PATIENT CARE Strategies for Scarce Resource Situations - Idaho Coronavirus
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PATIENT CARE Strategies for Scarce Resource Situations
STRATEGIES FOR SCARCE RESOURCE SITUATIONS CRISIS STANDARDS
OF CARE
TABLE OF CONTENTS
Ethical Framework........................................................................................................................... Page ii
Summary Card................................................................................................................................. Page iii
Oxygen............................................................................................................................................. Page 1
Personal Protective Equipment (PPE)............................................................................................ Page 2
Mechanical Ventilation................................................................................................................... Page 3
Critical Care Resources for Adults.................................................................................................. Page 4
Staffing............................................................................................................................................. Page 10
Medication Administration............................................................................................................ Page 12
Renal Replacement Therapy........................................................................................................... Page 15
ECMO (Extra-corporeal membrane oxygenation)........................................................................ Page 19
Palliative Care.................................................................................................................................. Page 20
Emergency Medical Services (EMS)............................................................................................... Page 30
Pediatrics.......................................................................................................................................... Page 31
Critical Care Resources for Pediatric Patients............................................................................... Page 36
Long-Term Care Facilities................................................................................................................ Page 38
Blood Products................................................................................................................................ Page 43
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street i
https://healthandwelfare.idaho.gov Boise ID 83702ETHICAL FRAMEWORK CRISIS STANDARDS
OF CARE
This document provides guidance for preparing and responding to public health emergencies that may stress
and potentially overwhelm the healthcare system. The goal of providing care quickly and efficiently must be
guided by fairness, equality, and compassion. As such, the document is grounded in ethical obligations that
include the duty to care, duty to steward resources, distributive and procedural justice, and transparency. Its
guiding principle is that all lives have value and that no patients will be discriminated against on the basis of
disability, race, color, national origin, age, sex, gender, or exercise of conscience and religion.
Although most of this document focuses on expanding capacity in response to a public health emergency,
parts do provide guidance for scarce resource allocation in the event that demand for healthcare resources
outstrips supply. Scarce resource allocation protocols should only be enacted if: 1) healthcare capacity is,
or shortly will be, overwhelmed despite taking all appropriate steps to increase surge capacity; and 2) an
emergency declaration that crisis standards of care are in effect has been issued by the appropriate state
official. The scarce resource allocation protocols aim to maximize benefit for populations of patients. The
focus is on saving the most lives, within the context of ensuring equitable healthcare access for all patients,
ensuring individualized patient assessments, and diminishing the negative effects of social inequalities that
lessen some patients’ long-term life expectancy. Importantly, persons with disabilities should not be denied
access to healthcare resources based on stereotypes, assessments of quality of life, or judgments about
a person’s relative “worth” based on the presence or absence of disabilities. When applying these scarce
resource allocation protocols, decisions regarding candidacy for treatment should be based on individualized
assessments using the best available objective medical evidence. In all phases of evaluation and treatment,
communication assistance should be provided to all patients and families/designees who request such
assistance.
The contents of this guide were adapted and/or modified by the Idaho Department of Health and Welfare
(IDHW) and the State of Idaho’s Disaster Medical Advisory Committee (SIDMAC) from the Minnesota
Department of Health’s (MDH) Health Care Preparedness Program Patient Care Strategies for Scarce Resource
Situations, the University of Pittsburgh School of Medicine’s Allocation of Scarce Critical Care Resources During
a Public Health Emergency, the North Carolina Protocol for Allocating Scarce Inpatient Critical Care Resources
in a Pandemic, and published crisis standards of care from the state of New York and the Veterans Health
Administration.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street ii
https://healthandwelfare.idaho.gov Boise ID 83702PATIENT CARE CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
Summary Card
Potential trigger events: • Mass Casualty Incident (MCI) • Supplier shortage
• Infrastructure damage/loss • Recall/contamination of product
• Pandemic/Epidemic • Isolation of facility due to access problems (flooding, etc.)
How to use this card set:
1. Recognize or anticipate resource shortfalls.
2. Implement appropriate incident management system and plans; assign subject matter experts (technical specialists) to problem.
3. Determine degree of shortfall, expected demand, and duration; assess ability to obtain needed resources via local, regional, or national vendors or partners.
4. Find category of resource on index.
5. Refer to specific recommendations on card.
6. Decide which strategies to implement and/or develop additional strategies appropriate for the facility and situation.
7. Assure consistent regional approach by informing public health authorities and other facilities if crisis strategies will continue beyond 24h and no regional options exist for re-supply
or patient transfer; activate regional scarce resource coordination plans as appropriate.
8. Review strategies every operational period or as availability (supply/demand) changes.
Core strategies to be employed (generally in order of preference) during, or in anticipation of a scarce resource situation are:
Prepare - pre-event actions taken to minimize resource scarcity (e.g., stockpiling of medications).
Substitute - use an essentially equivalent device, drug, or personnel for one that would usually be available (e.g., morphine for fentanyl).
Adapt – use a device, drug, or personnel that are not equivalent but that will provide sufficient care (e.g., anesthesia machine for mechanical ventilation).
Conserve – use less of a resource by lowering dosage or changing utilization practices (e.g., minimizing use of oxygen driven nebulizers to conserve oxygen).
Re-use – re-use (after appropriate disinfection/sterilization) items that would normally be single-use items.
Re-allocate – restrict or prioritize use of resources to those patients with a better prognosis or greater need.
