to a standard thatis functionally equivalentto usualpatientcare practices. These spaces

orpracticesmaybeused temporarilyduring a majormass casualtyor on a more sustainedbasis during a disaster (when the

demandsof the incidentexceed community resources)

Crisis Capacity - Adaptive spaces, staff, and supplies are not consistent

with usualstandardsofcare, but provide sufficiency of care in the setting ofa catastrophic disaster (i . e ., provide the best possible care to patients given

the circumstances and resources available) . Crisis capacity activationconstitutes a significant and adjustment to standardsof care (Hick et al,2009) .

Strategy Conventional CrisisRECOMMENDATIONS

Substitute &

Conserve

Conserve

InhaledMedications

• . Use compressed or room air foradministration ofnebulizedmedicationswhen clinically appropriate.• 2 . Restrict the use of Small VolumeNebulizerswhen inhaler substitutes are available .

• 3 .Restrict continuousnebulization therapy.

4 .Minimize frequency throughmedication substitution that results in fewer treatments (6h -12h instead of 4h-6h applications).

• 5. Change children from albuterolcontinuousnebulizers to Albuterol8 puffsMDI Q2 hrs when they are readyto stop continuoustreatments . Only use albuterolnebulizers in continuous form for truly acute status asthmaticus.

High -Flow Applications

• 6 . Assure all resuscitation oxygen bagshave shutoff valves and are shut off when not in use .

7 . Restrict the use ofhigh-flow adult cannula systemsas these can demand 12 to 40 LPM flows.8 . Restrict the use of simple andpartialrebreathingmasks to 10 LPM maximum .

• 9 . Consider intubation or non -invasiveventilation with a well-sealedmask over the use of high flow oxygen delivery systemsfor bothadult and pediatric patients during critical shortages.

Air -Oxygen Blenders10. Eliminate the low -flow reference bleed occurring with any low -flow metered oxygen blender use . This can amount to anadditional 12 LPM . Reserve air -oxygen blender use for mechanical ventilators using high- flow non -metered outlets. (These do not

utilize reference bleeds).11. Disconnectblenderswhen not in use.

Oxygen Conservation Devices• 12. Use reservoir cannulas if available at 1/ 2 the flow setting of standard cannulas.

• 13. Replace simple and partial rebreather mask use with reservoir cannulas or venti-masks at flow rates of - 10 LPM

14. Use High Efficiency nebulizers and use air flow instead of oxygen when clinically possible .

Conserve

Conserve

Substitute&

Adapt

Augment Oxygen Supply

• 15. Use hospital -based or independent homemedical equipment supplier oxygen concentrators if available to provide low - flow

cannula oxygen for patients and preserve the primaryoxygen supply for morecriticalapplications.16 . Consider other source of oxygen such as dentalor veterinary offices.

• 17 . Obtain oxygen supply from industrial sources, such assupplied by welding companies and underwater divingoperations.

• 18 .Reducehospitalwide from 50-40.

Substitute &

Conserve

Conserve

Monitor Use and Revise ClinicalTargets

• 19. Employoxygen titration protocolsto optimize flow or % to match targets for SPO2or20 . Discontinue oxygen at earliest possible time.

Conserve

© 2020 NorthwestHealthcareResponseNetwork.

• 21. Considervariableparameters for initiatingand continuingoxygen therapy:

StartingExample Initiate 02 Target Note: Thesetargetrangesneedtobe continually

NormalLungAdults SPO2 - 90% SPO290 %re-evaluated depending on resources available ,

the patient' s clinicalpresentation, ormeasured

Pediatrics SPO2 90 % SPO2 90 % determination . Ifno pulse oximetry isavailableinitiateoxygen therapybased on

Severe COPD History SPO2 <85 % SPO2 88 - 90 % clinicalassessment(e. g. cyanosis, increasedwork

ofbreathing , valid respiratory scores etc.)

Expendable Oxygen Appliances• 22 . All non -standard disinfection and sterilization procedures should betested and assessed prior to widespread use. Possible options

during crisis include: Use terminal sterilization or high -level disinfection procedures for oxygen appliances, small & large-bore tubing ,and ventilator circuits. Bleach concentrations of 1 :10 , high - levelchemical disinfection , or irradiation maybe suitable . Ethylene oxide

gas sterilization (if available ) is optimal, butrequires a 12- hour aeration cycle to prevent ethylene chlorohydrin formation with

polyvinylchloride plastics .

Oxygen Re-Allocation Implementation23 . For patientprioritization for oxygen administration or re-allocation during severe resource limitationsplease see Adult andPediatricCriticalCare Algorithms.

Re-use

Re-Allocate

Adapted From theMinnesota DepartmentofHealth, OfficeofEmergencyPreparedness DRAFTREVISION As ofMarch 29, 2019

WashingtonStateDepartmentof

HealthNORTHWESTHEALTHCARE

ResponseNetwork.

©2020NorthwestHealthcareResponseNetwork.

RenalReplacementTherapy Card

STRATEGIESFOR SCARCE RESOURCE SITUATIONSContingencyCapacity Thespaces, staff, and suppliesusedarenot

ConventionalCapacity The spaces, staff, andsuppliesusedCrisis Capacity - Adaptivespaces, staff, and supplies are not

consistentwith daily practices, butprovidecare to a standard thatis consistentwithusualstandardsofcare, butprovidesufficiencyofcareareconsistentwithdailypracticeswithintheinstitution. These

functionallyequivalenttousualpatientcarepractices. Thesespacesor in the setting of a catastrophic disaster ( i . e . , provide the best possiblespaces and practices are used during a majormass casualty

practicesmaybeusedtemporarilyduringamajormasscasualtyincidentor caretopatientsgiventhecircumstancesandresourcesavailable) .incidentthat triggersactivationofthefacilityemergency

on amoresustainedbasisduringa disaster(whenthedemandsof the Crisiscapacityactivationconstitutesa significantandadjustmentto

operationsplanincidentexceedcommunityresources) standards ofcare (Hick et al, 2009 ) .

Category RECOMMENDATIONS Inpatient Outpatient Strategy Conventional contingency Crisis

1 . Allorganizations that provide dialysis need to maintain internalemergency plans toprovidecare for the specialneedsofdialysispatientsduringany externalor internalemergencythatmay disruptstandardoperations. These plansshould addressappropriatewaterandpowersupply, equipmentand supplyneedsand staff/ providerconsiderations. (See links to resourcesin # 2 below)

All dialysisprovidersmustadvisetheir patientsin developingtheirownpreparednessplansincludingemergencyand contingencyplansfor food, medications,transportationandemergencycontactresources.

Dialysis patients need to be self-sufficient for up to 96hrs . Note that shelters are

unlikely to have foods appropriate for renal dietary needs (low sodium , etc . ) . PreparePersonalplanning guidance is available at:https:/ /www .kidney.org / sites/default/files /11- 100807 IBD disasterbrochure.pdf

https:/ /www .davita.com / kidney disease overview / living-with -ckd emergencypreparedness-for-people -with -kidney -disease / e /4930

3. Medicalneeds ofre-located renal failure patients from outside our region aresubstantial; themedical leadership ofNorthwest Kidney Center, DaVita and NW Renal

Network need to bemade aware of such incoming patients in order to be able to planfor their medical needs.

A.General

Prepare

Transportation Interruptions

4 . Chronic dialysis patients should coordinate with their service providers / dialysis clinics

first for transportation and other assistance during service / transportationinterruptions.

5 . Ifindividualproviders /dialysis clinics are unable to meet emergent supplementaltransportationneeds, referto the KingCountyWinterWeatherMedicalTransport

Plan and PierceCountyDepartmentof EmergencyManagementfortheirpossible

assistance

Adapt

Water Supply6 . Identify and quantify water -purifying capabilities for dialysis

7 . Identify alternative water source ifcity water is unavailable

Prepare

B.Water

8 . Identify limitationsand specialarrangementsneeded to use water tanker

a ) Availability ofreverse osmosis (RO )machines with carbon tanks

b ) Available means to generate adequate water pressure to units providing dialysis

Prepare

Water Contamination

9. Consider alternate sourcesofhighly purified water ( e. g. NorthwestKidney Centerwater reservetank, individualfacility wells, etc. ) keeping in mindthat potablewater

alone is NOT sufficiently purified for dialysis.

10. Consider transferring stable inpatients to outpatient dialysis centers for dialysis

treatmentsand vice versa dependingon locationof purifiedwatersource

Substitute

Adapt

© NorthwestHealthcareResponseNetwork

11. Consideruseofotherregionalassets forwaterreserves

Adapt

a ) JBLM assets: well, tanker

b ) Navy assets: desalinationandreverseosmosis capabilities(ship dependent)

c ) Commercialvessels

12 . Consider transferring stable inpatients to outpatientdialysis centers for dialysistreatmentsandviceversa

C.

