key: cord-0005688-ul91jrpd authors: Christian, Michael D.; Devereaux, Asha V.; Dichter, Jeffrey R.; Rubinson, Lewis; Kissoon, Niranjan title: Introduction and Executive Summary: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement date: 2016-01-07 journal: Chest DOI: 10.1378/chest.14-0732 sha: a68f2bf87aea334eeabedff4439a8aba8c4fc0a0 doc_id: 5688 cord_uid: ul91jrpd Natural disasters, industrial accidents, terrorism attacks, and pandemics all have the capacity to result in large numbers of critically ill or injured patients. This supplement provides suggestions for all of those involved in a disaster or pandemic with multiple critically ill patients, including front-line clinicians, hospital administrators, professional societies, and public health or government officials. The current Task Force included a total of 100 participants from nine countries, comprised of clinicians and experts from a wide variety of disciplines. Comprehensive literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert-opinion-based suggestions that are presented in this supplement using a modified Delphi process. The ultimate aim of the supplement is to expand the focus beyond the walls of ICUs to provide recommendations for the management of all critically ill or injured adults and children resulting from a pandemic or disaster wherever that care may be provided. Considerations for the management of critically ill patients include clinical priorities and logistics (supplies, evacuation, and triage) as well as the key enablers (systems planning, business continuity, legal framework, and ethical considerations) that facilitate the provision of this care. The supplement also aims to illustrate how the concepts of mass critical care are integrated across the spectrum of surge events from conventional through contingency to crisis standards of care. Natural disasters, industrial accidents, terrorism attacks, and pandemics all have the capacity to result in large numbers of critically ill or injured patients. 1 Depending on their magnitude, the response to these surges may vary from a conventional response, where critically ill patients are managed with no signifi cant alterations in standards or process of care, to a crisis response, where resource limitations dictate signifi cant alterations in both standards and process of care to provide minimal basic critical care to the maximum number of patients ( Fig 1 ) . 2 -6 Th is supplement provides suggestions for all of those involved in a disaster or pandemic with multiple critically ill patients, including front-line clinicians, hospital administrators, professional societies, and public health or government offi cials. Although it is important for all providers to be familiar with the aspects of critical care disaster/pandemic management, Table 1 provides an overview of the suggestions of most interest to each of the groups. In 2008, the American College of Chest Physicians (CHEST) Task Force on Mass Critical Care published its fi rst series of disaster critical care suggestions. 1 , 5 , 7 -9 Th eir published document refl ected their consensus deliberations and proposed suggestions regarding the care of critically ill and injured patients from disasters. Th e supplement was received enthusiastically by both the medical and broader public health communities, becoming the second most frequently downloaded supplement from CHEST's website, and papers from the supplement have been cited in 157 publications indexed on the Web of Science ( http :// thomsonreuters . com / web -of -science ). Th e eff ort was timely, as many hospitals applied the suggestions to respond to regional crises related to the 2009 infl uenza A(H1N1) pandemic. 10 -16 Several recent disasters have brought new learning since the original documents were published. Also, the 2008 documents had minimal direction for the management of pediatrics, trauma, subspecialty ICU populations, or critical care outside of developed countries. Consequently, the Task Force for Mass Critical Care was reconvened with an expanded scope and expertise to provide a rigorously developed set of usable guidelines to critical care providers responding to disasters or pandemics throughout the world. Th e assumptions 1 upon which the fi rst Task Force suggestions were based remain largely unchanged. Since 2008, the world has coped with the 2009 A(H1N1) pandemic as well as a myriad of other events that have either resulted in or have had the potential to create large numbers of critically ill patients or disrupt existing regional critical care infrastructure: Japan earthquake/ tsunami 2011, 17 Buenos Aires train crash 2012, Brazil night club fi re 2013, Boston marathon bombing 2013, 18 , 19 Spanish train crash 2013, super-storm Sandy, 20 , 21 and the Westgate mall attack 2013 Nairobi. Th e horizon is studded with potential pandemics, such as H7N9 22 and MERS CoV 23 ; in addition, confl icts and regional instability increase the risk of conventional and chemical weapons attacks. 24 -26 Clearly, hospitals and clinicians still need to be prepared to manage large numbers of critically ill or injured patients. Cognizant of the burgeoning experience since the 2008 supplement, the Task Force for Mass Critical Care reconvened in 2012 and 2013 to review, update, and expand the suggestions presented in the 2008 Figure 1 -Th is fi gure depicts the spectrum of surge from minor through major. Th e magnitude of surge is illustrated by the alterations in the balance between demand (stick people) and supply (medication boxes). As surge increases, the demand-supply imbalance worsens. Conventional, contingency, and crisis responses are used to respond to the varying magnitude of surge. Varying response strategies are associated with each level of response. As the magnitude of the surge increases, the strategies used to cope with the response gradually depart from the usual standard of care (default defi ning the standards of disaster care) until such point that even with crisis care, critical care is no longer able to be provided. Our methodology had to recognize that there is still a paucity of high-quality evidence upon which to develop evidence-based recommendations for Mass Critical Care. Th e Task Force met in Chicago, Illinois in June 2012 to develop key questions. We then conducted comprehensive literature searches to identify evidence that could be used to answer the questions and provide evidence-based "recommendations." Although some relevant studies were identifi ed, none of the studies provided a suffi cient quality of evidence upon which to make recommendations; therefore, expert opinion was solicited to provide answers ("suggestions") to the key questions. To improve the rigor of the expert opinion, a modifi ed Delphi process was used following the structure and guidelines established by the CHEST Guidelines Oversight Committee. 