Capacity Definitions
Conventional capacity – The spaces, staff, and Contingency capacity – The spaces, staff, and supplies used are not consistent Crisis capacity – Adaptive spaces, staff, and
supplies used are consistent with daily practices with daily practices, but provide care to a standard that is functionally equivalent supplies are not consistent with usual standards of
within the institution. These spaces and practices to usual patient care practices. These spaces or practices may be used temporarily care, but provide sufficiency of care in the setting
are used during a major mass casualty incident during a major mass casualty incident or on a more sustained basis during a of a catastrophic disaster (i.e., provide the best
that triggers activation of the facility emergency disaster (when the demands of the incident exceed community resources). possible care to patients given the circumstances
operations plan. and resources available).
The content of this card set was developed by the Minnesota Department of Health (MDH) Science Advisory Team in conjunction with many subject matter experts, and adapted by Idaho’s
Department of Health & Welfare (IDHW) and the State of Idaho Disaster Medical Advisory Committee (SIDMAC). Facilities and personnel implementing these strategies in crisis situations
should assure communication of this to their healthcare and public health partners to assure the invocation of appropriate legal and regulatory protections in accord with State and Federal
laws. This guidance may be updated or changed during an incident by IDHW. The weblinks and resources listed are examples and may not be the best sources of information available. Their
listing does not imply endorsement by IDHW. This guidance does not replace the judgement of the clinical staff and consideration of other relevant variables and options during an event.
This card set is designed to facilitate a structured approach to resource shortfalls at a healthcare facility. It is a decision support tool and assumes that incident management is implemented
and that key personnel are familiar with ethical frameworks and processes that underlie these decisions (for more information see the Institute of Medicine’s 2012 Crisis Standards of Care:
A Systems Framework for Catastrophic Disaster Response). Each facility will have to determine the most appropriate steps to take to address specific shortages. Pre-event familiarization with the
contents of this card set is recommended to aid with event preparedness and anticipation of specific resource shortfalls. The cards do not provide comprehensive guidance, addressing only
basic common categories of medical care. Facility personnel may determine additional coping mechanisms for the specific situation in addition to those outlined on these cards.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street iii
https://healthandwelfare.idaho.gov Boise ID 83702OXYGEN CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS Strategy Conventional Contingency Crisis
Inhaled Medications Substitute
• Restrict the use of oxygen-driven nebulizers when inhalers or air-driven substitutes are available.
&
• Minimize frequency through medication substitution that results in fewer treatments (6h-12h instead of 4h-6h
Conserve
applications).
High-Flow Applications
• Restrict the use of high-flow cannula systems as these can demand flow rates in excess of 40 LPM.
• Limit the use of simple and partial rebreathing masks.
Conserve
• Restrict use of Gas Injection Nebulizers as they generally require oxygen flows between 10 LPM and 75 LPM.
• Eliminate the use of oxygen-powered venturi suction systems as they may consume 15 to 50 LPM.
• Consider use of early intubation to avoid high-flow oxygen rates.
Air-Oxygen Blenders
• Eliminate the low-flow reference bleed occurring with any low-flow metered oxygen blender use. This can amount to
an additional 12 LPM. Reserve air-oxygen blender use for mechanical ventilators using high-flow non-metered outlets. Conserve
(These do not utilize reference bleeds).
• Disconnect blenders when not in use.
Oxygen Concentrators if Electrical Power Is Present Substitute
• Use hospital-based or independent home medical equipment supplier oxygen concentrators if available to provide &
low-flow cannula oxygen for patients and preserve the primary oxygen supply for more critical applications. Conserve
Monitor Use and Revise Clinical Targets
• Employ oxygen titration protocols to optimize flow or % to match targets for SpO₂ or PaO₂.
• Minimize overall oxygen use by optimization of flow.
• Discontinue oxygen at earliest possible time.
Conserve
Starting Example Initiate O₂ O₂ Target Note: Targets may be adjusted further downward
Normal Lung Adults SpO₂PERSONAL PROTECTIVE EQUIPMENT (PPE) CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS
Guidance
• For the COVID-19 pandemic, please consult Optimizing Personal Protective Equipment (PPE) Supplies, which includes conventional, contingency, and crisis
strategies specific to eye protection, isolation gowns, facemasks, and N95 respirators.
Additional General Principles
• Healthcare providers must be protected and should never be required to use equipment that is not considered PPE.
• Healthcare providers should be allowed, but not required, to bring to work PPE for their personal use in the event of shortages of conventional PPE.
• Healthcare providers should not be penalized for expressing their views to anyone about the status and use of PPE.
• All elective procedures and surgeries should cease as soon as shortages of PPE are anticipated.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 2
https://healthandwelfare.idaho.gov Boise ID 83702MECHANICAL VENTILATION CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS Strategy Conventional Contingency Crisis
Increase Hospital Stocks of Ventilators and Ventilator Circuits, ECMO or Bypass Circuits Prepare
Access Alternative Sources for Ventilators/Specialized Equipment
• Obtain specialized equipment from vendors, health care partners, regional, state, or Federal stockpiles
Substitute
via usual emergency management processes and provide just-in-time training and quick reference
materials for obtained equipment.
Decrease Demand for Ventilators
• Increase threshold for intubation/ventilation.
• Decrease elective procedures that require post-operative intubation.
Conserve
• Decrease elective procedures that utilize anesthesia machines.
• Use non-invasive ventilatory support when possible.
• Attempt earlier weaning from ventilator.
Re-use Ventilator Circuits
• Appropriate cleaning must precede sterilization.
• If using gas (ethylene oxide) sterilization, allow full 12 hour aeration cycle to avoid accumulation of toxic Re-use
byproducts on surfaces.