PowerSubstitute

Adapt13. Consider transferring inpatients or outpatients to other hospitals or facilities out of

the affected region untilissueshavebeen resolved.

Prepare

D.Supplies

Dialysis Catheters , Machines Reverse Osmosis Machines , and / or

Other Supply Shortages14 . Maintain adequate stock of dialysis tubing sets and venous/peritoneal access

catheters (Quinton, etc.) andmedications(e. g. Kayexalate)

15. Identifyother sourcesof suppliesandmachines

16. Transfermachines/ suppliesbetweenoutpatientcentersandhospitals, or betweenhospitals Substitute

17. Consideralternativestaffingassignmentswith thefollowingrecommendations:

Dialysis Techs

1 .FormerDialysis

Techs who arenowtechs in other

specialties

2.GeneralNursewith

prior dialysis

experience .

E.Staff

Alternative Staff Recommendations

( listed in order of consideration )

Dialysis Nurses MDs(Nephrologist)

1. GeneralRN or 1 . Telemedicine

TransplantRN with nephrologist

previousexperience 2 . Retired nephrologist

who hasmaintained2 . Critical Care nurse medical license

with a dialysis

training 3 . trained in

dialysis

3. CriticalCareNurse

with no dialysis 4. CriticalCare MDwithexperienceandJIT experienceddialysis

nurseandJIT training.

4 . Generalnursewith

JIT 5 . Dialysisnurse with

extensive inpatient

dialysis experience

Substitute

Hemodialysis2PeritonealDialysis3Just-in -time Training (i . e. video, written instructions, handbook, etc.)

F.Treatment

Crush Syndrome

18. Initiate normalsaline IV hydration and acidosis prevention protocols immediately

either pre hospital or as soon as possible upon arrival to a healthcare facility toprevent/ treat rhabdomyolysis. Additional treatment recommendations :

a ) avoid nephrotoxic agents such as NSAIDS, aminoglycosides, ACE/ ARB' s alongwith other drugswhich may causehyperkalemia

b ) aggressive monitoring and treatment ofpotentialhyperkalemia

c) close monitoringof fluid status.

Conserve

©2020NorthwestHealthcareResponseNetwork.

Mode ofDialysis19. Optimize the mode of dialysisto providecare for the mostpatientspossible given

resourcesavailable

a ) ifwater is scarce, consider PD and CRRT asmodes of dialysis

b ) ifwater is readily available restrict to HD or PD and discontinue CRRT for staffconsiderations

Substitute

IncreasedDemandon Resources20. Shorten duration ofdialysis for patients that aremore likely to tolerate it safely

21. Patientsto utilize their home“ kits” ofmedication (Kayexalate) and follow dietaryplansto help increase timebetween treatments.

Conserve

Conserve

G.Triage

InsufficientResourcesAvailable For All Patients RequiringDialysis

22. Changedialysis from to needed based on clinical and laboratoryfindings( particularlyhyperkalemiaandimpairedpulmonaryfunction) parameters

may change based on demand for resources

23. Conceivable (but extraordinary) situationsmay occur whereresources areinsufficient to the point that some patients may not be able to receive dialysis (forexample, pandemic when demand nationwide exceeds available resources ).Prioritization should follow the Crisis RRT Triage Algorithm andWorksheet . In multiorgan system failure (MOSF ) refer to the Adult /Pediatric Critical Care TriageAlgorithm and Worksheet .

Re-allocate

Approved : 5 / 10/ 17AdaptedFrom the Minnesota DepartmentofHealth, Officeof Emergency Preparedness

1MedicalLeadership Contact Information: DaVita (253 -733 -4602); Northwest Kidney Centers (206 -720 -8505); NW RenalNetwork (206 -923-0714).

2 Contact PublicHealth Seattle King County Dutyofficer, PierceCounty EmergencyManagement Duty Officer or theNorthwestHealthcareResponseNetwork DutyOfficer formore information.

WashingtonStateDepartmentof

Health1NORTHWESTHEALTHCARE

Response Network.

©2020NorthwestHealthcareResponseNetwork.

Washington State Department ofNORTHWEST HEALTHCARE

Response Network .

PARTICULATE RESPIRATORS AND GENERAL PPE

(N95 , Elastomeric , PAPR , CAPRSTRATEGIES FOR SCARCE RESOURCE SITUATIONS

ConventionalCapacity– Thespaces, staff, andsuppliesusedareconsistentwith daily practiceswithin theinstitution. These spacesandpracticesareused duringamajormasscasualty incidentthattriggersactivation of the facility emergencyoperationsplan.

Contingency Capacity The spaces, staff, and supplies used

are not consistentwith daily practices, butprovide care to a

standard that is functionally equivalentto usualpatient care

practices. These spacesor practicesmaybe used temporarily duringa majormasscasualty incidentor on a more sustained basis during a

disaster (when the demandsof the incident exceed communityresources)

Crisis Capacity Adaptivespaces, staff, and supplies are notconsistentwith usualstandardsof care, butprovidesufficiency of care in

the setting of a catastrophicdisaster ( i. e. ,providethe bestpossible caretopatientsgiven the circumstancesand resourcesavailable). Crisis

capacity activation constitutes a significant and adjustmentto standardsof care (Hick etal, 2009).

RECOMMENDATIONS Strategy Conventional contingency Crisis

GeneralInfection ControlProcedures

• 1. Screen allpatientsforsymptomsspecific to currentsituation andkeepupdatedto anychangingscreeningrecommendations

2. Athealthcarefacilitieswherepatientshavescheduledappointments, considerscreeningprior to arrivalto limitexposureandresources

3. Establish procedures formanagingvisitors and illhealthcare personnel.

4 . Establish triage procedures and separate areas for ill andwellpatients .

• 5 .Assign dedicated staff to minimize exposure.

6 .Require when possible, or strongly encourage vaccination of primarypersonneland first responders, according to vaccinescheduleasrecommendedfor existingcircumstancesbythe CDC andtheAdvisoryCommitteefor ImmunizationPractices(ACIP).

7. Seriouslyconsidercreationof a registryto reflectthe vaccinationstatusofprimarypersonneland first respondersto aid indecisionsregardingservice assignments.

8. Educateandroutinelytrain allstaffregardingappropriateuseandproperdonninganddoffingproceduresofPPEand particulaterespirators.

9.Maintaingoodhandhygieneproceduresincludinggloves, handwashingwith soap andwaterand/oralcoholbasedhandsanitizersdepending on the current recommendations.

10. Maintain plan for N95 Fit Testing

PrepareEngineering Controls

11. When applicable to specific institution consider designing and installing engineering controls to reduce or eliminate exposure byshielding healthcare providers and otherpatients from infection individuals. Examples of engineering controls include physical

barriersor partitions to guidepatients through triage areas , curtainsbetween patients in shared areas, closed suctioning systemsfor

airway suctioning for intubated patients, aswell as appropriate air-handling systems(with appropriate directionality , filtration ,

exchange rate, etc. ) that are installed and properly maintained.

Cache / Increase Supply Levels

12. Clarify currentCDC and OSHA guidelinesforrespiratorand otherPPEuse;monitorfor updatesand recommendations.

13 . CacheadditionalsuppliesofPPE and respiratorsand their functionalcomponents(e. g. fit testing supplies, batteries, cartridges,filters, hoods etc .).

• 14 . Review vendor agreements , contingencies for delivery and production , including alternate vendors .

15 . Consider other NIOSH approved respirators in times of short supply ( . g . These include N99, N100 , P95 P99 P100 , R95 , R99, andR100.)

• 16 . Review current supply of PPE and determinebaseline and surge burn rates to better plan supply needs.17 .Maintain a reserve sufficient to meet estimated needs of PPE for allinfectiousdiseases.18 .Review cached PPE on a regular basis for expirations dates and consider replacing/updating caches by rotating PPE into daily use19. Obtain masks , cartridges and other PPE from alternate sources such as industrial suppliers and companies welding ,

manufacturing , etc. - as indicated .

Substitute

© NorthwestHealthcareResponseNetwork

Substitute

& Conserve

Conserve

Re-use

20 . Request Strategic NationalStockpile ofrespiratorswith theknowledgethat they maybe from differentmanufacturers. They

may notbe functionalin all situations(i. e surgical use ) andtheymay require additionalfit testingbeforedeployment.

21.Donotdiscard unused expired PPE; submit for extension through * ** (?NIOSH ? CDC?)

DecreaseUse ofPPE22. Clarify currentCDC, OSHA and NIOSH guidelines for PPE use;monitor for updatesand recommendations

23 .Medical/ surgicalmasks can bereusedby infected patientsuntilthemasksare no longer useabledueto moistureor damage.