27 Th e primary context for the Task Force's suggestions remains health-care systems in the developed world. Th e language used throughout this supplement is not intended to refer to any one specifi c national context but rather should be viewed to be applicable in most large countries organized with a geographically based political structure incorporating a single national government with successive tiers of governments extending to local levels ( Fig 3 ) . 28 , 29 Because the audience for these suggestions is those in resource-rich settings in developed countries, the Task Force has separately addressed the issue of mass critical care in resource-poor settings and provides suggestions to improve the provision of care in this context by strengthening existing systems and leveraging strategic relationships with world bodies and organizations from developed countries. We provide a summary of the suggestions from the 13 articles included in the supplement. Please refer to the appropriate article for a detailed discussion of the suggestions. Role of Critical Care in Disaster Planning 1. We suggest hospital and local/regional disaster committees include a critical care expert to optimize critical care surge capacity planning. Barbera et al. 29 ) Targets for Surge Response 3. We suggest in the presence of a slow onset, impending disaster/threat, targets for surge capacity and capability be focused, where possible, on projected patient loads. 4a. We suggest hospital critical care resources be able to expand immediately by at least 20% above the baseline ICU maximal capacity for a conventional response. 4b. In a contingency response, we suggest hospital critical care resources be able to expand rapidly by at least 100% above the baseline ICU capacity to meet patient demand using local and regional resources. 4c. We suggest hospital critical care resources be able to expand by at least 200% above baseline ICU capacity to meet patient demand in a crisis response using any combination of local, regional, national, and international resources. We suggest more prolonged demands on critical care compared with the demands placed on other sections of the hospital (ie, days rather than hours) be taken into consideration when resuming routine hospital activities that may require ICU support. Situational Awareness and Information Sharing 6. We suggest facilities, coalitions, and other components of the emergency response system, including those related to government entities, study how information about patients, events, and epidemiology are shared on a routine basis and during a major incident. Information technology (IT) should be leveraged to provide better indicators, more rapid alerting, and better patient data to facilitate decision-making. 7. We suggest the ability to provide dynamic forecasting of the functioning and sustainability of the supply chain be supported by hospitals. Mitigating the Impact on Critical Care 8a. We suggest medically fragile patients be supported and protected by pre-event planning for ongoing medical support in the community to mitigate their reliance on hospital-based resources during a disaster event. 8b. We suggest local and regional authorities be responsible for integration of preventive community medical support in the plans to treat medically fragile patients during disasters. 8c. Given a situation where mitigation measures fail, medically fragile patients and victims of a disaster or pandemic should be given equal consideration for access to ICU resources. Planning of Surge Capacity for Unique Populations 9a. We suggest regional planning include the expectation that the hospital be able to provide initial stabilization care to unique populations that they may not normally serve such as pediatrics, burn and trauma patients. 9b. We suggest access to regional expertise for care of all patients who require specialty critical care services including participation in the planning phase and access to just-in-time consultation for care coordination during a response. 10a. We suggest hospitals adopt a process of engineered systems cessation when the staff and/or material resources required for the ongoing critical care of a small number of patients could be used to save a greater number of lives. 10b. We suggest hospital cessation of the delivery of critical care services be considered if such endeavors are likely to entail signifi cant personal risk to the treating team despite the availability of personal protective equipment and appropriate medical countermeasures. 10c. We suggest a hospital's decision to restrict or expand the delivery of critical care be made as part of a local/regional decision-making process with consultation and input provided by hospital ICU leadership. Stockpiling of Equipment, Supplies, and Pharmaceuticals 1. We suggest hospital support services, including pharmacy, laboratory, radiology, respiratory therapy, and nutrition services, also be included in the planning of critical care surge. 2. We suggest equipment, supplies, and pharmaceutical stockpiles specifi c to the delivery of mass critical care (MCC) be interoperable and compatible at the regional level and ideally at the state/provincial level, so as to ensure uniformity of response capabilities, coordinated training, and a mechanism for exchange of material among facilities. 3. We suggest facilities should ensure adequate availability of disaster supplies through facility-based caches, with vendor agreements and understanding of supply chain resources and limitations. We suggest the existing MCC hospital target lists for basic equipment, supplies, and pharmaceuticals remain relevant for institutions seeking to plan for MCC response. 5. We suggest regional and hospital stockpiles include equipment, supplies, and pharmaceuticals that can be used to accommodate the needs of unique populations that are likely to require critical care in centers other than specialty care centers, including pediatric, burn, and trauma patients. 19. In crisis surge response, we suggest less intensive treatment of moderately injured patients be prioritized over the deployment of temporary critical care services when it would result in improved outcomes for larger numbers of patients. Using Transportation Assets to Support Surge Response 20. We suggest surge capacity plans include predetermined standards that defi ne minimal ongoing critical care capability in order to defi ne the framework for decisions regarding patient transfer as the demands on the system gradually increase during a disaster or pandemic. We suggest priority be given to transfer of assets to patients, particularly when transfer of patients to defi nitive care is limited by dangerous conditions (including considerable risk posed by available transportation options). Transportation used for patient evacuations may also be used to bring in assets (eg, specialty providers and equipment), particularly when access/transport capacity is the limiting factor in patient movement. Form Hospital and Transport Agreements 1a. We suggest local and regional mutual-aid agreements should be established with other appropriately staff ed and resourced hospitals to redistribute critically ill and injured patients from an evacuating hospital(s), and these agreements should be integrated within the framework of disaster preparedness plans. 