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Volume 13, Number 6
December/January 2015
Critical Connections
The Complete News Source for Critical Care Professionals
Thank you for your membership in
the Society of Critical Care Medicine.
Learn more about the benefits of
membership at www.sccm.org or
call +1 847 827-6888.
In This Issue…
Disaster Management
Better understand the nuances
of quarantine and isolation. . . . . . . . . 10
Learn how to effectively manage
resources in a disaster. . . . . . . . . . . . 12
Review best practices for
disaster preparedness. . . . . . . . . . . . 14
SCCM Members Treat Ebola Patients in West Africa
Society of Critical Care Medicine
(SCCM) member David Porembka, DO,
FCCM, understood the risks.
“I told my kids before I left that there
was a good chance I would not come
back,” he said. “I knew how dangerous it
would be medically.”
A veteran intensivist who will soon be
joining Avera McKennan Hospital &
University Health Center, Dr. Porembka
spent three weeks in Sierra Leone during
mid-August to early September treating Ebola patients and those who were
suspected of having the deadly virus.
“I always wanted to do missionarytype work and help others in need,” he
said.
“SCCM Members Treat Ebola Patients in West Africa” p16
Clinical Spotlight
Highly Contagious Diseases:
Preparation and Response
In the last century, there has been a significant reduction in the proportion of deaths caused by communicable disease due
to the advent of effective medications and vaccinations.1 Despite these advances, contagious diseases still require recognition and preparation to minimize human, economic and societal hardship and cost.
The U.S. Centers for Disease Control and Prevention has classified communicable diseases as category A, B or C.
Category A diseases have a high potential for adverse public health impact and large-scale dissemination and are thus the
highest priority agents.2 These currently include anthrax, smallpox, plague, botulism, tularemia, and viral hemorrhagic
fevers like Lassa fever, yellow fever, Marburg disease, and Ebola virus disease (EVD).
Unlike conventional disasters, infectious diseases can affect large groups of individuals over prolonged periods in
multiple regions. This places significant stress on a larger range of healthcare resources. For example, the Sept. 11,
2001, attacks had minimal impact on hospitals in the affected areas. Of 6,000 patients treated by 91 local hospitals,
only 500 were admitted.3
“Highly Contagious Diseases: Preparation and Response” p15
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“Highly Contagious Diseases: Preparation and Response” continued from p1
Compare this to the pandemic flu (H1N1), which
caused over 12,000 deaths, almost 275,000 hospitalizations and 60 million infections between April 2009
and April 2010 in the United States alone.4
There is not only a human cost but also an emotional and financial impact related to the outbreak
of any highly contagious disease. In 2003, severe
acute respiratory syndrome (SARS) was recognized.
It spread to over 12 countries,5,6 with more than 750
deaths and 8,000 people infected. It was estimated by
Bloomberg News that SARS cost the global economy
more than $40 billion, due in large part to public
panic.7 At the time of this writing, the economic
effect of Ebola virus disease (EVD) is estimated to be
in the hundreds of billions of dollars in West Africa
and has even been cited as contributing to recent
volatility in the U.S. stock markets.8
Public health measures to control and contain
infectious outbreaks are crucial and critical. Adequate
preparedness at each level of the healthcare system
can lead to seamless, high quality patient care, limit
inadvertent contagion of healthcare workers and
patients, and mitigate public anxiety.
Disaster medicine can be defined as the coordinated medical response to unexpected disruption of
the system of healthcare delivery.9 The goal during
a disaster is to mitigate death, disease and further
injury. This is done through preplanning, education
and training that includes drills. As of January 1,
2014, it is a Joint Commission requirement for critical
access hospitals to have an emergency manager10 for
disaster management. Good resources for disaster
medicine education include the Society of Critical
Care Medicine’s Fundamental Disaster Management
course.
Disaster Management - Preparation Stage
In concert with mitigation strategies, preparation
is the most important stage of the disaster cycle.
It involves multiple steps, such as identifying the
incident command leadership for the intensive care
unit (ICU). The leadership should perform a hazard
vulnerability analysis, preferably organized with the
hospital’s emergency manager, develop an emergency
management plan and regularly conduct realistic
drills to develop operational insight into how a surge
of sick people might strain the resources of the
ICU.9 The ICU leadership team should identify the
institution’s greatest disaster risks, preparedness gaps
and vulnerabilities. This also is a Joint Commission
requirement for hospitals, and these plans must be
discussed with senior hospital leaders who oversee
strategic planning and budgeting.10 The concept of
surge capacity building is critical for the successful
rollout of a plan. An effective tool is the so-called
staff, stuff, space, and structure paradigm.11
Critical Care Staffing
This may involve cross-credentialing, accelerated or
expedited credentialing (as Louisiana did for physicians and nurses during Hurricane Katrina), and
canceling vacations and recalling staff.