• 24 .When PPE, especially Respirators are in shortsupply, aerosol- generating procedures should only beperformed onpatientswhenmedically necessary and cannotbepostponed

25. Limit the number of healthcarepersonnelwith patientcontact to only those essentialforpatientcare andsupport, especially

during aerosolgenerating procedures.

26 . Consider primary use of PAPRS, Elastomericor other Respirators to conserve on N95masks

27. Ensure staff are educated and understand specific PPE requirementsduring current situations so asnotto overuse PPE28 . Develop specific protocolsfor PPE distribution so asto ensure PPEisbeing used responsibly29 . Cohort patientswith known disease to limitdonningand doffingof PPE

• 30 . Considerlimiting visitors31. Consider changes in staffing (i. e. unimmunized staff given assignments that would not require significant PPE use)

Respirator Extended

• 32. Clarify currentCDC and OSHA guidelinesfor respiratoruse; monitorforupdatesand recommendations.

• 33. Policiesand recommendationsaround extendeduse” or“ re-use respiratorsshouldincludeinputfrom occupationalhealth,

infection control, infectiousdisease specialists, state and localpublichealth and anynationalrecommendationsaroundthe situation

at hand.

34. For N95, considerwearing a loose-fittingbarrierthat doesnot interferewith fit or seal ( e . g., surgicalmask, face shield ) over the

respirator to extend itsuse.

35. In general, wearing an respirator overmultiple serialpatient encounters(while minimizing touching) is favored over

removingandre-donningbetweenencounters(i. e. extendeduse is favoredoverre-useofN95).

36 . Cleaningand filterreplacementproceduresandextendeduse of filters and/ orhoods/shieldson all othermechanicalrespirators( . e. elastomericrespirators, PAPRS .) should be done accordingtomanufacturers protocolsandguidelines.

Re-useRespiratorAfterRemoval

37 . Clarify current CDC and OSHA guidelines for respirator use; monitor for updates and recommendations .

38 . Review manufacturer recommendations for cleaning and re -using and CAPR face shields when appropriate .

• 39 . Policies and recommendations around " extended use" or " re-use of respirators should include input from occupational health ,

infection control, infectious disease specialists, state and localpublic health andany nationalrecommendationsaround the situation

athand.

• 40. Use and storeusedrespirators(hood, mask, shield) individuallyin such a way that thephysicalintegrityandefficacyoftherespirator will notbe compromised

• 41. Label respirator with a user' s name before use to preventinadvertent use by another individual.

• . Practice appropriate hand hygienebefore and afterremovalof the respirator and, ifnecessary and possible, appropriatelydisinfect the object used to store it.

Respirators should be discarded if visibly damaged or contaminated .

44 . The specific number ofsafe reuses for N95' s is very difficult to estimate . In general check the specific N95 manufacturer

recommendations. In generalFive (5 ) is the recommendednumber of donning of a re-usedN95- type respirator

45 . ConsiderN95 decontaminationwith ultravioletgermicidalirradiation (UVGI) , or other testedmethodof decontamination to

extend theuseofrespirators.

Re-allocate/ prioritize

46 . Respiratorsuse shouldbeprioritizedonly to thosehealthcareprovidersidentifiedashighestriskbasedon epidemiologyofcurrentsituation.

. Identifymedicalpersonneland caregiverswith documentedvaccination, immunityafter an illnessor lowerrisk ofcomplicated

infection to provide directpatientcontactwithout a respirator.

Re-use

Re-allocate

Re-use

Re-allocate

©2020 Northwest Healthcare Response Network .

1 to any device such asN95, elastomeric respirators, PoweredAir Purifyingrespirators (PAPRS, ControlledAir PurifyingRespirator ( ) equivalent. NIOSH approved particulaterespiratorscanbe found at:

https: / / www . cdc. gov /niosh / npptl/ topics / respirators / disp part/RespSource html; https: / /www . cdc. gov/ niosh / npptl/ topics / respirators / disp part /default .html

2CDC and NIOSH overview ofrespirators : https: / www . cdc. gov / niosh / topics / respirators default html

eTool: https:/ /www .osha . gov / SLTC / etools/ respiratory / index. html

4 Extendeduse is defined aswearing the samerespirator for repeated close contact encounterswith multiplepatientswithoutremoving the respirator betweenpatients (e. g. triage area, dedicated waiting roomsorwards, etc). "Reuse " is defined as using the same respirator formultiple encounters but removing itafter each encounter https: / www . cdc. gov /niosh / topics recommendedguidanceextuse. html

https: / www . cdc. gov/ niosh / npptl/ topics/ respirators/ disp part / respsource3respreuse. html

researchon the decontaminationofN95Respirators: https: / / . ncbi.nlm . nih. gov/pmc/ articles/ PMC4699414/pdf/ nihms747549.pdfhttps: / academic.oup.com / annweh/ article/ 53/8 /815/ 154763

https: / / academic.oup.com / annweh/ article / 56 / 1/ 92/

5 https:/ / www .cdc. gov /niosh / npptl/ topics / respirators/ disp part/ default html

https: / /www.cdc. gov / niosh/ topics/howcontrols/recommendedguidanceextuse.html

FINAL APPROVED : 2 / 2020

NextRevision due: 2023

©2020NorthwestHealthcareResponseNetwork.

WashingtonState Departmentof

Health NORTHWEST HEALTHCARENORTHWESTHEALTHCAREResponseNetwork

Crisis Capacity Adaptive spaces, staff, and supplies arenotconsistentwith usualstandardsofcare, butprovide sufficiency ofcare in

the settingof a catastrophicdisaster (i.e ., providethebestpossible care

to patients given the circumstancesand resourcesavailable) . Crisis

capacity activation constitutes a significantand adjustmentto standardsof care (Hick etal, 2009).

Strategy Conventional Crisis

Prepare

STAFFING

STRATEGIES FOR SCARCE RESOURCE SITUATIONSContingency Capacity The spaces , staff , and supplies used

Conventional Capacity – The spaces, staff, and supplies used are are notconsistent with daily practices, but provide care to a

standard that is functionally equivalent to usualpatient careconsistentwith daily practices within the institution . These spaces and

practices. These spacesor practicesmaybe used temporarilyduringpracticesare used during a majormasscasualty incident that triggers

a majormasscasualtyincidentoron a more sustainedbasisduringaactivationofthe facility emergencyoperationsplan.

disaster ( when the demands of the incident exceed communityresources

RECOMMENDATIONS

Staff and Supply PlanningAssure facility has process and supporting policies for disaster credentialing and privileging - including degree of supervision required,clinicalscope of practice,mentoringand orientation, and verification of credentials.

Encourage employee personalpreparednessplanning (ready. gov, redcross.org) .Cacheadequatepersonalprotectiveequipment(PPE) and supportsupplies.

Educate staff on facility disaster response andrecommend regularly scheduled HICS training .

• Educate staff on community , regional and state disaster plans and resources .Develop facility plans addressing staff' s family / pets or staff shelter needs ( such as daycare and unaccompanied minor needs ) as well

as transportation plansfor staff to get to and from the facility .

Include a process of staff identification and verification . Recommend photos and hard - copy files.Create Job Cards for essential services and functions.

Pre-identify criticalpositionsand ensureredundantstaffing for these.Recommendredundantstaff communicationsand notificationplans/procedures.

FocusStaffTimeon CoreClinicalDuties• Minimize meetings and relieve administrative responsibilities not related to event.

Cohort inpatients per OSHA /Public Health or CDC guidelines.

Reduce documentationrequirements.

UsingSupplementalStaff• Utilizeadministrativepositions( e.g. nursemanagers) as patientcare extenders.

Adjustpersonnelwork schedules(longerbutless frequentshifts, etc. ) ifthiswillnotresultin skill / PPEcompliancedeterioration.

• Voluntary call-back of staff

• Increaseuse ofagency, perdiem , travelers, floatpools, locumsstaff

Retain staff for extendedhours in accordancewith labor contract andexistingcontracts/ agreementswhen applicable)

Use familymembers/lay volunteers to providebasicpatienthygieneand feeding - releasing staff for other duties.

Postpone andreschedule out-patientnon-acute andpreventative care appointmentsto openmore acutecareout-patientappointments during surge .

Focus Staff Expertise on Core Clinical Needs

Personnelwith specific critical skills (ventilator, burn management ) should concentrate on those skills; specify job duties that can besafely performedby othermedicalprofessionals.

Reduceavailabilityofnon-timesensitivelaboratory, radiographic, and otherstudies.Postponeand rescheduleelectiveproceduresifitwillimprovestaffingand space needsand does notresultin unduepatientinconvenience

Have specialty staff overseelargernumbersofdifferently specializedstaffandpatients( for example, medical/ surgerynursesworking

in criticalcareareoverseen by a criticalcare nurse) .