1b. We suggest creation of predisaster formal agreements between hospitals and transport agencies or between Health Coalitions or Regional Health Authorities and transport agencies for air or ground transport of critically ill patients during a disaster. Prepare for and Simulate Critical Care Evacuation 2a. We suggest staffi ng requirements within disaster plans should take into account the staffi ng resources necessary for desired surge capability to both safely move patients and to provide continuous care for patients remaining in the ICU. 2b. We suggest developing a detailed vertical evacuation plan using stairs when applicable for critically ill and injured patients. 2c. We suggest hospital exercises should simulate a mass critical care event and include vertical evacuation when applicable that evaluates (1) patient movement using specialized evacuation equipment and (2) the ability to maintain eff ective respiratory and hemodynamic support while moving down stairs. Prepare for and Simulate Critical Care Transport 3a. We suggest specialized care is resource intensive, and specialized ground and aeromedical teams may be required to ensure appropriate initial and ongoing care prior to and during evacuation. 3b. We suggest preidentifying unique transport resources that are required for movement of specifi c populations, such as critically ill neonates, children, and technology-dependent patients, at a regional level. Th is information can then be used in real time to match allocated resources to patients. 3c. We suggest conducting detailed and realistic exercises that require ICU evacuation with local and regional ground and air transport agencies. 4d. We suggest CCTLs and staff should receive special training, education, and practice on patient categorization and transport requirements. 4e. Expert providers from evacuation teams and outside facilities, when possible through face-to-face communication on site, can help ensure appropriate transport planning and distribution based on available resources during transport and in receiving facilities. 5a. If pre-event hospital evacuation of critically ill patients might be required, then we suggest planning for patient evacuation or shelter in place using an Incident Command System should begin as early as possible. Possible strategies include shelter in place, partial evacuation, or early evacuation, depending on the circumstances. 5b. We suggest Hospital Incident Command during a threatened hospital evacuation should have a clear and direct mechanism for communication with local governing bodies that control the timing and issuance of regional evacuation orders. To prevent obstruction of ground medical transport during hospital evacuation, coordination with local government regarding timing of recommendations for evacuation of the general population may be required. Effi cient ground medical transport of patients during a hospital evacuation may be facilitated by providing a time period for hospital evacuation prior to recommendations for evacuation of the general population. Requesting Assistance for Evacuation 6a. We suggest during a disaster or pandemic that overwhelms local and regional resources and requires large-scale hospital evacuations assistance, from national and/or international government medical support and evacuation agencies should be requested. 6b. We suggest the CCTL should be aware of the process for requesting evacuation assistance and the resources available at a regional and national level. 7a. We suggest surge ventilators with fl exible electrical power and oxygen requirements should be available to support patients with respiratory failure that can maintain function while either (1) sheltering in place or (2) evacuating to an outside facility. Th ese ventilators should be portable, run on alternating current power with battery backup, and have the ability to run on low-flow oxygen without a highpressure gas source. Surge ventilators may be of limited capability but should be able to ventilate and oxygenate patients with acute lung injury or ARDS as well as airfl ow obstruction. This requires capability to deliver a high minute ventilation, high fl ow, and high posi tive end-expiratory pressure. Th ey should be safe (disconnect alarm) and relatively easy for staff to operate. 7b. We suggest availability of adequate portable energy and medical gas fl exible ventilators that can provide accurate small tidal volumes or pressure limits for the premature and neonatal patients expected at designated hospitals (for instance pediatric centers or hospitals with a neonatal ICU). Special consideration should be given to creating a standard, quickly accessible regional stockpile of mechanical ventilators for evacuation of neonatal patients as it may not be feasible for some nonpediatric centers to have adequate numbers of portable energy and gas fl exible neonatal ventilators. 9b. We suggest during multiple-facility, large, or late ICU evacuations, the usual provider-to-provider system of communication for identifi cation of receiving facilities should be augmented by other Regional or National Incident Management Systems. 9b.i. Every hospital should be specifi cally affi liated with (and drill evacuation with) a Regional or National Command Center for such events. Regional or National Command Centers may need to assume responsibility for designation of the receiving facilities for their patients. 9b.ii. We suggest when a Regional or National Emergency Command Center assumes responsibility for patient distribution, they should be responsible for identifying receiving facilities that match ICU patient resource requirements. 9b.iii. We suggest the Regional or National Emergency Command Center should enlist assistance of regional specialist experts to assist in the above matching process for distribution of patients requiring highly specialized care among receiving centers. 9c. We suggest assignment of transportation resources and lines of critical care patient evacuation should follow common existing referral patterns provided receiving facilities retain adequate capacity to care for these patients. 