key: cord-0004726-cvuvsbwl authors: Sprung, Charles L.; Cohen, Robert; Adini, Bruria title: Chapter 1. Introduction date: 2010-03-07 journal: Intensive Care Med DOI: 10.1007/s00134-010-1760-5 sha: 795dee44eab7765b4c518eeb9d42efb57e4da233 doc_id: 4726 cord_uid: cvuvsbwl BACKGROUND: In December 2007, the European Society of Intensive Care Medicine established a Task Force to develop standard operating procedures (SOPs) for operating intensive care units (ICU) during an influenza epidemic or mass disaster. PURPOSE: To provide direction for health care professionals in the preparation and management of emergency ICU situations during an influenza epidemic or mass disaster, standardize activities, and promote coordination and communication among the medical teams. METHODS: Based on a literature review and contributions of content experts, a list of essential categories for managing emergency situations in the ICU were identified. Based on three cycles of a modified Delphi process, consensus was achieved regarding the categories. A primary author along with an expert group drafted SOPs for each category. RESULTS: Based on the Delphi cycles, the following key topics were found to be important for emergency preparedness: triage, infrastructure, essential equipment, manpower, protection of staff and patients, medical procedures, hospital policy, coordination and collaboration with interface units, registration and reporting, administrative policies and education. CONCLUSIONS: The draft SOPs serve as benchmarks for emergency preparedness and response of ICUs to emergencies or outbreak of pandemics. Abstract Background: In December 2007, the European Society of Intensive Care Medicine established a Task Force to develop standard operating procedures (SOPs) for operating intensive care units (ICU) during an influenza epidemic or mass disaster. Purpose: To provide direction for health care professionals in the preparation and management of emergency ICU situations during an influenza epidemic or mass disaster, standardize activities, and promote coordination and communication among the medical teams. Methods: Based on a literature review and contributions of content experts, a list of essential categories for managing emergency situations in the ICU were identified. Based on three cycles of a modified Delphi process, consensus was achieved regarding the categories. A primary author along with an expert group drafted SOPs for each category. Results: Based on the Delphi cycles, the following key topics were found to be important for emergency preparedness: triage, infrastructure, essential equipment, manpower, protection of staff and patients, medical procedures, hospital policy, coordination and collaboration with interface units, registration and reporting, administrative policies and education. Conclusions: The draft SOPs serve as benchmarks for emergency preparedness and response of ICUs to emergencies or outbreak of pandemics. Keywords Recommendations Á Standard operating procedures Á Intensive care unit Á Hospital Á H1N1 Á Influenza epidemic Á Pandemic Á Disaster In December 2007, the European Society of Intensive Care Medicine established the Task Force for Intensive Care Unit (ICU) Triage during an Influenza Epidemic or Mass Disaster to develop recommendations and standard operating procedures (SOPs). At this time worldwide intensive care, infectious disease/microbiology, pulmonary and nursing societies were contacted to send representatives to participate. Society representatives Microbiology and Infectious Diseases, Infectious Diseases Society of America, British Infection Society and the French Infectious Disease Society) and pulmonary disease (French Respiratory Society) have been involved in the project from its initiation. The Task Force consists of experts in intensive care medicine, microbiology/ infectious diseases, nursing, epidemiology, public health, medical engineering and ethics. The initial idea was that the recommendations and standard operating procedures (SOPs) would be relevant for any disaster that would create an increased demand for hospital beds, a demand that would be difficult to meet. A procedure described below was developed to provide consensus for the final recommendations and SOPs. Although the procedure has not ended, the potential for a severe H1N1 pandemic outbreak in the upcoming winter months in the Northern hemisphere and the demands such an outbreak will create for ICU resources led the Task Force to immediately publish the recommendations and SOPs in their present state. The following chapters present the recommendations and SOPs of the key topics identified and developed by the Task Force, stressing points relevant to H1N1. A summary of these recommendations has been published as a review [1] . The information should also be helpful for other hospital areas and other types of emergency scenarios including mass casualty events. Search terms used for the literature review are shown in Appendix 1. The author's first-hand experience with emergency responses is found in Appendix 2. Preliminary information regarding H1N1 patients is available. Approximately 8% of H1N1 patients are hospitalized [2, 3] (23 per 100,000 population) [4] ; 6.5-25% of these require being in the ICU [2, 4, 5] ; (28.7 per million inhabitants) [6] for a median of 7-12 days [6, 7] with a peak bed occupancy of 6.3-10.6 per million inhabitants [6] ; 65-97% of ICU patients require mechanical ventilation [3, [6] [7] [8] with median ventilatory duration in survivors of 7-15 days [5, 7, 8] ; 5-22% require renal replacement therapy [6, 7] , and 28-day ICU mortality is 14-40% [5, 7, 8] . Health care professionals in many countries have recognized the need to develop plans or programs to respond to both man made and natural emergencies and disasters [9, 10] . A SOP is a set of written instructions that describe a routine or repetitive activity that is performed in an organization [11] . SOPs are viewed as the basis for efficient management of all types of emergencies and are an integral part of a successful quality system as they provide guidance to the staff on how to perform a job properly and facilitate consistency of actions [10, 11] . A hospital SOP defines the specific procedures, precautions and equipment needed for management of emergencies, and provides guidelines and protocols for the hospital to plan its response, prepare the infrastructure