ED Accreditation Update
New recommendations focus on mass critical care
The Working Group on Emergency Mass Critical Care has released recommendations to help EDs meet the accreditation standard that requires their facilities to prepare to respond to an influx, or the risk of an influx, of infectious patients.1 The recommendations include the following:
• Modify usual standards of care.
In a mass casualty event, available resources will be overmatched by patient needs, "therefore the usual standard of care must be degraded to focus upon life-saving treatments to the maximum number of victims," says Michael Allswede, DO, program director of the emergency & disaster medicine residency at Conemaugh Health System in Johnstown, PA.
EDs' disaster programs should have plans that include the element of scale, he says. "What to do when there are not enough ventilators, medications, or operating rooms to care for all the victims in a normal manner is the problem," he says.
• Emphasize essential elements of critical care delivery (measure oxygen saturation, temp, blood pressure, and urine output).
The point of this recommendation is that the optimal management of each disease/toxidrome requires a core of monitored findings, Allswede says. "As increasing numbers of victims are added, these measurements must be used to triage critical resources," he says. "Without these critical measurements, the medical system will be flying blind."
• Implement triage decisions regarding who should receive critical care.
EDs will not have endless resources to provide to countless number of patients requiring care, says Dan Hanfling, MD, FACEP, director of emergency management and disaster medicine at Inova Health System and clinical associate professor of emergency medicine at George Washington University, both in Falls Church, VA.
"Decisions will have to be made regarding who is most likely to benefit from the limited resources available, and these decisions will have to be consistent, transparent, and defensible," he says. It may be a fallacy to say that there will altered standards of care, Hanfling says. "What is more likely to occur is that there will be a global deterioration of services," he adds.
• Develop policy addressing who should provide emergency mass critical care.
Emergency mass critical care will have to be provided by those not usually engaged in the delivery of critical care medicine, Hanfling says. To a large extent, even the role of ED physicians will change, he says. "We are used to starting such care, but often not sustaining it beyond the very initial resuscitation, certainly not past the first few hours of care," Hanfling says. "This will likely change."
A disaster officer can be appointed who understands the disease-toxidrome-injuries to be treated and the capability of the hospital to deliver that treatment, Allswede says. "In cases when there are more victims than capability to care, triage decisions are best made by an authority with these understandings," he says.
• Develop stockpile of key pharmaceuticals (key emphasis on IV fluids and vasopressors).
Personal protective equipment, vaccination, antidotes, prophylactic medications are important to have on hand for staff, Allswede says. "The next level up would be to provide for the families of medical providers such that hospital personnel do not feel obligated to stay home and care for their families," he says.
The third level would be scaled based on a median event size in the ED's location, Allswede says. The largest strategy is to consider a stockpile sufficient to sustain operations should little or no help be available from state or federal authorities, he says. "This last level would represent the pandemic flu paradigm," Allswede says.
• Emphasize key prophylactic interventions (elevate head of bed, deep vein thrombosis prophylaxis).
"The point of the recommendation is to understand that terrorism or infectious disease emergencies do have critical actions that mean more than, for example, a domestic violence screen or an inventory of childhood nutrition," Allswede says. "In a rapidly progressing event such as a mass poisoning or car bombing, normal documentation, inventory control, and perhaps other normal functions would need to be dropped."
Reference
- Rubinson L, Nuzzo JB, Talmor DS, et al. Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: Recommendations of the Working Group on Emergency Mass Critical Care. Crit Care Med 2006; 33:2,393-2,403.
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