9d. We suggest patients who require advanced specialty care should be directed to high-volume centers and distribution take into account the capacity and resources required to provide ongoing care to these patients. 10a. We suggest standardized preparation of critically ill patients should be performed prior to hospitalto-hospital transfer, including initial stabilization, diagnostic procedures, damage control procedures, and medical interventions, to address anticipated physiologic changes during transport. 10b. We suggest the transport team should provide the equipment used for transport to ensure compatibility and familiarity during transport and retain important resources at the source institution for ongoing care of the remaining patients. 10c. We suggest evacuation planning and coordination should include the provision of additional expert providers, staff, and equipment to assist in the ongoing provision of care in situations where patient volume, acuity, or nature of illness or injury exceeds the capabilities of the CCTL and staff. 10d. We suggest utilizing a staging area for patients prepared and awaiting transport. Th is area should ideally be located near the point of embarkation and be staff ed by medical personnel with training and experience in critical care evacuation. Th ese personnel should be prepared to provide triage and perform ongoing medical care interventions prior to transport. Th e area should have the capability for additional surgical and medical stabilization pretransport if necessary. 11a. We suggest electronic transfer of patient information to the receiving hospital is optimal because a complete medical record can be included. Electronic transfer may be through an intranet or by copying patient information onto a USB flash memory drive or compact disk and transferring the information with the patient (see the "Business and Continuity of Operations" article in this consensus statement). 11b. We suggest a paper medical record be required to travel with the patient because there may be no ability to send an electronic copy of the medical record, or the receiving facility may not be able to read the electronic format of the medical record. A backup paper system may require (a) a printed copy of the electronic medical record or (b) a handwritten patient identifi cation on a standardized patient tracking form. Any paper system should include basic patient identifi cation, problem lists, and medications on forms that travel with the patient. Transporting Critical Care Patients to Receiving Hospitals 12a. We suggest transportation methods should prioritize moving the greatest number of patients as rapidly and safely as possible to locations with adequate capacity and expertise where defi nitive care can be provided. 12b. We suggest local evacuation of highest acuity patients to hospitals with additional capacity by ground or rotary transport may be most appropriate to minimize risk and reduce ongoing critical care demands at the incident facility. 12c. We suggest alteration in the usual standards for modes of transport may be required during a disaster where transport resources are overwhelmed and evacuation and transport of critically ill patients to a receiving hospital ICU is required. 13c. We suggest tracking systems may be electronic or paper. In the event of complete power failure, however, a redundant paper system for tracking of patients and equipment should be performed by both sending and receiving hospitals, with communications provided to the sending hospital and/or a centralized coordinating center to confi rm receipt of the patients. 13d. We suggest evacuation drills should test tracking of patients and equipment both by electronic and paper systems. 1. In the event of an incident with mass critical care casualties, we suggest all hospitals within a defi ned geographic/administrative region (eg, state), health authority, or health-care coalition should implement a uniform triage process and cooperate when critical care resources become scarce. We suggest critical care only be rationed when resources have, or will shortly be, overwhelmed despite all eff orts at augmentation and a regional-level authority that holds the legal authority and adequate situational awareness has declared an emergency and activated its mass critical care plan. 3. We suggest health-care systems provide oversight for any triage decisions made under their authority via activation of a mass critical care plan to ensure they comply with the prescribed process and include appropriate documentation. We suggest health-care systems that have instituted a triage policy have a central process to update the triage protocol/system so that information that becomes available during an event informs the process in order to promote the most eff ective allocation of resources. We suggest health-care systems establish in advance, a formal legal and systematic structure for triage in order to facilitate eff ective implementation of triage in the event of an overwhelming disaster. incremental survival rather than on a fi rst-come, fi rst-served basis when a substantial incremental survival diff erence favors the allocation of resources to another patient. 7a. We suggest health-care systems that have instituted a triage policy have clinicians with critical care triage training function as triage offi cers (tertiary triage) to provide optimum allocation of resources. 7b. We suggest triage offi cers should have situational awareness at both a regional level and institutional level. 7c. We suggest in trauma or burn disasters, triage be carried out by triage offi cers who are senior surgeons/ physicians with experience in trauma, burns, or critical care and experience in care of the age-group of the patient being triaged. 7d. We suggest in environments where triage is not usual, individual triage offi cers or teams consisting of a senior intensive care physician and an acute care physician be designated to make mass critical care triage decisions in accordance with previously prepared, publicly vetted, and widely disseminated guidelines. 7e. We suggest in limited resource settings in which there is a limited need for expansion of critical care resources, a continuation of well-established systems is appropriate. 8. We suggest triage protocols (clinical decision support systems), rather than clinical judgment alone, be used in triage whenever possible. 9. We suggest in health-care systems that have instituted a triage policy, technology such as baseline ultrasound, oxygen saturation as measured by pulse oximetry, mobile phone/Internet, and telemedicine be leveraged in triage where appropriate and available to augment clinical assessment in an eff ort to improve incremental survival and effi ciency of resource allocation. 