Conserve

Adapt

Substitute

Adapt

Conserve

Substitute

Conserve

Use AlternativePersonnelto MinimizeChangesto Standardsof Care

• Bringin equally trainedstaff(burnor criticalcarenurses, DisasterMedicalAssistanceTeam [DMAT), otherhealth system or Federalsources).

• Cancelallnon-acute /preventative care appointments,surgeries andprocedures(e.g. endoscopies,etc.) anddivert staff to emergencydutiesincludingin -hospitalor assistingpublichealth at externalclinics/ screening/ dispensingsites.

Adapt

© 2020 Northwest Healthcare Response Network .

• Use less trainedpersonnelfrom outsideinstitutionwith appropriatementoringand just-in-timeeducation(e.g.,healthcaretraineesorotherhealthcare workers,MedicalReserveCorps,retirees).

• Implementalternateconsultationand care techniquessuch as telemedicine.• Providejust-in-timetrainingfor specificskills.

AdaptedFromthe MinnesotaDepartmentof Health,OfficeofEmergencyPreparedness Updated: March21, 2019

©2020NorthwestHealthcareResponseNetwork.

Washington State Department of

HealthNORTHWESTHEALTHCAREResponseNetwork.ADULT Critical Care Triage Algorithm

Crisis Standards of Care

Updated Version:Mar 2020

This Algorithm is intended to be used alongside the attached Worksheet.

Answering each question requires the supplemental information in theWorksheet.

* * * Please use them together * **

Assumptions for use:1. Health Officer has declared a crisis situation requiring scarce resourcemanagement and crisis standards ofcare,

where crisis standardsofcare is defined as “ substantialchange in usualhealthcare operations and the levelof

care it is possible to deliverwhich ismade necessary by a pervasiveor catastrophic disaster”.

2 . Healthcaresystemsare overwhelmed despitemaximizing allpossible surge and mitigation strategies impactingthespace and/or staff and/or suppliesneeded to deliver usuallevels ofcare.

Washington State has adopted and will use the ethical framework developedby the NationalAcademyofMedicine,

which stresses the importance of an ethically grounded system to guide decision -makingin a crisis standards ofcare

situation . Alldecisions and communications willbebased on the ethicalprinciples below . The National Academyof

Medicine defines these ethicalprinciples as:

Fairness – Standards that are, to the highest degree possible , recognized as fair by those affectedby them

including themembers of affected communities , practitioners, and provider organizations, evidence basedand responsive to specific needsof individuals and the population .

Duty to care Standards are focused on the duty ofhealthcareprofessionals to care forpatients in need ofmedicalcare .

Duty to steward resources – healthcare institutions and public health officials have a duty to steward scarceresources, reflectingtheutilitarian goalofsaving the greatest possible numberof lives.

Transparency in design decisionmaking, and informationsharing.

Consistency – in application across populations and among individuals regardless of their human condition

( . g race, age disability, ethnicity, ability to pay, socioeconomic status, preexisting health conditions, socialworth, perceived obstacles to treatment, past use of resources).

Proportionality - public and individualrequirements mustbe commensurate with the scale of the emergencyand degree of scarce resources .

Accountability – of individualdecisions and implementation standards, and of governments for ensuringappropriate protections and just allocation of available resources .

1 . IOM ( InstituteofMedicine2009. Guidancefor EstablishingCrisis StandardsofCarefor in DisasterSituations: A LetterReport.

Washington, DC: NationalAcademies Press

Northwest Healthcare Response Network . CriticalCare Adult Algorithm 1

WashingtonStateDepartmentofADULT Critical Care Triage AlgorithmCrisis Standards of CareUpdated Version :Mar 2020

HealthNORTHWESTHEALTHCARE

ResponseNetwork.

Discharge to

palliativecareNO

STEP

Screen Patient for ICU Care after

reviewingpatient's end oflife directive/POLST or similar livingwill agreements

Reassessdaily to

determine continued

priority for

hospitalization

- -

STEP 2

A . Doespatientmeet ICU inclusioncriteria? and

B . Willpatientbenefitfrom ICU care?

Consider

discharge topalliativecare

- - - - - -

YES NO

Admit to floor

STEP 3

ICU Resource available ?NO

STEP 4

Compelling reason forreallocation ofresource ?

NO

STEP 5

Add patienttoICU waitinglist

YES YES

Re -evaluate

STEP 6 ADMIT TO ICU

Data Collection

1. Expected duration ofneed 2. Prognosis

3 . Response to treatment 4 .MSOFA 5 . Baseline functional status

UNCHANGED

WORSENING

Considerdischarge fromcritical care , provide

appropriate palliative care .

Consider continued ICU care

or consider moving to floorwith oxygen or NIPPV (as

appropriate ) . Reassess dailyto determine continuedneed

for hospitalization.

IMPROVING

ConsidercontinuedICUcare. Ifextubatedwithnosignificantorganfailure,

transfer to flood and

reassess daily to determine

continuedneed for

hospitalization.

© 2020NorthwestHealthcareResponseNetwork. CriticalCare Adult Algorithm

ADULT Critical Care Triage WorksheetCriticalCareGuidelines During Crisis Capacity

Washington State Department of

HealthNORTHWESTHEALTHCAREResponseNetwork.

This Worksheet , alongwith the corresponding Adult Critical Care Algorithm , are to be usedby “ Triage Teams” duringa declared emergency eventwhereby an appropriate healthcare official has implemented crisis standards of care. It isrecommended that a “ Triage Team comprised of seniormedicalpersonnel, preferably not those primarily takingcare of the individualpatient under consideration . Please see “ Scarce Resource Triage Team Guidelines” for furtherinformation

STEP 1: Screen adult patients for ICU care during scarce resources

Proceed to following after reviewingpatient' s end of life directives/ POLSTor similar livingwill documents. For the

following conditions consider available staffing and resources. If resources are inadequate, considertransferringthe following patients to out-patientor palliative care with appropriate resources and support as

can be provided .

1. Pre -existing or Persistent coma orvegetative state

2 . Severe acute trauma ( e. g.non -survivable head injury)

3. Severeburnswith Low Survivalburn scoresbasedon the TriageDecisionfor Burn Victimstable (See Table A

below ). See Burn Scarce Resource Card for managementofcriticalburn patientoutside of a Burn Center.

4. Significant underlying disease process that predict poor short term survival*

* Examples of underlyingdiseasesthat predict poor short-term survival, despite standard treatment, includebut

are notlimited to :

Severe congestive heart failure

Severe chronic lung disease• Centralnervous system , solid organ orhematopoietic malignancy with prognosis for recovery

Severe cirrhotic liver disease with multi-organ dysfunction

5. Baseline functional status (consider loss ofreserves in energy , physicalability , cognition and general health )

© 2020NorthwestHealthcareResponseNetwork. CriticalCare Adult Algorithm 3

STEP 2: Determineifpatientmeets ICU Inclusion Criteria

2A : Patientsmusthave at least one of the following INCLUSION CRITERIA :

1. Requiresventilatory support, either invasiveornon- invasive

Clinicalevidenceofimpendingrespiratoryfailure

• Refractoryhypoxemia (SpO2< 90 % on 0.85)• Respiratoryacidosis (pH<7.2)

Inability to protect ormaintain airway

2 . Hypotension(SBP < 90) secondary to eitheran acute medicalor traumacondition, with clinical

evidenceof shock (alteredleveloff consciousnessdecreasedurineoutput, or other evidenceof end

stage organ failure ) refractory to volume resuscitation that cannotbemanaged in a non-ICU setting .

2B : To determine critical care resource allocation the following should be considered :

• Expected durationofneedof criticalcareresource

• Prognosiswith consideration to both currentepidemiology and underlyingillness

• Response to currenttreatment

• DegreeofOrgan Dysfunction as measuredby theMSOFA (ModifiedSequentialOrgan FailureAssessmentScore) Please see Step 6 regardinguse of scoring system

• Baseline functionalstatus (consider loss of reserves in energy , physical ability, cognition and generalhealth )

* Examples ofunderlying diseases that predictpoor short- term survival, despite standard treatment,include but are not limited to :

Severe congestiveheartfailure

Severe chronic lung disease

Centralnervous system , solid organ or hematopoietic malignancy with poorprognosis for recovery

Severe cirrhotic liverdisease withmulti-organ dysfunction

STEP 4 : Assess forre-allocationofCriticalCare Resource

To determinecriticalcare resourceallocation thefollowingshould beconsidered:

• Expected duration need of criticalcareresource

• Prognosis with consideration to both currentepidemiology and underlyingillness

• Response to currenttreatment• DegreeofOrgan Dysfunction asmeasuredby theMSOFA (Modified SequentialOrgan Failure Assessment

Score) Please see Step 6 regarding use ofscoring systems

• Baselinefunctionalstatus (considerloss ofreserves in energy,physical ability , cognition and generalhealth )

* Examples ofunderlying diseasesthat predictpoorshort- term survival, despite standard treatment,includebut are notlimited to :• Severe congestive heartfailure

Severe chronic lung disease• Centralnervous system , solid organ or hematopoieticmalignancy with poor prognosis for recovery

Severe cirrhotic liverdisease with multi-organ dysfunction

©2020 NorthwestHealthcareResponseNetwork. CriticalCare Adult Algorithm 4

STEP 5 : Critical care waiting list

If a patient meets ICU inclusion criteria and resources are not available , patientwill be placed on an ICU waitinglist. As resources become available their clinical situation willbe re- assessed and they will be re-triaged based

on criteria outlined in Step 6 . If a clear distinction cannot be made between patients of similar triage priority ,

the resource willbe allocated to thepatient who has been waiting the longest.