required and train medical teams [9, 12] . It has been repeatedly demonstrated that preplanning saves time, facilitates integrated efforts and helps ensure that essential activities are carried out efficiently [13] . It is important to recognize that the availability of an SOP in itself does not guarantee efficient and effective functioning of personnel and the organization during an emergency. In order for an SOP to be effective, it should be periodically updated, and the personnel involved in managing an emergency should be trained how to utilize it [14] . The aim of this project was to develop recommendations and SOPs for the effective operation of ICUs during an influenza epidemic or mass disaster. The materials focus on the ICU, but are also helpful for the hospital. SOPs provide direction for the medical personnel to manage the emergency situation [15] . The SOPs establish the minimum acceptable performance criteria for dealing with the emergency and are aimed at outlining standards that are fair and equitable for all who choose to adopt them [16] . An SOP defines the legal basis for emergency management activities, outlines the authority and organizational relationships during emergency situations, and describes how actions should be coordinated. The SOP assigns responsibilities to the organizations and individuals for carrying out specific emergency actions to protect lives; to identify personnel, equipment, facilities, supplies and other resources available for use during response and recovery operations; to define prevention and response actions to reduce threats and damages and to outline procedures to expand surge capacities and reinforce resources [13] . The SOP defines the performance expectations for personnel, provides a benchmark for evaluating the operational performance, and helps to standardize activities and promote coordination and communication among the medical teams [17] . In developing the SOPs, the following process was implemented [16, 18] . Based on a literature review and contribution of content experts, a listing of essential categories and subcategories for which SOPs would be developed were identified. A modified Delphi process was S5 used by the Task Force members to obtain consensus regarding the categories and subcategories and rate their importance. Task Force members voted for the major categories by agreeing, disagreeing or modifying them and rating their level of importance as essential, important or not important for inclusion. They were also requested to add categories that might impact on the emergency preparedness and that they believed were missing. Categories for which 80% or more of the raters agreed on the level of importance were defined as having achieved ''consensus'' and warranted inclusion in the study. Categories that did not receive this level of consensus were returned to the Task Force members with a request that they modify them in such a way that would be rated as important or that they be discarded as a category. A total of three Delphi cycles were conducted. Following the completion of the third Delphi cycle, agreement was reached that the following categories are important for emergency preparedness: triage, infrastructure, essential equipment, manpower, protection of staff and patients, medical procedures, hospital policy, coordination and collaboration with interface units, registration and reporting, administrative policies and education. Following the consensus for determining the categories and subcategories to be included in the SOPs, each category was assigned a primary author and expert group to draft the SOPs for that category. The drafted materials were then sent for review and comments to task members in order to map consensus and determine which elements were not agreed upon. To date, an organized poll of the entire task force for each chapter has not yet been implemented. Similar modified Delphi cycles will be conducted in order to approve each specific part of the chapters. As chapters for hospital policy, registration and reporting and administrative policies have not yet been written, important factors for those chapters have been incorporated in the present chapters. The chapters are presented in the order one might prepare their hospital for a disaster or H1N1 pandemic outbreak. These SOPs have been developed to provide guidance in the preparation and management of a mass disaster or disease outbreak. This guidance should be used as a framework to guide the development of detailed systems and processes at local facilities. The detailed guidelines for frontline use should therefore be a product of the SOP, local situational awareness and the specific threat faced. Even in the setting of H1N1, assumptions based on previous H1N1 data may change based on the present deployment of effective vaccines, viral mutations and resistance to antiviral drugs such as neuraminidase inhibitors for which the H1N1 virus is presently sensitive [6] . Known data are evolving rapidly and should result in appropriate responses and changes in frontline guidelines. Such changes will be necessary because preparations must occur as soon as possible. ''Any deaths from 2009 influenza A (H1N1) will be regrettable, but those that result from insufficient planning and inadequate preparation will be especially tragic [19] .'' Conflict of interest None. Appendix 1: Search terms used for the literature review 5. Equipment, pharmaceuticals and supplies-variations of equipment, ventilators, pharmaceuticals, drugs, medications and supplies with intensive care, critical care, disaster, epidemic, influenza and H1N1. 6 . Protection of patients and staff-no specific search strategy was used for this project. Searches were used for previous committees including ''critical disaster planning, H5N1 staff protection, SARS-protection for health care workers, staff morale in SARS, psychosocial care for health care staff, personal protective equipment in a pandemic, PPE in SARS, fit-testing for N95 respirators, reducing airborne infection in hospitals, medico-legal implications of pandemic, implications of triaging in Hurricane Katrina and health care workers attitudes to working in a pandemic.'' 7. Critical Care triage-no specific search strategy was used for this project. Searches were used for previous publications and committees. 