10. We suggest triage decision processes, whenever possible, provide for an appeals mechanism in case of deviation from an approved process (which may be a prospective or retrospective review) or a clinician request for reevaluation in light of novel or updated clinical information (prospective). 11a. We suggest tertiary-care triage protocols for use during a disaster that overwhelms or threatens to overwhelm resources be developed with inclusion and exclusion criteria. Defi ning Special Populations for Mass Critical Care 1. We suggest the defi nition of special populations for mass critical care be those patients that may be at increased risk for morbidity and mortality outside a fully functional critical care environment or those patients that present unique challenges to providers when a full complement of supportive services is not available. We include the chronically ill and technologically dependent as the fragility of their baseline health puts them at signifi cant risk for progression to a higher level of medical need. Special Population Planning 2. We suggest critical care disaster planning include special populations. 3. We suggest professional societies, advocacy groups, governmental, and nongovernmental organizations be consulted when planning special population disaster preparedness and just-in-time care. 4. We suggest daily needs assessment of shelters include identifi cation of those residents from special populations susceptible to decompensation to critical illness. A system to refer those identifi ed to appropriate medical care should be in place. We suggest disaster preparedness for special populations be part of their primary health-care maintenance. Th ese patients should also be identifi ed pre-event by their community (ie, nursing home facilities, health-care services, and social services providers) as an at-risk group for decompensation during a disaster and measures be taken to ensure they have a continuum of care during the event. Planning for Access to Regionalized Services for Special Populations 6. We suggest identifi cation of regionalized centers and establishment of communication be included in mass critical care planning. 7. We suggest regional specialized centers have mass disaster plans in place that include easily accessible, multidimensional, round-the-clock expertise available for consultation by local providers during mass critical care events. 8. Some special populations of mass critical care may require early transfer to specialized centers to maximize outcomes so should be identifi ed early. Therapeutic Considerations 10a. We suggest local, regional, and national critical care pharmacists and resources be identifi ed during disaster preparedness. 10b. We suggest access to critical care or specialist pharmacist and resources include consideration for special populations such as those with burns, cirrhosis, organ transplant, and need for dialysis. 10c. We suggest pharmacists, especially those with critical care and specialty training, be an integral part of any mass critical care disaster team. 12. We suggest experts in the care of technology-and resource-dependent special populations convene to discuss and determine the acceptable parameters for crisis standards of care for a disaster. National Government Support of Health-care Coalitions/Regional Health Authorities-Policy 1a. We suggest political leadership at national levels should support health-care preparedness through fi nancial assistance, support of market driven incentives, and preparedness requirements to health-care coalitions/regional health authorities (HC/RHAs). 1b. We suggest national governments should support the development of responsive and nimble disaster/pandemic research processes that can both organize and assess information from prior disasters/pandemics, acquire real-time data in an ongoing one to provide situational awareness, and which can also learn from and support international disaster relief eff orts. 1c. We suggest national, state/province/regional, and city/district governments should: greater health-care community to develop and refi ne specifi c "trigger" criteria for formal legal activation and step down termination procedures and processes of disaster/pandemic plans and standards of care. 1d. We suggest local governments and government agencies should be formal partners in their local health-care coalition(s), and be actively engaged with their ongoing preparedness and response activities. Models of Advanced Regional Care Systems 7. Advanced Regional Care Systems instituted within large hospitals, and across hospitals, health systems and HC/RHAs, will have the greatest chance for success if they are established with the following goals: • Support the creation of computer models utilizing industry templates in collaboration with their own administrative, clinical, and technical resource experts from participating system partners. Models should include government and military resources when applicable, and include provision of maintenance of chronically ill patient populations. • Collaborate with modelers in the design, implementation, and testing of these models; and with the interpretation and application of these results. • Support the data requirements for such system models, and develop repositories for operationally relevant data that can be used in future modeling eff orts. • Leverage their relationships with national, regional, and local governments and public health agencies and emergency medical service providers to obtain necessary data on the transportation and patient logistic components of such models as required. Supply Chain Vulnerabilities in Mass Critical Care 1. We suggest highest priority critical care supplies and medications needed for routine day-to-day care, and crucial in mass casualty events, for which no substitutions are available be identifi ed (eg, ventilator circuits, N95 masks, insulin, etc). Once identifi ed, dual sourcing should be used for routine purchasing of these key supplies and medications to reduce the impact of a supply chain disruption. 3. We suggest health-care systems use integrated electronic systems to track purchase, storage, and use of medical supplies. We suggest these systems be used to identify equipment, supplies, and medications that are in short supply and for which increased routine inventory levels would be needed to adequately address both day-to-day and mass casualty event planning. We suggest modifi ed use protocols, which restrict routine use of aff ected medications and supplies and encourage use of alternatives, be implemented at the earliest opportunity when impending medication and medical supply shortages are identifi ed, and for which adequate resupply may not be available in a timely manner. 