STEP 6 : Admit to ICU

Patient data collection outlined on Step 6 of the Algorithm willbe continuous and ongoing. It isrecommendedthat every 24 hours of a patient's ICU stay, their clinicalcondition willbe reviewed and they willbe determinedtobe “ Improving” “Unchanged or “Worsening” . This determination must not only take into account data pointsas outlinedin Step 6 butmustalso include updated epidemiology , criticalcare resource availability and censusdemands.

Previously, recommendationshad been madeto use MSOFA score aloneto determine triagecategories.However, based onmore recentdata2,3itis current consensus that a specific SOFA orMSOFA score cannot

accurately define clinical categories alone, and therefore all criteria outlined in Step 6 including currentepidemiologymust be taken into accountwhen deciding if patients are “ Improving,” “Unchanged,

Worsening”

Other Adult Considerations

All patients receiving critical care before the onset of crisis standards will be re-assessed based on the samecriteria as all incoming critical care patients . The same Data as outlined in Step 6 should be obtained andresources re-allocated ifneeded dependent on the Triage Team assessment and decisions.

The use of ECMO should be decided on an individual basis by the ICU attending, nursing supervisor and ECMOrepresentative based on prognosis, suspected duration of ECMO, availability of staff and other resources .

1 . CrisisCapacity: Adaptive spaces, staffand supplies arenot consistentwith usualstandardsofcare, butprovidesufficiencyofcare in the setting

of a catastrophic disaster ( i . . provide thebest possible care to patients given the circumstancesand resources available) . Crisis capacity

activation constitutes a significant adjustmentto standardsof care. (Hick et al,2009, IOM

2 . Grissom ,Colin K DisasterMed Public Health Preparedness 4(4 ):277 -284 , 2011

3. Shahpori, R ; Crit CareMed 39( 4):827-832, 2011

© 2020NorthwestHealthcareResponseNetwork. CriticalCare Adult Algorithm 5

Percent TBSA burn size

20 -29 30- 39 40 -49 50 -59 60 -69 70 -79 80 -890 - 9 10 - 19 90

0 - 1. 9

2 - 4

5 - 19

20- 29 Outpatient Delayed Immediate

Age,inyears

30- 39

40 -49

50-59

60 -69 Low survival,mayoptforexpectantmanagement

Table A

al the of outcomes to resources forSaffle, JR etal. Definingtheratioofoutcomesto resourcesfor triageofburnpatientsinmasscasualties. J burnCareRehabil

2005 ( 6) :478

© 2020NorthwestHealthcareResponseNetwork. CriticalCare Adult Algorithm 6

Washington State Department ofPediatric Critical Care Triage AlgorithmCrisis Standards ofCareUpdated Version :Mar 2020

HealthNORTHWESTHEALTHCAREResponseNetwork.

This Algorithm is intendedtobeused alongsidethe attachedWorksheet.

Answeringeach questionrequiresthesupplementalinformationin theWorksheet.

* * * Please use them together. * *

Assumptions for use:

1. Health Officer has declared a crisis situation requiring scarce resourcemanagementand crisis standardsofcare,where crisis standardsofcare is defined as “ substantialchange in usualhealthcare operations and the levelof

care it ispossible to deliverwhich ismadenecessary by a pervasive or catastrophic disaster” .

2 . Healthcaresystemsare overwhelmed despitemaximizing allpossible surge and mitigation strategies impacting

thespace and/orstaff and/orsuppliesneededto deliverusuallevelsofcare.

Washington Statehas adopted and willuse the ethicalframework developedby theNationalAcademy ofMedicine,which stressesthe importanceofan ethically grounded system to guide decision -makingin a crisis standards ofcaresituation. Alldecisionsand communicationswillbe based on the ethical principlesbelow . The NationalAcademyof

Medicine defines these ethicalprinciplesas:

Fairness – Standards that are, to the highestdegree possible, recognized as fair by those affectedby them

including themembers ofaffected communities, practitioners , and providerorganizations , evidence based andresponsive to specific needs of individuals and the population .

Duty to care Standards are focused on the duty of healthcare professionals to care for patients in need ofmedical care.

Duty to steward resources – healthcare institutions and public health officials have a duty to steward scarceresources,reflecting the utilitarian goalof saving the greatest possible number of lives.

• Transparency in design decision making, and information sharing.

Consistency – in application across populationsand among individuals regardless of their human condition

(e g. race, age disability, ethnicity, ability to pay, socioeconomic status, preexisting health conditions, socialworth , perceivedobstacles to treatment, past use of resources) .

Proportionality and individualrequirementsmustbe commensurate with the scale of the emergencyand degree of scarce resources.

Accountability individualdecisions and implementation standards, and of governments for ensuringappropriate protections and just allocation of available resources.

1 , 2 IOM ( InstituteofMedicine) 2009 .Guidance for EstablishingCrisis Standardsof Care for in DisasterSituations: A Letter

Report. Washington, DC:NationalAcademiesPress.

© 2020NorthwestHealthcareResponseNetwork. CriticalCare Pediatric Algorithm | 1

Washington State Department ofPediatric Critical Care Triage AlgorithmCrisis Standards of CareUpdated Version :Mar 2020

HealthNORTHWESTHEALTHCAREResponseNetwork.

STEP 1

Discharge to

palliative careNO Screen Patient for ICU Care after

reviewing goals of care with patient and

family

Reassess daily to

determine continued

priority for

hospitalization

-

STEP 2

A . DoespatientmeetICU inclusioncriteria and

B. Willpatientbenefit from ICU care? dischargetopalliativecare

- - - - -

YES

NO

- - - -

Admit to floor

i

Consult adult ICU partners to

discuss extendingthe definition

of adult criticalcareto

accommodateolder children

STEP 3

ICU Resourceavailable?

STEP 4

Compellingreason forreallocationof resource?

NO

STEP 5

Add patientto

ICU waitinglist

YES YES

Re-evaluate

STEP 6 ADMIT TO ICU

Data Collection

1. Expected duration of need 2 . Prognosis

3. Responseto treatment4 . PELOD

IMPROVINGUNCHANGED

WORSENING

Consider discharge fromcriticalcare, provide

appropriate palliative care.

Consider continued ICU care

or considermovingto floorwith oxygen or NIPPV (as

appropriate). Reassess dailyto determine continued need

for hospitalization.

Consider continued ICUcare. Ifextubated with no

significant organ failure ,

transferto flood and

reassessdaily todetermine

continuedneedfor

hospitalization.

© 2020NorthwestHealthcareResponseNetwork. Critical Care Pediatric Algorithm

Washington State Department ofPediatric CriticalCare TriageWorksheetCriticalCareGuidelinesDuring Crisis CapacityUpdated Version: Mar 2020

HealthNORTHWESTHEALTHCAREResponseNetwork.

This Worksheet , along with the corresponding Pediatric Critical Care Algorithm , are to be used by TriageTeams” during a declared emergency eventwhereby an appropriate healthcare official has implemented crisis

standards ofcare . Itis recommended that a “ Triage Team comprised of seniormedicalpersonnelpreferably not those primarily taking care of the individualpatient under consideration . Please see Scarce

Resource Triage Team Guidelines” for further information .

STEP 1: Screen PediatricPatientsfor ICU care DuringScarceResources

Proceed to the following after reviewing goals of care with patient and family ( .g . limited code status ). The

goals of care should reflect the best interest of thepatient.

For the followingconditionsconsideravailablestaffingandresources. Ifresourcesareinadequate, consider

transferringthe followingpatientsto out-patientorpalliativecare with appropriateresourcesand supportas canbeprovided.

1. Pre-existingor Persistent encephalopathy, comaor vegetative state

2 . Severe acute trauma( e . g . non -survivable head injury)

3 . Severeburnswith Low Survivalburn scoresbased on the Triage Decision for Burn Victimstable

( See Table A . See Burn Scarce Resource Card formanagement of critical burn patient outside of aBurn Center .