• Use irradiation or other techniques as appropriate.
Use Alternative Respiratory Support Technologies
• Use transport ventilators with appropriate alarms - especially for stable patients without complex
ventilation requirements.
• Use anesthesia machines for mechanical ventilation as appropriate/capable.
Adapt
• Use bi-level (BiPAP) equipment to provide mechanical ventilation.
• Consider bag-valve ventilation as an emergent transitional measure while awaiting definitive solution/
equipment (as appropriate to situation – extremely labor intensive and may consume large amounts of
oxygen).
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 3
https://healthandwelfare.idaho.gov Boise ID 83702CRITICAL CARE RESOURCES FOR ADULTS CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
Ethical goal of the allocation framework
This document provides guidance for the triage of critical care resources in the event that a public health emergency creates demand that outstrips supply.
These triage recommendations should be enacted only if: 1) critical care resource capacity is, or shortly will be, overwhelmed despite taking all appropriate
steps to increase the surge capacity to care for patients requiring critical care resources; and 2) an emergency declaration that crisis standards of care are in
effect has been issued by the appropriate state official. The critical care resource allocation framework is grounded in ethical obligations that include the duty
to care, duty to steward resources, distributive and procedural justice, and transparency. Its guiding principle is that all lives have value and that no patients
will be discriminated against on the basis of disability, race, color, national origin, age, sex, gender, or exercise of conscience and religion.
The primary goal of the critical care resource allocation framework is to maximize benefit for populations of patients. The focus is on saving the most lives,
within the context of ensuring equitable healthcare access for all patients, ensuring individualized patient assessments, and diminishing the negative effects
of social inequalities that lessen some patients’ long-term life expectancy.
We recognize that predicting survival can be clinically difficult and that each patient is unique; the allocation framework therefore includes no categorical
exclusions and does not dictate the use of a specific severity of illness score in assessing a person for access to critical care resources. Importantly, persons
with disabilities should not be denied access to critical care resources based on stereotypes, assessments of quality of life, or judgments about a person’s
relative “worth” based on the presence or absence of disabilities. Decisions regarding candidacy for treatment should be based on individualized assessments
using the best available objective medical evidence.
The critical care resource allocation framework needs to be followed step by step and in order. It starts with triaging to non-critical care patients who do not
want critical care or who are unlikely to survive even with immediate and aggressive medical intervention. The next steps involve using a severity of acute
illness score and determination of other medical conditions that may impact survival to hospital discharge. The severity of acute illness score in combination
with the severity of underlying medical conditions that impact the likelihood of survival to hospital discharge, determine a patient’s Priority Score and Priority
Category for access to critical care resources. The framework includes guidance for resolving “ties,” if multiple patients in the same Priority Category need
access to the same critical care resource. The framework recommends the formation of a local Triage Team that is separate from the patient’s treatment team,
that can adjudicate access to critical care resources using this framework. Note that pediatric patients have their own critical care resource allocation protocol
for Steps 1-3 (see page 36), and then join this critical care resource allocation framework at Step 4 (page 8).
The Idaho Department of Health and Welfare (IDHW) and the State of Idaho’s Disaster Medical Advisory Committee (SIDMAC) adapted the University of
Pittsburgh School of Medicine’s Allocation of Scarce Critical Care Resources During a Public Health Emergency and North Carolina’s Protocol for Allocating
Scarce Inpatient Critical Care Resources in a Pandemic to create this critical care resource allocation guidance. IDHW and SIDMAC also used published crisis
standards of care from the state of New York, and from the Veterans Health Administration to inform the guidance.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 4
https://healthandwelfare.idaho.gov Boise ID 83702CRITICAL CARE RESOURCES FOR ADULTS CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS Strategy Crisis
STEP 1: Evaluate the patient’s clinical indication for scarce life-saving resources.*
Triage to Non-Critical Care
Advance directive requesting non-critical care interventions only.
Cardiac arrest for which survival is unlikely: unwitnessed arrest, recurrent arrest without hemodynamic stability, arrest
unresponsive to standard interventions and measures.
Re-Allocate
Severe trauma: traumatic brain injury with no motor response to painful stimulus (i.e. best motor response = 1 on
Glasgow Coma Scale), trauma-related arrest, or severe burn where predicted survival ≤ 10% even with unlimited
aggressive therapy.
Any other conditions resulting in immediate or near-immediate mortality even with aggressive therapy.
*For Step 1 for pediatric patients, see Critical Care Resources for Pediatric Patients on page 37.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 5
https://healthandwelfare.idaho.gov Boise ID 83702CRITICAL CARE RESOURCES FOR ADULTS CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS Strategy Crisis
STEP 2: Use a severity of acute illness score to determine the patient’s prognosis for hospital survival based on acute physiology. A
universally accepted score currently does not exist; however, many states utilize the Sequential Organ Failure Assessment (SOFA) score.