6. We suggest health-care facilities, health systems, and health-care coalitions encourage, comply with, and support ongoing governmental and non-governmental organizational eff orts to reduce global medical supply chain vulnerabilities. Portable Mobile Support Information Networks: 7. We suggest hospitals have the mobile technology necessary to identify patients quickly and eff ectively, including in austere parts of the hospital (eg, parking lots). 8. We suggest hospitals have the ability to set up ad-hoc secure networks in austere sections of the hospital campuses for mobile technology. 9. We suggest hospitals have a strategy for supplying austere sites with electric power to charge the mobile devices, provide local network facilities, and provide essential services for an extended period of time. 10. We suggest hospitals be capable of transferring patient identifi cation, identifi cation of next of kin with contact information, and a defi ned minimal database of medical history with every patient. Th is minimal database of medical history should be able to be printed, or hand written if necessary, in the absence of computer technology. . We suggest hospitals have the ability to effectively and quickly download all patient-related information into a mobile package (eg, a flash drive or disk) that can be easily read by other information systems, and can be rapidly prepared for transport with the patient. Th is should obey the clinical document architecture/continuity of care document documents currently specifi ed under meaningful use proposals, making them both human and digitally readable. 13. We suggest hospitals have the necessary information technology (IT) functionality to store health information when hospital systems are not available, and be able to rapidly upload and download clinical information once connections are reestablished. 14. We suggest hospitals have the means to ensure confi dentiality of all patient protected information. 15. We suggest patient information may be uploaded and stored in central, off site databases, similar to that used by the Veterans Administration system in the United States, and consistent with local health-care laws and regulation pertaining to patient privacy and protections. Hospitals and Health-Care IT Preparedness Planning 16. We suggest hospitals have a plan for rapid movement of the data center to off site remote operations in the case of prolonged local power disruption for critical functions. 17. We suggest a plan be in place to provide power to the client machines, analyzers, networking equipment, etc along with the data center for an extended period of time. Engagement and Education 1. We suggest integrated communication systems and a robust infrastructure of the electronic health record system to facilitate tracking the number of people aff ected by a mass event, including the types and severity of injuries and detection of secondary illnesses. Such technologies need to be established and used prior to mass critical care delivery in order to provide familiarity to the users. 4. We suggest public health/government offi cials at centralized or regional emergency management coordinating centers use expert medical guidance, such as burn, neuro, or trauma critical care, specifi c to the nature of the incident to inform decision-making for mass critical care delivery. We suggest every ICU clinician participate in disaster response training and education. 6. We suggest expectations regarding clinician response to disasters or pandemics be delineated in contractual agreements, medical staff bylaws, or other formal documents that govern the array of responsibilities to the health-care system. 7. We suggest hospitals employ and/or train ICU physicians in disaster preparedness and response. 8. We suggest hospitals ensure appropriate ICU leadership with knowledge and expertise in the management of surge capacity, disaster response, and ICU evacuation. 9. We suggest critical care leaders be invited to participate in health-care coalitions so they can facilitate sharing expertise, resources, and knowledge between ICUs in the event of a regional disaster. 10. We suggest incorporation of disaster medicine into critical care training curricula will facilitate future ICU clinician training and engagement in disaster preparedness and response activities. 11. We suggest expert opinions be considered in mass critical care education curricula. We suggest an independent panel of multidisciplinary specialty society experts determine the core competencies for mass critical care education curriculum. 13. We suggest translating competencies into multidisciplinary learning modules become a core focus of academic, professional organizations, governmental, and nongovernmental organizations whose students and responsible agencies may be called upon to provide mass critical care. 14. We suggest standing committees in education, or a reasonable equivalent in relevant stakeholder groups, review and endorse the curriculum and competencies. vidual, organizational, community) , realistic, and challenging training opportunities. 16 . We suggest stakeholder organizations determine the thresholds and milestones for trainer education and certifi cation. critical care medicine be tested on the core competencies (when developed) by their certifi cation process. 18. We suggest those involved with critical care disaster education develop ongoing, internal process improvement methodologies and metrics to ensure their programs remain current, responsive, and relevant. 19. We suggest accreditation bodies that ensure safe and eff ective critical care delivery processes for hospitals consult with professional societies to develop metrics and tools of assessment to ensure ICUs can continue to provide quality care during a disaster or pandemic. 20. We suggest engagement of critical care clinicians in disaster preparedness eff orts occur in advance of and in preparation for pandemics and disasters in order to enhance mass critical care delivery and coordination. 1a. We suggest health agencies at all levels of government (ie, Local, Regional, State/Province, and National) and relevant health-care system entities (eg, hospitals, long-term care facilities, and clinics) develop mass critical care (MCC) response plans in furtherance of a legal duty to prepare for mass critical care emergencies. Th ese plans should be integrated into or with existing crisis standards of care, surge capacity, or other applicable health emergency plans and frameworks. Th e regional health authority (eg, in the US, state health departments) should facilitate and ensure the development of mass critical care plans at the sub-national and health-care facility levels to promote inter-jurisdictional consistency and collaboration within the state/province, across state/province lines, and with national partners. 