4. Significant underlying disease process that predictpoorshort term survival*

* Examplesofunderlyingdiseasesthatpredictpoorshort- term survival, despitestandardtreatment, include

butare notlimitedto:•Knownsevere chromosomalabnormalities with poorprognosis

•Knownsevere metabolic, neuromuscular, cardiac, oncologic or pulmonary disease with poor

prognosis

•Extreme prematurity at the limitsof viability

© 2020NorthwestHealthcareResponseNetwork. CriticalCare Pediatric Algorithm 3

STEP 2 :Determine ifpatient meets ICU Inclusion Criteria

2A : Patients must have at least one of the following INCLUSION CRITERIA :

1. Requires ventilatory support , either invasive or non -invasive

Clinicalevidence of impendingrespiratoryfailure• Refractoryhypoxemia( 90 % on > .85)

• Respiratoryacidosis (pH < 7 .2)Age

InabilitytoprotectormaintainairwaySBP (mmHG)

0-28 days <602. Hypotension(seetable A ) or clinicalevidenceof

shock ( defined as an alteredlevelof consciousness, 1month 1year <70

decreased urineoutput, or other evidence end 1year 10 years (age in years x 2) + 70stage organ failure) refractory to volume

> 10 years < 90resuscitation secondary to either an acutemedical

or trauma condition that cannotbemanaged in a Table A

non - setting.2B : To determine critical care resource allocation the following should be considered :

Expected duration ofneed of critical care resource

• Prognosis with consideration to both current epidemiology and underlying illness *

• Response to current treatment

• Degree of Organ Dysfunction asmeasured by the Pediatric Logistic Organ Dysfunction (PELOD 2) score.

(Table C) see Step 6 regardinguseofscoring systems.

*Examples ofunderlying diseases thatpredictpoor short-term survival, despite standard treatment,includebutare not limited to :

•Known severe chromosomal abnormalities with poor prognosis•Known severe metabolic , neuromuscular , cardiac , oncologic orpulmonary disease with poor

prognosis

• Extreme prematurity at the limits of viability

STEP 4 : Assess for re-allocation ofCritical Care Resource

To determine critical care resource allocation the following should beconsidered :• Expected duration ofneed of criticalcareresource

• Prognosiswith consideration to both currentepidemiology and underlying

• Response to currenttreatment• Degree ofOrgan Dysfunction asmeasuredby the Pediatric Logistic Organ Dysfunction (PELOD 2 ) score.

(Table C) Pleasesee Step 6 regardinguse ofscoringsystems.

* Examplesof underlyingdiseases that predictpoorshort-term survival, despite standard treatment,includebutare notlimitedto :

severe chromosomalabnormalities with poor prognosis

•Knownseveremetabolic, neuromuscular, cardiac, oncologic or pulmonary disease with poorprognosis

• Extreme prematurity at the limits of viability

© 2020NorthwestHealthcareResponseNetwork. Critical CarePediatricAlgorithm 4

STEP 5 : Critical carewaiting list

If a patientmeets ICU inclusion criteria and resourcesare notavailable, patientwillbe placed on an ICUwaiting list. As resourcesbecomeavailable their clinical situation willbere-assessed and they willbe retriaged based on criteria outlined in Step 6 . If a clear distinction cannotbemadebetween patientsofsimilartriage priority, theresource will be allocated to the patientwho has been waiting the longest.

STEP 6 : Admit to ICU

Patient data collection outlined on Step 6 of the Algorithm willbe continuous and ongoing. Itisrecommended that every 24 hours of a patient' s ICU stay , their clinical condition will be reviewed and they

will be determined to be “ Improving ” “Unchanged “Worsening ” . This determination must not only

take into account data points as outlined in Step 6 butmust also include updated epidemiology , criticalcare resource availability and census demands .

Pediatric prognostic scoring systems currently available ( e . g . PELOD2) are unable to accurately predictpatient outcomes and thus should notbe used as a sole indicator ofprognosis especially in a disaster

situation . When considering critical care resource allocation in a crisis , it is recommended that decisions be

made by a Triage Team . Decisions should be made based on best clinical judgment with full knowledge ofregional resource availability . (Ped Crit Care 2011)

Other Pediatric Considerations

All patients receiving critical care before the onset of crisis standards willbere-assessed based on the same criteriaas all incoming critical care patients. The sameData as outlined in Step 2 should be obtained and resources reallocated if needed dependent on the Triage Team assessment and decisions .

The use of ECMO should be decided on an individual basis by the PICU and/or NICU attending,nursing supervisorand ECMO representative based on prognosis , suspected duration of ECMO , availability of staff and otherresources

Percent TBSA burn size

10-19 20- 29 30- 39 40 -49 50-59 60 - 70 -79 80 -890 - 9 90

0 - 1. 9

2- 4

5 - 19

20 - 29 Outpatient Delayed Immediate

Age,inyears

30-39

40 -49

50-59

60-69 Low survival,may optforexpectantmanagement

Table B

Saffle, JR , etal. Definingtheratio of outcomesto resourcesfor triageofburn patientsinmasscasualties. J burn Care Rehabil200526 (6 ):478

© 2020NorthwestHealthcareResponseNetwork. CriticalCare Pediatric Algorithm 5

Table C. PELOD2Scoring System

Points bySeverityLevels

4 5 6

10 3 4Both fixed

5.0 - 10. 9 . 0

31- 45 17- 30

25 - 38

31-43

39 -54

44 -59

OrganDysfunctions

andVariables

NeurologicGlasgow Coma Score 211Pupillary reaction Both reactive

Cardiovascular

Lactatemia (mmol/ L < 5. 0

Mean arterial pressure (mm Hg)

O 1mo

1- 11mo

12-23 mo

24 -59mo60 - 143 mo

144 mo

Renal

Creatinine ( L

mo

1 - 11mo

12-23 mo

24 mo

60 - 143 mo

144mo

262 46 -61 32- 44

49-64

52- 66

36 - 48

38 -51

No

Respiratory

Pao, (mm Hg) /

Paco, (mm Hg) 59 - 94

Invasive ventilation Yes

Hematologic

WBC count( > 2

Platelets ( 10°/ L ) 77 - 141

variablesmustbecollected butmeasurementscan be doneonly if justified by thepatient' s clinicalstatus. If a variable isnotmeasured, it shouldbeconsiderednormal. If a variable is measuredmore than once in 24hr the worstvalue is used in calculatingthe score fraction ofinspired oxygen.Neurologicdysfunction: Glasgow ComaScore: usethe lowest value. If the patientis sedated, record the estimatedGlasgow ComaScore before sedation.

Assess only patients with known or suspected acute centralnervous system disease. Pupillary reactions: nonreactivepupilsmust be > 3mm.Donotassessafter iatrogenicpupillary dilatationCardiovasculardysfunction: Heartrate and mean arterial pressure: do notassessduring cryingor iatrogenicagitation.Respiratorydysfunction: Pao arterialmeasurementonly. Pao / ratio is considerednormal in children with cyanotic heartdisease. Paco, canbe

measuredfrom arterial, capillary, orvenous samples. Invasiveventilation the useofmask ventilation is notconsideredinvasiveventilation.Logit(mortality) = - 6 .61 + PELOD- 2 score.

Probabilityofdeath = 1/( 1 + exp logit(mortality) . CRITICAL CARE MEDICINE

1. Crisis Capacity : Adaptive spaces, staff and supplies are not consistent with usual standards of care, but provide sufficiency of care in

thesettingof a catastrophic disaster ( i . e . provide thebestpossible care to patients given the circumstancesandresourcesavailable) .

Crisis capacity activation constitutes a significant adjustment to standards of care. (Hick et al, 2009 )

2 . ECCGuidelines 2010 , Circulation 2010; 122 Suppl3: -

3 . Leteurtre, Stéphane; Duhamel, Alain ; Salleron , Julia ; Grandbastien , Bruno; Lacroix, Jacques ; Leclerc, Francis; on behalf of theGroupe Francophone de Réanimation et d Urgences Pédiatriques ( ; Critical Care Medicine41 7 ): 1761- 1773, July2013 . doi: 10 .1097 / CCM .Ob013e31828a2bbd

© 2020NorthwestHealthcareResponseNetwork. CriticalCare Pediatric Algorithm 6

Washington State Department of

HealthNORTHWESTHEALTHCARE

ResponseNetwork.

Scarce Resource Triage Team GuidelinesTo be used in conjunction with Scarce ResourceAlgorithmsduring Crisis Standards ofCareUpdated:Mar 2020

IntroductionIn the event of a large scale disaster - either a no notice eventsuch as a naturaldisaster or a prolonged situationsuch as a pandemic there is the potentialfor an overwhelmingnumberof critically illor injured patients. In thesesituations, certain medicalresourcesmay becomescarce and prioritizationofcaremayneed to be considered.