A modification of the severity of acute illness score that is used may be a necessary accommodation for patients with disabilities. The
SOFA score, for example, requires calculation of the Glasgow Coma Scale (GCS) score, which is based on best eye, motor, and verbal
responses. GCS scores may appear to be low for patients with chronic hearing/speech impairments, motor impairments, or cognitive
deficits. However, the GCS applies to acute neurological changes only, and for patients with chronic disabilities, the GCS score must be Re-Allocate
calculated by assessing any change from baseline. For example, a patient with known quadriplegia should be given 6 out of 6 points
for best motor response if they are at their baseline. It may be necessary to review medical history or contact a patient’s family, health
care designee or support agency to determine their baseline prior to calculating the GCS or SOFA score. In all phases of evaluation and
treatment, communication assistance should be provided by family, paid support or health care designees to all patients who present
with pre-existing disabilities which might impact the GCS baseline or who request accommodation due to disability.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 6
https://healthandwelfare.idaho.gov Boise ID 83702CRITICAL CARE RESOURCES FOR ADULTS CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS Strategy Crisis
STEP 3: Using the chart below, determine the patient’s Priority Score based on their severity of acute illness score (1 to 4 points, depending
on severity) plus the presence or absence of major chronic medical conditions that may reduce chances of survival to hospital discharge
even if critical care resources are provided (2 or 4 points, depending on severity). Add the points from the first line of the table to the points
from the second line of the table to obtain a Priority Score. Lower scores indicate a higher likelihood of benefiting from critical care.
Line 1: If using the SOFA score as the severity of acute illness score, a SOFA score 12 would be assigned 4 points. Given the complexity of
determining the prognosis for survival to hospital discharge and the absence of a universally accepted severity of acute illness score,
consultation with experts in critical care is recommended. Critical access hospitals may wish to request assessment by the Triage Team at
their regional tertiary care hospital, as discussed further on page 9.
Line 2: Assign 2 points for a single major chronic medical condition that causes dysfunction to a vital organ that reduces chances of hospital
survival even if critical care resources are provided. Assign 4 points for one or more major chronic medical conditions causing dysfunction of
multiple vital organs that make hospital survival unlikely regardless of the provision of critical care resources.
POINT SYSTEM
Principle Specification Re-Allocate
1 2 3 4
Prognosis for
survival to hospital
Very likely to Less likely to
discharge (severity Likely to survive Not likely to survive
survive survive
of acute illness
score)
Chronic medical No points added Major chronic No points added One or more major chronic
Save the most conditions medical condition medical conditions
lives affecting chances causing dysfunction causing dysfunction of
of survival even of a vital organ that vital organs that makes
if critical care reduces chances hospital survival unlikely
resources provided of hospital survival regardless of provision of
even if critical care critical care resources
resources provided ADD 4 POINTS
ADD 2 POINTS
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 7
https://healthandwelfare.idaho.gov Boise ID 83702CRITICAL CARE RESOURCES FOR ADULTS CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS Strategy Crisis
STEP 4: Assign the patient, whether adult or pediatric, to a Priority Category, based on their Priority Score. Prioritize patients in the “Red”
category first for access to critical care resources , then patients in the “Orange” category, and then patients in the “Yellow” category. Given
the complexity of determining prognosis for survival to hospital discharge and the absence of a universally accepted severity of acute
illness score, it is recommended that the Triage Team pause and consider whether or not the Priority Score and Category are aligned with a
patient’s individualized assessment, prior to using the Priority Category to make treatment recommendations. The Priority Score and Priority
Category may need to be adjusted if the Triage Team determines that they are not clinically consistent with the patient’s individualized
assessment.
Use Raw Score from Step 3 to Assign Priority Category
Level of Priority and Code Color Priority from Step 3 Scoring System
RED Priority Score
Highest Priority 1-3
ORANGE Priority Score
Intermediate Priority 4-5
(reassess as needed) Re-Allocate
YELLOW Priority Score
Lowest Priority 6-8
(reassess as needed)
Resolving “Ties”
When two patients cannot be distinguished after the individualized assessments based on best objective medical evidence, one or more
tiebreakers may need to be used in order to determine which patient receives limited critical care resources, as follows:
First tiebreaker: When two patients are apparently the same on all other measures at a given point in time, if one patient’s clinical
trajectory is declining more rapidly than the other patient needing the same limited critical care resources, the limited resources should
be assigned to the patient with the less rapid rate of clinical decline and thus the greatest prospect of survival to hospital discharge.
Second tiebreaker: When two patients remain tied after assessment of their respective clinical trajectories, a judgment should be made
regarding which patient has the greater prospect of survival to hospital discharge based on additional clinical judgment of the patient’s
medical record and overall presentation of relevant symptoms, so long as this judgment is not based on any unlawful considerations of
race, color, national origin, disability, age, or sex.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 8
https://healthandwelfare.idaho.gov Boise ID 83702CRITICAL CARE RESOURCES FOR ADULTS CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS Strategy Crisis
Triage Team
Tertiary care hospitals working under crisis standards of care should implement a Triage Team to help treatment teams assess patients for access
to critical care resources. It is recommended that the Triage Team determines Priority Scores and Priority Categories and that the Triage Team
makes decisions about allocation. The Triage Team should collaborate with the treatment team in disclosing triage decisions to patients and
families, especially in the event of reallocation of critical care resources. The Triage Team should be readily available and should be separate from
the treatment team, to promote objectivity, avoid conflicts of commitments, and minimize moral distress.
Any critical access hospital (CAH) within the usual catchment area of a tertiary care hospital should be permitted to request an assessment
by the Triage Team at the tertiary care hospital if they have a patient within their facility needing transfer to access critical care resources. If
the Priority Category indicates the patient in the CAH should have access to the critical care resource and it is logistically feasible to transfer
that patient, then transfer should be arranged, even if resources need to be reallocated from a patient already at the tertiary care facility. If a
Triage Team at the tertiary care hospital has not been activated, the CAH should still be permitted to request an individualized assessment
and prioritization of their patient for access to critical care resources with the same criteria by which patients at the tertiary care hospital are
assessed and prioritized. In other words, every patient in the catchment area should have equitable access to critical care resources.
