Chapter 7. Critical care triage. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster

Abstract

Purpose: To provide recommendations and standard operating procedures for intensive care unit (ICU) and hospital preparations for an influenza pandemic or mass disaster with a specific focus on critical care triage.

Methods: Based on a literature review and expert opinion, a Delphi process was used to define the essential topics including critical care triage.

Results: Key recommendations include: (1) establish an Incident Management System with Emergency Executive Control Groups at facility, local, regional/state or national levels to exercise authority and direction over resources; (2) developing fair and equitable policies may require restricting ICU services to patients most likely to benefit; (3) usual treatments and standards of practice may be impossible to deliver; (4) ICU care and treatments may have to be withheld from patients likely to die even with ICU care and withdrawn after a trial in patients who do not improve or deteriorate; (5) triage criteria should be objective, ethical, transparent, applied equitably and be publically disclosed; (6) trigger triage protocols for pandemic influenza only when critical care resources across a broad geographic area are or will be overwhelmed despite all reasonable efforts to extend resources or obtain additional resources; (7) triage of patients for ICU should be based on those who are likely to benefit most or a 'first come, first served' basis; (8) a triage officer should apply inclusion and exclusion criteria to determine patient qualification for ICU admission.

Conclusions: Judicious planning and adoption of protocols for critical care triage are necessary to optimize outcomes during a pandemic.

Fig. 1

The incident management system (IMS) structure. Dashed lines indicate the continuity of the lines of authority for triage from the CTC down through the IMS levels. Two-way communication should flow through this chain. This is not meant to indicate lines of command and control. The dash-dotted line indicates the direct data inputs that will flow between (bidirectional) the local triage officer and the CTC