In 2009 the Institute ofMedicine ( currently the NationalAcademyof Medicine )published a landmark report,

Guidance for Establishing Crisis Standards of Care for use in Disaster Situation : A Letter Report. In this report theauthors defined surge capacity as a continuum from conventional to contingency and finally crisis. This framework

hasbeen nationally accepted and adopted . The definition of Crisis Capacity ” as set by the NAM , is a situationwhere space, staff and supplies “ are notconsistentwith usual standardsof care ,butprovide sufficiency of care inthe context of a catastrophic disaster (i. . , provide thebest possible care to patients given the circumstances and

resources available ).

The content of this document is based on a thorough review of the literature , guidelines published by leadingnationalhealthcare specialty colleges and societies, recommendationsofthe NationalAcademy ofMedicine anddetailed discussion and deliberation by theWA State Disaster MedicalAdvisory Committee (DMAC ), the DisasterClinical Advisory Committee (DCAC ) Central District and included input from both local and state CommunityEngagement Reports. ,3

This document is to be used in conjunction with the DOH ScarceResource Triage Algorithmswhich were developedby regional workgroups of Subject Matter Experts (SME), and approved by the Disaster Clinical Advisory Committee(DCAC) Central District . Implementation of these algorithms depends upon the development of individual CrisisStandards of Care Hospital, HospitalSystem , and Regional Triage Teams as outlined below .

Purpose

To provide a transparent, fair, equitable , and consistent approach to allocation of scarce resources during a declaredemergency in which Crisis Standards of Care (CSC)has been implemented .

Scope

Allhealthcareorganizationsandproviderswithin theaffectedregion ofthe CSC declaration.

Assumptions• A Health Officerhas declared a crisis situation and crisis standards ofcare has been activated.

• Healthcare systemsare overwhelmed despitemaximizingall possible surge andmitigation strategiesimpactingthe space and/ or staff and /or supplies needed to deliver usual levels of care

• Federal assets have been requested butmay bedelayed .

1. IOM ( InstituteofMedicine) 2009. Guidance forEstablishingCrisis StandardsofCare for in Disaster Situations: A LetterReport

Washington, DC:NationalAcademiesPress

2. 2 Washington StateCrisisStandardsof CareCommunityEngagementReport, June2019,WADOH.

3 . 3 Li-Vollmer, M .Health Care Decisionsin Disasters: EngagingthePublicOnMedicalService PrioritizationDuringa Severe InfluenzaPandemic.JournalofParticipatoryMedicine. Vol2 . December14, 2010 .

©2020 Northwest Healthcare Response Network . ScarceResource Triage Team Guidelines 1

Implementation Recommendations

A . General

All healthcare organizations within the affected region agree to implement a uniform triage process asoutlined in this document to be used along with the DOH Scarce Resource Triage Algorithms to include : AdultCritical Care , Pediatric Critical Care and RenalReplacement Therapy (pending) Algorithms.

B . CSC Triage Teams: Identification and Composition

1. CSC HospitalClinicalTriage Team

It is recommended that every in patient healthcare institution have a CSC Hospital ClinicalTriage Team

which will report to the Medical Care Branch Director (or equivalent position within organization' scommand structure during activation ofHICS.

a . It is recommended the CSC HospitalClinical Triage Team

• At least 2 -3 senior clinicianswith experiencein tertiary triage (e. g. CriticalCare, EmergencyMedicine,

TraumaSurgery, etc.), with one designatedas LeadTriage Officerwho oversees all Triageprocesses.• 1medicalethicist

• When possibleclinicianson the Triage Team willnotbe primary providersof the patientsunderconsideration

• When patients requiring a scarce resource fall under a specific specialty such asburn , trauma, pediatrics , etc.then all attemptswillbemadeto consultthatspecialtyeitherin person or remotelyduringconsideration

b . Allpatientspresentedto the CSC HospitalClinicalTriage Team willberecorded in a CSC Hospital

Clinical Triage Team Log, which will include:

• Date andtimeofreferral

Nameof referringclinician andcontact information

Patientidentifiers: These shouldinclude only date of birth and sex. Patient' s nameandotherdemographic data should notbe considered by the Triage Team . Hospital specific MRN should be

notated to confirm patient identification butshould notbemade available to the Triage Team

All clinical information presented to the Triage Team at the timeof decision

Triage Team decision, date andtime of thedecision, and all supporting documentation reviewed andproduced for the decision

Ifpatient isreferred , date and time of referral and contact information of receiving Clinical Triage Team

• Patientoutcome(ifknown)

C . If the patientrequiresreferraloutsidean individualhospitaland the hospitalis partof a widerhospitalsystem please see Section 2 . Ifthehospital is not part of a larger hospitalsystem thenplease refer to Section 3 .

d . It is recommended the CSC HospitalClinical Triage Team follow the communication guidelinesoutlined in this document in order to maintain accurate and up to date situationalawareness.

2. Hospital systemsduring CSC

It is recommendedeveryHospitalSystem maintain goodcommunicationsbetweenindividualhospitalsin

their system to assistin situationalawarenessfor thescarceresourcein question. It is recommendedthat

everyhospitalsystem havea mechanism bywhich a criticalresourcecan bemaximizedanddistributed

throughouttheir system and thatall appropriatechannelshavebeen exhaustedto obtain additionalresources. When a specifichealthcarefacilitywithin a hospitalsystem lacksa specificresource, identifying

thatresourcewithin their system shouldbethe firststep in patientplacement. This wouldbemanagedbythe CSCHospitalSystem TriageTeam .

©2020 Northwest Healthcare Response Network . Scarce Resource Triage Team Guidelines

a . All patientspresented to the CSC HospitalSystem Triage Team willbe recorded in a CSC Hospital

System Triage Team Log, which will include:

Date and timeofreferral

Nameof referring clinician andcontact information• Patientidentifiers : These should include only date ofbirth and sex. Patient' s name and other

demographicdata should notbeconsideredby the Triage Team . HospitalspecificMRNshould be

notated to confirm patient identification butshould notbemade available to Triage Team .

All clinical information presented to the Triage Team at the timeofdecision

Triage Team decision , date and time of the decision , and allsupporting documentation reviewed and

produced for the decision

• Ifpatient is referred to the Regional Triage Team , date and time of referraland contact information ofreceiving RegionalTriage Team

Patient outcome ( ifknown)

b Those patients who cannot bemanaged within their system will need to bepresented to the CSCRegionalClinicalTriage Team for consideration and prioritization within a differenthospitalsystem .

3 . CSC Regional Clinical Triage Team

It is recommended a CSC RegionalClinicalTriageTeam manageprioritizationandplacementofpatients in

need of a scarce resource in the affected geographic region who cannotbemanaged within a specifichospitalsystem .

It is recommendedthe CSC RegionalClinicalTriage Team fairly representthe healthcarefacilities andsystemswithin the region. If a region hasdeveloped a healthcare coalitionDCACthen itis recommendedthatmembersof theCSC Regional Triage team bedetermined in coordinationwith localDCAC, StateDMAC LHO , other Public Health experts, outside SMEs, etc and can consist ofmembersfrom thelocalDCAC, healthcareexecutivesor the clinicalcommunityatlarge.

If a regiondoesnothave a localDCAC then CSC RegionalClinicalTriageTeam memberswillbedeterminedby the State DMAC in coordinationwith the SHO, LHO, other Public Health experts, outsideSME' s, etc. and

can consist ofmembersfrom the DMAC, healthcareexecutivesor the clinicalcommunity atlarge.Recommendedmembersof the CSC RegionalClinical TriageTeam are as follows:

• Seniorclinicianswith experiencein tertiary triage (e. g. CriticalCare, EmergencyMedicine, TraumaSurgery,etc. ), with one designated as Lead TriageOfficerwho oversees all Triage processes .

• 1medicalethicist

• When possible, clinicians on the CSC RegionalClinical Triage Team willnotbe primary providers ofthepatients under consideration,normembers of the referring CSC Hospitalor HospitalSystem ClinicalTriage Team (s ).

When patients requiring a scarce resourcefall under a specific specialty such asburn , trauma, pediatrics,

etc . then all attemptswillbemade to consult thatspecialty eitherinperson or remotelyduringconsideration .

a. Allpatientspresentedto the CSC RegionalClinical Triage Team willbe recordedin a CSC RegionalClinical Triage Team Log which will include:

• Date and timeof referral

Nameofreferring clinician and contact information

Patient identifiers : These should include only date ofbirth and sex. Patient's name and otherdemographic data should not be considered by the Triage Team . Hospital specific MRN should be

notated to confirm patient identification ,butshould notbe made available to Triage Team .

All clinical information presented to the Triage Team at the time of decision Triage Team decision dateand time and all supporting documentation

Patientoutcome (ifknown)

©2020 Northwest Healthcare Response Network . Scarce Resource Triage Team Guidelines

b Itis recommended the CSC Regional Clinical Triage Team follow the communication guidelines below in

order to maintain accurate and up to date situationalawareness .