For more information about Triage Teams, please see the University of Pittsburgh School of Medicine’s 2021 guidance Allocation of Scarce
Critical Care Resources During a Public Health Emergency. For pediatric patients, the pediatric triage team at the receiving children’s hospital
should be involved in triage decisions whenever possible. If the pediatric triage team is not available, decisions should be made in consultation
with a local or regional pediatric critical care specialist, pediatric hospitalist, or pediatrician.
Appeals Re-Allocate
Under crisis standards of care, appeals will only be reviewed if the treatment team believes the Triage Team has made a mistake in assigning a
Priority Category. Appeals will need to be urgently reviewed by the Triage Team in order to allow timely allocation of critical care resources.
Chronic Ventilator Use
All efforts should be made to allow patients with their own private ventilators to continue to use their own ventilator in the hospital during
crisis standards of care. If they need a new or hospital-grade ventilator, they would enter the triage algorithm like any other patient. Like other
personal belongings, privately owned ventilators should be inventoried with patient belongings and should be returned to the patient upon
discharge. Privately owned ventilators should not be reallocated to other patients.
Diversion
When crisis standards of care are in effect, hospitals would not be expected to go on diversion even when their resources are extremely
stretched, as access to care would be similarly limited across the region. Instead, hospitals should triage patients presenting for care throughout
the region for access to resources and facilitate transfers between institutions as needed, including triage and transfer for access to critical care
resources as described in the “Triage Team” section above.
Patient Transfers
When crisis standards of care are in effect, patients opting to receive care may at times need to be transferred, whether voluntarily or
involuntarily, to other facilities.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 9
https://healthandwelfare.idaho.gov Boise ID 83702STAFFING CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS Strategy Conventional Contingency Crisis
Staff and Supply Planning
• Assure facility has process and supporting policies for disaster credentialing and privileging - including
degree of supervision required, clinical scope of practice (e.g. allowing providers to work outside their
typical scope of practice), mentoring and orientation, electronic medical record access, and verification
of credentials.
• Encourage employee preparedness planning (www.ready.gov and other resources).
• Collaborate with the Board of Medicine to facilitate licensure of out-of-state providers or retirees. Prepare
• Cache adequate personal protective equipment (PPE) and support supplies.
• Educate staff on institutional disaster response.
• Educate staff on community, regional, and state disaster plans and resources.
• Develop facility plans addressing staff’s family/pets or staff shelter needs.
• Provide psychological support for staff, including resources for recognizing and addressing staff burnout
and psychological distress.
Focus Staff Time on Core Clinical Duties
• Minimize meetings and relieve administrative responsibilities not related to event.
Conserve
• Implement efficient medical documentation methods appropriate to the incident.
• Cohort patients to conserve PPE and reduce staff PPE donning/doffing time and frequency.
Use Supplemental Staff
• Bring in equally trained staff (burn or critical care nurses, Disaster Medical Assistance Team [DMAT], other
Substitute
health system or Federal sources).
• Bring in equally trained staff from administrative positions (nurse managers).
• Adjust personnel work schedules (longer but less frequent shifts, etc.) if this will not result in skill/PPE
compliance deterioration.
Adapt
• Use family members/lay volunteers to provide basic patient hygiene and feeding – releasing staff for
other duties.
Focus Staff Expertise on Core Clinical Needs
• Personnel with specific critical skills (ventilator, burn management) should concentrate on those skills;
specify job duties that can be safely performed by other medical professionals.
• Have specialty staff oversee larger numbers of less-specialized staff and patients (e.g., a critical care nurse
oversees the intensive care issues of 9 patients while 3 medical/surgical nurses provide basic nursing
Conserve
care to 3 patients each).
• Limit use of laboratory, radiographic, and other studies, to allow staff reassignment and resource
conservation.
• Limit availability/indications for non-critical laboratory, radiographic, and other studies.
• Reduce documentation requirements.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 10
https://healthandwelfare.idaho.gov Boise ID 83702STAFFING CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS Strategy Conventional Contingency Crisis
Use Alternative Personnel to Minimize Changes to Standard of Care
• Use less trained personnel with appropriate mentoring and just-in-time education (e.g., health care
trainees or other health care workers, Idaho Medical Reserve Corps, retirees).
• Use less trained personnel to take over portions of skilled staff workload for which they have been
trained. Collaborate with the Board of Medicine to temporarily license these alternate providers. Adapt
• Provide just-in-time training for specific skills.
• Cancel most sub-specialty appointments, elective procedures, and elective surgeries, to divert staff
to emergency duties including in-hospital or assisting public health at external clinics/screening/
dispensing sites.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 11
https://healthandwelfare.idaho.gov Boise ID 83702MEDICATION ADMINISTRATION CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS Strategy Conventional Contingency Crisis
Cache/Increase Supply Levels*
• Patients should have at least a 30 day supply of home medications and obtain 90 day supply if
pandemic, epidemic, or evacuation is imminent.
• Increase supply levels or cache critical medications - particularly for low-cost items and analgesics.
• Coordinate with other hospitals throughout the state and consider sharing medications as able.
• Restrict elective procedures and surgeries if shortages of relevant medications are anticipated.
• Examine formulary to determine commonly-used medications and classes that will be in immediate/
high demand. This may involve coordination with insurance companies/pharmacies. Key examples
include:
Analgesia • Opioid and non-opioid analgesics
• Particularly benzodiazepine (lorazepam, midazolam, diazepam) injectables,
Sedation ketamine, propofol, dexmetomidine, and anti-psychotic agents.