1b. We suggest MCC plans clarify approaches and processes for evacuating patients and for shelteringin-place. Th is includes identifying the lines of authority for evacuation and shelter-in-place decision-making and the potential legal and ethical implications associated with such decisions. 1c. We suggest MCC plans recognize the importance of responsible and accountable MCC decision making among clinicians, government, and individual health-care entities by addressing how reviews of decisions made under the auspices of MCC plans will occur. Further, we suggest separate, effi cient processes be developed to: (1) during the response, address fact-based appeals by ICU providers of decisions made during the response before resources are reallocated; and (2) following the response, review patient/family member or ICU provider concerns about fi delity to the processes outlined in properly-vetted and adopted MCC plans. 4. We suggest governments develop approaches to formally and temporarily expand the available pool of qualifi ed practitioners to address MCC staffi ng shortages and to ensure that all responding practitioners receive appropriate liability protections during a MCC response. Further, we suggest this could occur through implementing effi cient processes for licensing, credentialing, and certifying in-country practitioners who are not normally authorized to practice in the impacted area to facilitate the emergency response; temporarily expanding professional scopes of practice for applicable types of health-care practitioners; and, if appropriate, accepting and using offi cial, formally vetted foreign medical teams. Triage and Allocation 1. We suggest resources not be held in reserve once a mass disaster protocol is in eff ect. 3. We suggest triage systems based even on limited evidence are ethically preferable to those based on clinical judgment alone. We suggest critical care resources be allocated based on specifi c triage criteria, irrespective of whether the need for resources is related to the current disaster/pandemic or an unrelated critical illness or injury. We suggest it may be ethically permissible to use exclusion criteria for critical care resources, since the advantages of objectivity, equity, and transparency generally outweigh potential disadvantages. We suggest developing countries strive to build capacity by leveraging critical care expertise and resources that exist in such disciplines as surgery, obstetrics, internal medicine, and pediatrics. 6 . In order to support those countries with limited critical care assets, we suggest professional critical care societies in resource-rich, developed countries should advocate broadly to mitigate the intellectual siphoning of critical care providers from resource poor countries. 7. We suggest investment in critical care education and development of processes where limited resources can be applied to those patients most likely to benefi t from the interventions. 7a. We suggest such processes explore innovative staffi ng methods and preventative and supportive care that decreases critical illness. Building Capacity and Quality in District Hospitals: 8. We suggest performance improvement activities be instituted at district or regional level facilities and information shared such that other ICUs and hospitals can learn from one another. We suggest, where feasible, that surgical capacity of the district or regional hospital build capacity to optimize surgical volumes and maintain skills in order to reduce preventable morbidity and mortality. Prehospital Care and Transport: 11. We suggest education and training of resuscitation, evacuation, and transport of the critically ill be a priority for providers. 11a. We suggest expanding pre-hospital support in the community through education of medical and non-medical laypersons. Strategic Planning to Build Capacity: 12. We suggest developing countries or settings that are chronically resource constrained develop a minimal level of critical care to be provided at district or regional hospital facilities. 12a. We suggest critical care advocates involve administrators, fi nanciers, nongovernmental organizations (NGOs), and other similar stakeholders to provide resources to expand capacity to meet such minimal levels. 13. We suggest focusing limited emergency and critical care resources at facilities where the greatest benefi t can be achieved. Although basic resuscitation capabilities must exist at all levels, rather than developing rudimentary critical care at primary health clinics, district or regional hospitals may be the most eff ective and effi cient areas of focus to improve national critical care capabilities. External Alliances: 14. We suggest local authorities establish formal relationships with coalitions of academic medical centers, professional societies, NGO's, and governmental organizations prior to an actual event in disaster-prone, resource poor regions. We suggest these partnerships have the following objectives: Research Considerations 9. We suggest research focus on health monitoring/ syndromic surveillance, needs assessment, prognostication, and cost eff ectiveness to help establish care priorities. 10. We suggest cost-eff ectiveness studies on critical care in developing countries to justify the need and ability to advocate for resources to provide basic critical care. Quality Improvement Factors 11. We suggest developing countries and health-care organizations institute quality improvement programs, in part to justify to donors, population, and government that increases in investment in health systems provide cost eff ective benefi ts. 12. We suggest professional critical care societies advise and support research that brings new technologies and diagnostic tools to resource-poor settings and stress adapting diagnostic and treatment modalities to this environment in a cost eff ective and effi cient manner. 