8. Medical procedures-pandemic, influenza, procedures, SARS, disaster planning and intensive care. 9. Educational process-staff education AND pandemic influenza AND training AND education AND preparation in various combinations. Also SARS AND staff education; SARS AND staff training. (CG-''SARS'' AND ''training OR in service training''). Michael D. Christian Experience Has been involved with disaster medicine for over 20 years, initially with his Incident Command training as a paramedic. Over the years he has responded to emergencies small and large. Most recently he was involved in both the clinical response to SARS in Toronto as well as participating on investigative and research teams. He has served in both expert and leadership roles in government disaster and pandemic planning. Academically Dr. Christian has been very active in the field of emergency preparedness conducting research as well as teaching others about emergency preparedness and disaster management. Christian Sandrock Experience (1) Is a physician with expertise in infectious diseases and pulmonary and critical care medicine. He specializes in disaster preparedness, emerging infectious diseases, terrorism and other threats to public health. (2) Bruria Adini Experience (1) Served in the Medical Corps of the IDF for 17 years. In her last post she served for 4 years as the head of the emergency hospitalization branch (responsible for the emergency preparedness of all general hospitals for emergencies). (2) For 3 years she served as the head of the Emergency Hospitalization and Alert Department in the Ministry of Health. (3) Since 2000, she has served as senior consultant to the Ministry of Health for preparedness of medical systems for emergencies. (4) She is currently a faculty member of the Emergency Medicine Department in the Ben-Gurion University of the Negev. Since 1987 she has specialized in emergency preparedness of health care systems for dealing with mass casualty events and disasters. She has acquired extensive experience in issuing national operational doctrines, SOPs and protocols for various types of emergency events and scenarios; medical manpower management and operation; planning, developing and conducting training programs, including instructive materials, such assimulation exercises and drills. (5) She has developed tools for evaluating readiness; training personnel from Israel and from other countries in developing and enhancing emergency preparedness. (6) Dr. Adini has a PhD in management of health systems. Her thesis focused on development of an evaluation tool to assess the level of emergency preparedness of acute-care hospitals to emergencies and disasters. Publications Republican National Convention and 2009 H1N1 events with consultative services provided to HHS during and after Hurricane Katrina. Publications Hick JL, Danila R (2001) Health care planning for chemical and biologic terrorism Personal protective equipment for healthcare facility decontamination personnel: regulations, risks, and recommendations Establishing and training healthcare facility decontamination teams Healthcare facility and community strategies for patient care surge capacity Concept of operations for triage of mechanical ventilation in an epidemic Clinical review: allocating ventilators during large-scale disasters: problems, planning, and process Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care: from a Task Force for Mass Critical Care summit meeting Task Force for Mass Critical Care. Definitive care for the critically ill during a disaster: medical resources for surge capacity: from a Task Force for Mass Critical Care summit meeting Task Force for Mass Critical Care. Definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity: from a Task Force for Mass Critical Care summit meeting Hospital response to a major freeway bridge collapse Emergency medical services response to a major freeway bridge collapse Surge capacity concepts for health care facilities: the CO-S-TR model for initial incident assessment Refining surge capacity: conventional, contingency and crisis capacity On behalf of the European Society of Intensive Care Medicine's Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Summary report of the European Society of Intensive Care Medicine's Task Force for intensive care unit triage during an influenza epidemic or mass disaster Pandemic Influenza A (H1N1) Virus Hospitalizations Investigation Team (2009) Hospitalized patients with 2009 H1N1 influenza in the United States Infection and death from influenza A H1N1 virus in Mexico: a retrospective analysis Australia's Winter with the 2009 pandemic influenza A (H1N1) virus Critically ill patients with 2009 influenza A(H1N1) in Mexico Critical Care Services and 2009 H1N1 influenza in Australia and New Zealand Intensive care adult patients with severe respiratory failure caused by Influenza A (H1N1)v in Spain Canadian Critical Care Trials Group H1N1 Collaborative. Critically ill patients with 2009 influenza A(H1N1) infection in Canada Accreditation Program: Hospital. Pre-publication version The World Trade Center Attack. Lessons for disaster management Organizational behavior in disasters and implications for disaster planning Are local health responders ready for biological and chemical terrorism? Available at Challenge of hospital emergency preparedness: analysis and recommendations State Emergency Management Plan for the management of emergencies associated with a structural collapse Emergency management standard Developing effective standard operating procedures Relationships between standards of procedures (SOPs) for pandemic flu and level of performance in drill The Delphi method: substance, context, a critique and an annotated bibliography Preparing for the sickest patients with 2009 influenza A (H1N1) (2) Chair of the Scottish Critical Care Delivery Group co-coordinating capacity building, prioritization plans and triage frameworks for Scottish government pandemic influenza planning; (3) critical care member and co-author of the UK Departments of Health report on 'Pandemic influenza-Managing Demand and Capacity in Health Care Organisations (surge); (4) member of UK Departments of Health Swine Flu Critical Care Clinical Group and Subgroup on ECMO provision; (5) Regional Health Board lead for Critical Care with responsibility for regional pandemic influenza contingency planning; (6) consultant in Intensive Care Medicine providing critical care for patients with H1N1 disease.