• Narrow and broad spectrum antibiotics for pneumonia, skin infections, open Prepare
Anti-infective fractures, sepsis (e.g., cephalosporins, quinolones, tetracyclines, macrolides,
clindamycin, penam class and extended spectrum penicillins, etc.), select antivirals.
• Metered dose inhalers (albuterol, inhaled steroids), oral steroids (dexamethasone,
Pulmonary prednisone).
Behavioral • Haloperidol, other injectable and oral anti-psychotics, common anti-depressants,
Health anxiolytics.
• Sodium bicarbonate, paralytics, induction agents (etomidate, propofol),
proparacaine/tetracaine, atropine, pralidoxime, epinephrine, local anesthetics,
Other antiemetics, insulin, common oral anti-hypertensives, diabetes medications,
tetanus vaccine and tranexamic acid, anti-epileptics (IV and oral), hypertonic saline,
and anti-diarrheals.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 12
https://healthandwelfare.idaho.gov Boise ID 83702MEDICATION ADMINISTRATION CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS Strategy Conventional Contingency Crisis
Use Equivalent Medications
• Obtain medications from alternate supply sources (pharmaceutical distributors, pharmacy caches).
• Explore options to compound or obtain from compounding pharmacies.
Substitute
• Consider alternate forms of administration (e.g., metered dose inhalers instead of nebulized
medications) or use other medications entirely (e.g., benzodiazepines instead of propofol for sedation
for ventilated patients).
Reduce Use During High Demand
• Restrict use of certain classes if limited stocks likely to run out (e.g., restrict use of prophylactic/empiric
antibiotics after low risk wounds, etc.).
• Decrease dose: consider using smaller doses of medications in high demand/likely to run out (e.g.,
reduce doses of medications allowing blood pressure or glucose to run higher to ensure supply of Conserve
medications adequate for anticipated duration of shortage).
• Allow use of personal medications (e.g., inhalers, oral medications) in hospital.
• Do without - consider impact if medications not taken during shortage (e.g., statins, etc.).
http://www.astho.org/Programs/Preparedness/Coping-With-Drug-Shortages/Drug-Shortage-
Report-2012/.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 13
https://healthandwelfare.idaho.gov Boise ID 83702MEDICATION ADMINISTRATION CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
RECOMMENDATIONS Strategy Conventional Contingency Crisis
Modify Medication Administration
• Emphasize oral, nasogastric, subcutaneous routes of medication administration.
• Administer medications by gravity drip rather than IV pump if needed
• Rule of 6: pt wt (kg) x 6 = mg drug to add to 100mL fluid = 1mcg/kg/min for each 1 mL/hour. Adapt
NOTE: For examples, see http://www.dosagehelp.com/iv_rate_drop.html.
• Consider use of select medications beyond expiration date, especially tablets/capsules.**
• Consider use of veterinary medications when alternative treatments are not available.**
Restrict Allocation of Select Medications
• Allocate limited stocks of medications with consideration of regional/state guidance and available
epidemiological information (e.g., anti-viral medications such as oseltamivir). Re-Allocate
• Determine patient priority to receive medications in limited stock.
*Resources:
1. ASPR TRACIE Hospital Disaster Pharmacy Calculator. This tool estimates the number of patients that should be planned for based on the size of the emergency
department and the role of the hospital.
2. ASPR TRACIE Factsheet: Drug Shortages and Disasters. This factsheet can help health care providers prepare for and respond to drug shortages that may arise
during and after a disaster.
**Legal protection such as Food and Drug Administration approval or waiver required.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 14
https://healthandwelfare.idaho.gov Boise ID 83702RENAL REPLACEMENT THERAPY CRISIS STANDARDS
REGIONAL RESOURCE CARD OF CARE
Resource cards are intended to provide incident-specific tactics and planning information to supplement the general strategy cards. They are organized according to the
‘CO-S-TR’ framework of incident response planning.
Category RESOURCES AND RECOMMENDATIONS Strategy Conventional Contingency Crisis
General Preparedness Information
Compared to other critical care interventions, hemodialysis offers equipment availability,
expansion capacity, and care coordination that greatly reduces the risk of contingency and
crisis care, at least in our geographic area.
Disaster dialysis challenges generally result from:
1. Lack of clean water sources (each hemodialysis requires about 160 liters ultra-
clean water).
2. Relocation of dialysis-dependent patients to a new area (evacuation of nursing
homes, flood zones, etc.).
3. Increase in patients requiring dialysis (crush syndrome, unusual infections).
Outpatient
• Primary providers are DaVita and Fresenius – both have extensive contingency
plans to increase capacity and relocate patients (including toll-free numbers to
access dialysis services).
Command, • Gem State Dialysis - University of Utah (Multi-state renal planning, quality, and
Control, emergency preparedness) has a database of all dialysis patients in the state/ Prepare
Communication, region and assists coordination of activities.
Coordination
Inpatient
• Most facilities lease inpatient services via contract with above or other agencies;
some have own nurses and program – plans should account for contingency use
of alternate services/leasing services.
Patient preparedness
• Patients should have a disaster plan – including specific foods set aside for up
to 72h. Note that shelters are unlikely to have foods conducive to renal dietary
needs (low sodium, etc.).
• Personal planning guidance from the National Kidney Foundation.
• Patients need to have access to personal protective equipment and a plan for
safe isolation, in the event of a pandemic.