Critical Connections
Critical Care Stuff
This entails having access to emergency medical
supplies through vendors or regional or national
stockpiles.12,13
Critical Care Space
Inova Health System in Virginia responded to the
September 11, 2001, terrorist attacks by making 343
additional beds available within three hours, and
the District of Columbia made available 200 beds
from their existing 2,904 staffed beds.14 One option
is canceling elective procedures to free up beds for
surge capacity building. In the case of infectious
disease outbreaks, environmental engineering experts
can redesign heating, ventilating and air conditioning
systems to provide negative-pressure environments.
Critical Care Structure
The United States Air Force has maintained critical
care aeromedical transport teams, each consisting of
an intensivist, a critical care nurse and a respiratory
therapist who can use portable ultrasound equipment,
mechanical ventilators and point-of-care testing to
provide care for up to three patients.11,15 A team structure like this can be adapted by using critical care
nurses who are cross-credentialed in dialysis and have
ventilator experience. Such medical personnel could
play a triple role when demands exceed resources.
Disaster Management - Response Stage
The disaster management plan should contain a
predetermined threshold or trigger for activating the
plan. Components of the plan should have backups if
the primary plan fails. Having a trained project manager on the team helps. Most accreditation organizations, including The Joint Commission, require emergency management programs, emergency operations
plans and standardized incident response systems.
Adapting and using the California Hospital Incident
Command System is a way to meet this requirement.16 It is cost-effective to adopt or adapt a proven
model rather than develop a new one. Some experts
suggest nontraditional ways to exercise the command
system through staff picnics, health awareness days or
inclement weather days.
Multipronged communications – both within an
organization and externally with emergency services,
such as police departments, fire departments and
emergency medical services – using both traditional
and nontraditional modes should be trialed and
tested.17 A dedicated and aggressive media outreach
approach can be very helpful, as evidenced by Emory
University Hospital when care was provided to two
EVD victims; the hospital did not see any decrease in
the volume of elective or emergency utilization due
to the intense media outreach to local and national
audiences.18 Using the buddy system for putting on
and taking off personal protective equipment should
be a standard.19-21 A staff support system should be in
place to take care of the anticipated emotional and
physical toll.22
www.sccm.org
The concept of a disease contained
only in another part of the world no
longer exists due to the rapidity and
breadth of modern travel.
Summary
The death of an EVD victim and subsequent infection of two healthcare workers in Dallas suddenly
brought a highly contagious disease back to the
forefront of public awareness. It suggested a lack of
preparedness on the part of most U.S. hospitals to
deal with a category A infectious disease.
Lessons can be drawn from the SARS outbreak in
Toronto and other recent mass casualty incidents in
the last decades.
ICU directors are in the unique position of having
some of the most highly trained staff in their hospitals. They should be able to leverage their staffs’ skill
sets to develop an effective disaster plan.
The concept of a disease contained only in another
part of the world no longer exists due to the rapidity
and breadth of modern travel. Diseases in China,
Hong Kong, the Arabian Peninsula, or West Africa
take less than a day to reach the coasts of the United
States, Canada or any country.
The Society’s Fundamental Disaster Management
course and other disaster courses offered by professional associations are a vital resource for ICU and
hospital leaders looking to facilitate and improve
disaster preparedness.
The opinions expressed here are those of the author (Dr. Geiling)
and do not represent official views or policies of the Department
of Veterans Affairs or the U.S. Government.
The opinions expressed here are those of the author (Dr.
Kyereme-Tuah) and do not represent official views or policies of
the Geisinger Medical Center or Department of Critical Care
Medicine.
References and disclosures are available at
www.sccm.org/criticalconnections.
Emmanuel Kyereme-Tuah, MBChB, is a critical care
medicine fellow at Geisinger Medical Center in Danville,
Pennsylvania, USA.
James Geiling, MD, MPH, FCCM, is Medical Service
Chief and ICU Director at the White River Junction
VA Medical Center in White River Junction, Vermont,
USA, and Professor of Medicine at the Geisel School of
Medicine at Dartmouth in Hanover, New Hampshire, USA.
December/January 2015
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