The CSC Regional Clinical Triage Team is under the sameOversight and Re-evaluation processes asthe CSC Hospital and HospitalSystem Triage Teamsoutlinedbelow .

. Oversight

In order to maintain transparency and ensure a fair, equitable andconsistentapproachto allocation of ascarceresourcesit is importantthatall triageteamshave an oversightprocessfor decisionsmadeduring

an event

1. CSC HospitalandHospitalSystemsOversightCommittee

When an event occurs which requires activation of the CSC Hospitalor HospitalSystem ClinicalTriageTeam the following documentationwillberequiredand should bemaintainedand reviewedby the CSCOversightCommittee designated by theMedicalOperations Branch DirectorunderHICS.

a . It is recommended the CSC Triage Team OversightCommittee consistoftheSenior clinicians with experience in tertiary triage (e .g. Critical Care, Emergency Medicine, Trauma Surgery,etc.) ,with one designated as Chair who oversees all processes

When possible clinicians on the CSC Triage Team Oversight Committee will not be primary providers ofthe patientsunderconsideration

• When patientsrequiringa scarceresourcefallundera specificspecialty such asburn, trauma,pediatrics, etc.then all attempts willbemade to consult that specialty either in person orremotely during consideration

At least one medicalethicist

b Allpatientspresentedto theCSCHospitalor HospitalSystem Triage Team willbe reviewedbyan

CSC Oversight Committee and will be recorded in an CSC Oversight Triage Team Log, which will

• All patient demographicsDate and time of the case consideration

• Allpatientinformation presented to theClinicalTriage Team at the timeof consideration

Triage Team decision, date and timeof the decision , and all supporting documentation reviewed and

produced for the decision

• Ifpatientwas referred, date and timeof referral and contact informationofreceiving ClinicalTriage Team

• Patientoutcome

C. It is recommendedthat at agreed upon intervalsthe CSC OversightCommitteewill review all

cases presented to the CSC Hospitalor HospitalSystem Triage Team to ensure the following:

• All appropriate clinical information was considered• Accurate documentation was recorded

• Significantvariancesbe reviewed and addressed

d . Depending on thenature of the incident oversightreview may be in real time(e. g. in a prolongedeventsuch as a pandemic) . Howeverin no notice, sudden or briefevents, this review may be

retrospective.

©2020 Northwest Healthcare Response Network . Scarce Resource Triage Team Guidelines

2 . CSC Regional Oversight Committee

When an event occurs which requires activation of the CSC Regional Clinical Triage Team the following

documentation willberequired and willbemaintained and reviewed by the CSC RegionalOversight

Committee. If a region has developed a healthcare coalition DCAC then it is recommended thatmembersof the CSC RegionalOversight team be determined in coordination with localDCAC, State DMAC LHO

other Public Health experts , outside SME s , etc. and can consist ofmembers from the localDCAC,

healthcare executives or the clinical community at large.

If a region does not have a local DCAC then the CSC RegionalOversight Team memberswill bedetermined by the State DMAC in coordination with the SHO, LHO , other Public Health experts, outsideSME s, etc . and can consist ofmembers from the DMAC (or their designees), healthcare executives or the

clinical community at large. Recommendedmembers of the CSC Regional ClinicalTriage Team are asfollows:

Senior clinicianswith experience in tertiary triage (e.g. CriticalCare, EmergencyMedicine, Trauma Surgery ,etc.), with one designated as Chair who oversees all processes.

When possible clinicianson the RegionalTriage Team Oversight Committeewill notbe primary providers ofthe patientsunder considerationnormembersof the RegionalTriage Team .

When patientsrequiring a scarceresourcefall under a specificspecialty such asburn, trauma,pediatrics, etc.then allattemptswillbemadeto consult that specialty either in person or remotely during consideration.

• At leastonemedicalethicist

a. Allpatients presented to the CSC RegionalOversight Committee will berecorded in a CSC RegionalOversight CommitteeLog, which will include:

All patientdemographics• Date andtime of the case consideration

• Allpatient information presented to the CSC Regional Clinical Triage Team at the timeof consideration.

• The CSC Regional Clinical Triage Team decision date, time and supporting documentation reviewed andproduced for the decision

Patientoutcome

b It isrecommendedthatat agreed uponintervals the CSC RegionalOversightCommittee willreview all casespresented to the Regional Triage Team to ensure the following:

All appropriate clinicalinformationwas considered

• Accurate documentation wasrecorded

Extremevariances bereviewedand addressed

C. Dependingon thenatureof the incidentoversightreview maybein realtime(i . e . in a prolonged

eventsuch as a pandemic). However in no notice, sudden orbriefevents, this review may be

retrospective.

©2020 Northwest Healthcare Response Network . Scarce Resource Triage Team Guidelines

D . Re- evaluationProcess DuringResponse

1. Request to change process

a. During an event individual clinicians may request a specific change to the Scarce Resource Cards,Triage Algorithmsorprotocolsbased on new clinicalinformationsuch as changesin prognosticindicatorsor outcomemeasure. These requestsshouldbemade in writingto the Chairand ViceChairof theWAStateDMAC(or theirdesignee) .

b . WA State DMACwillkeep a log andrecord of every CSC Reevaluation ProcessRequest, date and

timeofrequest , and all the supporting documentation presented during therequest and evaluation .

• Each request willbe reviewed by the DMAC Chair and Vice Chair or their designee alongwith allrelevant partners including additional inputfrom SME' s

All request decisions will be made in a timely fashion and will be based on consensus of all relevantpartners

Finaldecisions for all CSC Reevaluation Process Requestswillbein writing, dated and timed , andinclude all supporting documentation

2 . Requestto reevaluate specific case

a . Any clinician may bring a CSC Request for Patient Reevaluation of a specific case to the respectiveMedicalCare BranchDirectorand designatedethicist. TheMedicalCare Branch Directorhas

authorityover therespectiveCSC ClinicalTriage Team whomadetheinitialdecisionunder

consideration( . e . individualCSChospital, hospitalsystem , orregionalClinicalTriageTeam ).

At the individualhospital andhospital system , theMedicalBranch Directorwillbedeterminedbystandards HICS designations within the organization

• At the Regional level, theMedical Branch Director will theChair or Vice Chair of the State DMAC (or

their designee)

At all levels, a CSC Requestfor PatientReevaluationwillbe reviewedby theMedicalBranchDirector, a

designatedethicist and any other relevantpartners.

b A logwillbemaintainedof every RequestforReevaluation, date andtimeofrequest, and allsupportingdocumentation presented during therequest andreevaluation.

C. Every case broughtto theMedicalCare Branch Director and designated ethicistwillbe reviewed in

a timely fashion to ensure the Triage Team documentationwas completeand thedecisionprocess

was consistentwith Scarce Resource Cards, Triage algorithms, protocols or any other clinical

documentationrelated to the case thatwas available atthe timethe originaldecisionwasmade.

d Depending on the event ( i . . no notice vs prolonged ) it is understood that this process may be

retrospective. However, if theevent ismore prolonged and thepotentialoutcomesof thepatient

may be affected, then processesshould be in place to allow a sufficiently rapid decision.

e Finaldecisionsfor CSC RequestforPatientReevaluationof a specificcasewillbe in writing, dated andtimed, and includeall supportingdocumentation.

f . Decisionmadeby therespectiveMedicalCare Branch Director and designated ethicistwillbe final.

©2020 Northwest Healthcare Response Network . Scarce Resource Triage Team Guidelines 6

E . ResourceUpdate Protocols

1 Duringresponse

It is understood that during an event, the clinical situation may change depending on resource availability ,

new epidemiologic information , new treatment protocols and guidelines, etc. Itwillbe the responsibility

of the entire healthcare community to maintain close communication with the Local and State Health

Officer and all relevant partners to maintain accurate situational awareness and consensus regarding local

triage recommendations .

2 . Duringpreparedness

AllScarce Resource Cards and algorithmsand any supporting documentation willbe reviewed and updatedevery 3 years.

3 . Communicationsa. Duringresponse,NWHRN in conjunction with DMACwillbe responsible for identifying all

pertinentpartners during an activation of the Scarce ResourceTriage Team Guidelines to includebutnot limited to : LHO , SMEs , DOH and Federalpartners.

Depending on the situation , clinical updates may be required at various frequencies , and willbedetermined by DMAC Chair and Vice Chair , SHO , LHO and all other pertinent partners . State Health

officer ( SHO ) in conjunction with NWHRN will be responsible for disseminating this information in atimely fashion to all appropriate clinical entities.

. Communicationswillbe electronically, but if circumstancesare such that electronic

communication isnot possible , secondary communication processes will include FAX , phone andcourier.

©2020 Northwest Healthcare Response Network . Scarce Resource Triage Team Guidelines