Shortage of Renal Replacement Therapy (RRT) Resources
• Affected facility should contact involved/affected dialysis provider companies
and organizations as expert consultants.1
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 15
https://healthandwelfare.idaho.gov Boise ID 83702RENAL REPLACEMENT THERAPY CRISIS STANDARDS
REGIONAL RESOURCE CARD OF CARE
Category RESOURCES AND RECOMMENDATIONS Strategy Conventional Contingency Crisis
Relocated Patients Requiring Outpatient Dialysis
• Contact usual outpatient provider network to schedule at new facility – refer patients to
‘hotlines’ as needed.
Excess Patients Requiring Dialysis Substitute
Space • Transfer patients to other facilities capable of providing dialysis.
• Consider moving patients to facilities with in-house water purification if water quality is an
issue for multiple inpatients requiring dialysis.
• Consider moving other inpatient or outpatient dialysis staff and equipment to facilities
Adapt
requiring increased dialysis capacity.
Water Supply
• Quantify water-purifying machines available for bedside dialysis machines.
• Identify facilities providing high-volume services that purify their own water and pipe to Prepare
specific rooms in the dialysis unit, intensive care, etc.
• Identify water-purifying and dialysis machines to be obtained through lease agreements.
Water Contamination
• Consider alternate sources of highly purified water.
Prepare
• Consider transferring stable inpatients to outpatient dialysis centers for dialysis treatments
Substitute
and vice versa.
Adapt
• Consider use of Idaho National Guard water reserves and purification equipment – but must
assure adequate purity for dialysis (potable is NOT sufficiently clean).
Power Outage or Shortage
Supplies • Consider transferring stable inpatients to outpatient dialysis centers for dialysis treatments
and vice versa. Substitute
• Consider transferring inpatients to other hospitals. Adapt
• Consider transfer of outpatients to other facilities for care until issue resolved.
Dialysis Catheters, Machines, Reverse Osmosis Machines, and/or Other Supply Shortages
Note: Dialysis catheters and tubing are inexpensive, relatively interchangeable, and supplied by
several manufacturers.
• Stock adequate dialysis tubing sets and venous access catheters (Quinton, etc.) for at least one Prepare
month’s usual use. Substitute
• Identify provider network and other sources of supplies and machines, including provider
networks in other states.
• Transfer machines/supplies between outpatient centers and hospitals, or between hospitals.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 16
https://healthandwelfare.idaho.gov Boise ID 83702RENAL REPLACEMENT THERAPY CRISIS STANDARDS
REGIONAL RESOURCE CARD OF CARE
Category RESOURCES AND RECOMMENDATIONS Strategy Conventional Contingency Crisis
Dialysis Staff Shortages2
• Non-dialysis nursing staff to take on “routine” elements of dialysis nursing (e.g., taking VS, Substitute
monitoring respiratory and hemodynamic status, etc.).
• Dialysis nursing staff to supervise non-dialysis nursing staff providing some dialysis
functions.
Staff • Outpatient dialysis techs may be used to supervise dialysis runs if provider deficit is critical
issue.
• The majority of the state’s nephrologists are in the Treasure Valley (Boise Kidney & Adapt
Hypertension Institute 208-846-8335; Idaho Nephrology Associates 208-501-8955) or in
Idaho Falls (Idaho Kidney Center 800-881-5101); health systems experiencing nephrology
shortages should reach out to these nephrology groups for assistance.
Community Planning
• Medical needs of re-located renal failure patients are substantial; planning on the
Special community level should incorporate their medication and dietary needs during evacuation Prepare
and sheltering activities.
Insufficient Resources Available For All Patients Requiring Dialysis
• Change dialysis from ‘scheduled’ to ‘as needed’ based on clinical and laboratory findings
Conserve
(particularly hyperkalemia and impairment of respiration) – parameters may change based
on demand for resources.
• Consider hemodialysis or peritoneal dialysis if insufficient access to continuous renal
Substitute
Triage replacement therapy (CRRT).
• Conceivable (but extraordinary, given outpatient dialysis machine resources) situations
may occur where resources are insufficient to the point that some patients may not be able
to receive dialysis (for example, pandemic when demand nationwide exceeds available Re-Allocate
resources). In these situations, access to dialysis should be considered as part of critical
care intervention prioritization (see Critical Care Resources for Adults, pages 4-9).
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 17
https://healthandwelfare.idaho.gov Boise ID 83702RENAL REPLACEMENT THERAPY CRISIS STANDARDS
REGIONAL RESOURCE CARD OF CARE
Category RESOURCES AND RECOMMENDATIONS Strategy Conventional Contingency Crisis
Crush Syndrome
• Initiate IV hydration and acidosis prevention protocols “in the field” for crush injuries to Conserve
prevent/treat rhabdomyolysis in hospital settings.
Mode of Dialysis
• Restrict to hemodialysis only for inpatient care (avoid continuous renal replacement
therapy (CRRT) and peritoneal dialysis (PD) due to duration of machine use (CRRT) and Substitute
Treatment supply issues (PD)).
• Consider PD if dialysis supplies sufficient, but HD or CRRT machines limited.
Increased Demand on Resources
• Shorten duration of dialysis for patients that are more likely to tolerate it safely.
• Patients could utilize their home “kits” of medication (Kayexalate) and follow dietary plans Conserve
to help increase time between treatments, if necessary.
Transportation Interruptions
• Dialysis patients may require alternate transportation to assure ongoing access to dialysis
treatment.
Transpor- • Chronic patients should coordinate with their service providers/dialysis clinics first for Prepare
tation transportation and other assistance during service/transportation interruptions. Adapt
• Emergency management and/or the health and medical sector may have to supplement
contingency transportation to dialysis during ice storms or other interruptions to
transportation.