13. We suggest professional critical care societies advise and guide the development of disaster related protocols to study pressing issues relating to diagnosis, treatment, and systems improvement and have these vetted through ethics committees and other groups a priori in order to rapidly deploy them during or following an event. Despite increasing numbers of publications in disaster medicine and MCC during the past 5 years, high-quality research to support evidence-based recommendations for the care of critically ill and injured patients related to a pandemic or disaster is virtually nonexistent and desperately needed. Indeed, this research should be a moral imperative in both resource-rich and resourcepoor areas of the world. In the developed world, research should be directed at the provision of critical care during MCC; in resource-poor areas research on building capacity in the current system and on ways to decrease the need for intensive care would be of greater benefi t. Granted, signifi cant challenges exist with regard to conducting research in these settings, 30 but these challenges can be overcome by "disruptive creativity" and planning. Conducting research during disasters or pandemics requires novel approaches to address the unique logistic and ethical and methodology challenges of operating and collaborating in these environments. Research questions that currently need to be addressed are discussed in detail within each of the individual articles within this supplement. In the absence of scientifi c evidence, experts' opinion, although less than ideal, will have to suffi ce. Clearly, much research needs to be done to enrich the tacit knowledge of experts. Unfortunately, the potential need to provide care for critically ill or injured patients resulting from pandemics or disasters has not decreased. Lacking high-quality evidence to guide recommendations, the Task Force has endeavored to bolster the expertise of the Task Force and increase the rigor of the process through which the current expert-opinion-based suggestions were developed. In addition to updating the suggestions, this version of the Task Forces' suggestions addresses the broader issue of caring for the critically ill and injured from pandemics and disasters beyond the walls of the ICU, across the age continuum, and those from special populations who are particularly vulnerable to being negatively impacted and who require specialized critical care. Moreover, the Task Force provides suggestions regarding the evacuation of the critically ill and injured as well as the legal, ethical, and systems frameworks necessary to support an eff ective response. Finally, the Task Force has attempted to illustrate how the concepts of MCC should be integrated into the spectrum of surge response from contingency care through crisis care. Defi nitive care for the critically ill during a disaster: current capabilities and limitations: from a Task Force for Mass Critical Care summit meeting Refi ning surge capacity: conventional, contingency, and crisis capacity European Society of Intensive Care Medicine's Task Force for intensive care unit triage during an infl uenza epidemic or mass disaster . Chapter 2. Surge capacity and infrastructure considerations for mass critical care. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an infl uenza epidemic or mass disaster Health care facility and community strategies for patient care surge capacity Summary of suggestions from the Task Force for Mass Critical Care summit Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report Task Force for Mass Critical Care . Defi nitive 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 . Defi nitive 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 . Defi nitive 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 Survey about responsiveness of third-level hospitals to a medical disaster: aft er the pandemic infl uenza in Mexico H1N1 infl uenza: critical care aspects Hospital Civil de Guadalajara, Fray Antonio Alcalde Emerging Respiratory Infections Response Team . Hospital triage system for adult patients using an infl uenza-like illness scoring system during the 2009 pandemic-Mexico Preparing your intensive care unit for the second wave of H1N1 and future surges Planning for a pandemic: a view from the accident and emergency department Preparing for the sickest patients with 2009 infl uenza A(H1N1) Raff o L Infl uenza A(H1N1) epidemic in Argentina. Experience in a National General Hospital (Hospital Nacional Profesor Alejandro Posadas) Death toll climbs and healthcare needs escalate in Japan Boston's fi rst-in-class fi rst response Th e Boston Marathon response: why did it work so well? Emergency preparedness and public health: the lessons of Hurricane Sandy Hurricane Sandy and the greater New York health care system Clinical fi ndings in 111 cases of infl uenza A (H7N9) virus infection Hospital outbreak of Middle East respiratory syndrome coronavirus Chemical weapons. U.N. taps special labs to investigate Syrian attack Lack of atropine in Syria hampers treatment aft er gas attacks As Syria crisis mounts, scientist looks back at last major chemical attack Christian MD ; on behalf of the Task Force for Mass Critical Care . Methodology: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement Medical and Health Incident Management (MaHIM) System: A Comprehensive Functional System Description for Mass Casualty Medical and Health Incident Management Medical Surge Capacity and Capability: A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies Clinical research ethics for critically ill patients: a pandemic proposal InFACT: a global critical care research response to H1N1 Critical care resource allocation: trying to PREEDICCT outcomes without a crystal ball Financial/nonfi nancial disclosures: Th e authors have reported to CHEST the following confl icts: Dr Rubinson received grant money for two unrelated National Institutes of Health sponsored studies and makes public statements related to the subject of this manuscript. Th e remaining authors have reported that no potential confl icts of interest exist with any companies/organizations whose products or services may be discussed in this article . Current Resource Allocation During Crises: 15 . We suggest critical care providers use protocols to combine workable approaches that are also cost eff ective and effi cient. 16 . We suggest feasibility plans of a protracted event requiring long-term use of critical care resources be developed, whereby the health-care system will require a coordination between less resource-intense but large numbers of primary care patients in concert with resource-intense but fewer critical care patients. Resource-Poor Settings: Response, Recovery, and Research Response 1. We suggest developing countries or health-care systems employ an appropriate incident command system to organize the pre-hospital, transportation and in-hospital response eff ort.2. We suggest early in the response eff ort that attempts be made to estimate the needs beyond acute care and to inform and guide providers of rehabilitation and prolonged care needs.3. We suggest host nation rehabilitation and prolonged care capabilities that are likely to exist following the disaster be considered when determining the appropriateness of initiating critical intensive care. We suggest only critical care providers with previous training or expertise in disaster response, or those who are aligned with experienced groups (eg, foreign medical teams), and invited by the host nation deploy to support a disaster. We suggest if not available at the time of a disaster, critical care be instituted using an intensive care