Evacuation of the ICU: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

Abstract

Background: Despite the high risk for patient harm during unanticipated ICU evacuations, critical care providers receive little to no training on how to perform safe and effective ICU evacuations. We reviewed the pertinent published literature and offer suggestions for the critical care provider regarding ICU evacuation. The suggestions in this article are important for all who are involved in pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

Methods: The Evacuation and Mobilization topic panel used the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop seven key questions for which specific 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 using a modified Delphi process.

Results: Based on current best evidence, we provide 13 suggestions outlining a systematic approach to prepare for and execute an effective ICU evacuation during a disaster. Interhospital and intrahospital collaboration and functional ICU communication are critical for success. Pre-event planning and preparation are required for a no-notice evacuation. A Critical Care Team Leader must be designated within the Hospital Incident Command System. A three-stage ICU Evacuation Timeline, including (1) no immediate threat, (2) evacuation threat, and (3) evacuation implementation, should be used. Detailed suggestions on ICU evacuation, including regional planning, evacuation drills, patient transport preparation and equipment, patient prioritization and distribution for evacuation, patient information and tracking, and federal and international evacuation assistance systems, are also provided.

Conclusions: Successful ICU evacuation during a disaster requires active preparation, participation, communication, and leadership by critical care providers. Critical care providers have a professional obligation to become better educated, prepared, and engaged with the processes of ICU evacuation to provide a safe continuum of critical care during a disaster.

Figure 1 –

ICU Evacuation Timeline. We recommend this timeline as a general approach for ICU evacuation preparation and performance. The suggestions included in this article correspond by number to these steps. Similar to the three tiers for Crisis Standards of Care (conventional, contingency, and crisis), ICU evacuation comprises three stages: (1) no immediate threat, (2) ICU evacuation threat, and (3) ICU evacuation. Note that the ICU Evacuation Timeline is a continuum, with overlap between stages because many of the later-stage steps are actually initiated at an earlier stage (eg, preparation of patient information).

Figure 2 –

Example of a Critical Care Patient Categorization Checklist. We suggest that every ICU routinely categorize every ICU patient by (1) ICU resource requirement, (2) transport skill requirement, and (3) transport type. Ideally, this ICU patient categorization would occur at least daily during routine care and be entered into an electronic checklist, such as a whiteboard or portable computer device (with a backup paper checklist). During a threatened or actual ICU evacuation, every ICU would categorize its patients more frequently, even hourly. Categorization should be performed by each unit leader most aware of patient details (ie, ICU attending physician or ICU charge registered nurse) and then relayed directly to and verified by the Critical Care Team Leader. Additionally, there should be a mechanism for electronically collating these data so that both the Critical Care Team Leader and the Incident Command can have real-time ICU situational awareness. ALS = advanced life support; BIPAP = bilevel pressure ventilation; BLS = basic life support; CRRT = continuous renal replacement therapy; ECMO = extracorporeal membrane oxygenation; EVD = external ventricular drain; LVAD = left ventricular assist device; PEEP = positive end-expiratory pressure.