1. The major national dialysis corporations have extensive experience contending with disasters; their input during any anticipated or actual incident is imperative to
optimize the best patient care in Idaho.
2. See Staffing, pages 10-11.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 18
https://healthandwelfare.idaho.gov Boise ID 83702ECMO (Extra-corporeal membrane oxygenation) CRISIS STANDARDS
STRATEGIES FOR SCARCE RESOURCE SITUATIONS OF CARE
Category RESOURCES AND RECOMMENDATIONS Strategy Conventional Contingency Crisis
General Information
• Extra-corporeal membrane oxygenation (ECMO) is already a severely limited resource
Triage in Idaho. ECMO has very high staffing and supply needs; hospitals should use their Re-Allocate
discretion whether or not they are able to provide ECMO during crisis standards of
care.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 19
https://healthandwelfare.idaho.gov Boise ID 83702PALLIATIVE CARE CRISIS STANDARDS
SCARCE RESOURCE STRATEGIES OF CARE
ORIENTATION TO SPECIALTY AND GOALS
NOTE
This card provides a focused description of palliative care management principles in disaster situations. These principles are relevant to all patients, as well as those who
may receive palliative care as their only intervention due to demand on the health care system relative to their prognosis.
Specialty Description
Palliative care has a goal of providing the best possible quality of life for people facing the pain and stress of a serious, but not necessarily terminal, medical condition. It can
be appropriate for patients of any age and at any stage of an illness - from diagnosis on - and can be provided along with treatments for the medical condition.
Index
Orientation to Specialty
Page 20-21 Space Page 24-25 Special Page 28
and Goals
Planning Resources Page 22 Supplies Page 26 Triage Page 29
Communications and
Page 22-24 Staff Page 27
Coordination
Principles of Palliative Care
• Palliative care should be provided to ALL patients.
• Focuses on human contact and comfort in addition to medical care.
• Increases the physical and mental well-being of the patient.
• Is not abandonment or euthanasia, and does not aim to hasten death (though in some cases, the doses required to relieve severe symptoms may indirectly
contribute to the dying process; however, this meets the ethical criteria for the double-effect principle where indirect harm is permissible in the service of a greater
good).
• Relieves symptoms and provides physical comfort measures such as control of pain, nausea, dyspnea, temperature regulation, and positioning.
• Assures respectful care, reassurance, and emotional and social support as possible.
• Cultural diversity may have impact on acceptance of palliative care offerings.
• During a public health emergency, palliative care may be the only care that is able to be provided due to a patient’s prognosis and available resources. On these
resource cards, we refer to this type of palliative care as comfort care.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 20
https://healthandwelfare.idaho.gov Boise ID 83702PALLIATIVE CARE CRISIS STANDARDS
SCARCE RESOURCE STRATEGIES OF CARE
ORIENTATION TO SPECIALTY AND GOALS
Disaster Considerations
• Symptom support should be maintained in hospital and non-hospital environments. This will involve planning by outpatient entities such as hospice care,
pharmacies, medical equipment providers as well as inpatient entities such as palliative care hospital-based programs.
• For existing hospice patients, the spectrum of care should be defined.
• For those designated to receive comfort care, key considerations are:
◊ Expected survival - hours, days, or weeks – this helps to guide needs, referrals, and resources.
◊ Required interventions - this helps guide location of care and support planning.
◊ Basis for designation - if the decision for comfort care is based on the lack of a single resource, there must be a plan for re-assessment if the patient’s
condition improves or more resources become available (i.e., would they qualify to receive additional treatment if more resources become available and
how are they contacted/monitored) - see triage tree on page 29.
• Home health and other agencies will need to prioritize services relative to hospice patients during a disaster (as this can have significant impact on patient/family/
agency planning).
• Supportive measures should be offered that maintain comfort, but do not prolong the dying process :
◊ If death is inevitable, there may be no benefit in providing intravenous fluids or nutritional support.
◊ If death is not certain, other forms of support may be very reasonable as other resources become available.
IDAHO DEPARTMENT OF HEALTH & WELFARE Pete T. Cenarrusa Building
Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 21
https://healthandwelfare.idaho.gov Boise ID 83702PALLIATIVE CARE CRISIS STANDARDS
SCARCE RESOURCE STRATEGIES OF CARE
Category RESOURCES AND RECOMMENDATIONS Strategy Conventional Contingency Crisis
Planning Resources
General palliative care resources and fact sheets:
• Palliative Care Network of Wisconsin (PCNOW).
• PCNOW Fast Facts and Concepts.
ICU care:
• Improving Palliative Care in the ICU (IPAL-ICU project).
Planning General resources in palliative care and non-pharmacologic intervention: Prepare
Resources
• American Academy of Hospice and Palliative Medicine.
• Center to Advance Palliative Care.
• World Health Organization Essential Medicines in Palliative Care.
• UpToDate—What’s new in Palliative Care.
• Cambia Palliative Care Center of Excellence.
• VITALtalk.
Key Idaho Organizations
• Local home care agencies
• Inpatient palliative care programs: Palliative care MD on 24 hour pager for most
Communications facilities/systems. Prepare
and Coordination
• Hospice programs: Majority of State has hospice program coverage and most
programs usually have hospice MD on 24 hour pager. Check with hospital health
systems for main contact/referral phone line.
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Version 5.0 February 2022 DIVISION OF PUBLIC HEALTH 450 West State Street 22
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