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CORD-19:3cf7bf4d0a1cbe9a6fa635ddbeb3e20c9728cc2f JSONTXT 11 Projects

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Id Subject Object Predicate Lexical cue
T1 0-57 Sentence denotes Definitive Care for the Critically Ill During a Disaster:
T2 58-207 Sentence denotes Current Capabilities and Limitations* From a Task Force for Mass Critical Care Summit 9S 14S Definitive Care for the Critically Ill During a Disaster
T3 209-217 Sentence denotes Abstract
T4 218-369 Sentence denotes In the twentieth century, rarely have mass casualty events yielded hundreds or thousands of critically ill patients requiring definitive critical care.
T5 370-580 Sentence denotes However, future catastrophic natural disasters, epidemics or pandemics, nuclear device detonations, or large chemical exposures may change usual disaster epidemiology and require a large critical care response.
T6 581-833 Sentence denotes This article reviews the existing state of emergency preparedness for mass critical illness and presents an analysis of limitations to support the suggestions of the Task Force on Mass Casualty Critical Care, which are presented in subsequent articles.
T7 834-1049 Sentence denotes Baseline shortages of specialized resources such as critical care staff, medical supplies, and treatment spaces are likely to limit the number of critically ill victims who can receive life-sustaining interventions.
T8 1050-1304 Sentence denotes The deficiency in critical care surge capacity is exacerbated by lack of a sufficient framework to integrate critical care within the overall institutional response and coordination of critical care across local institutions and broader geographic areas.
T9 1305-1329 Sentence denotes (CHEST 2008; 133:8S-17S)
T10 1331-1528 Sentence denotes M ass casualty events occur frequently worldwide 1 ; fortunately, the majority of these do not generate overwhelming numbers of critically ill or injured victims requiring definitive critical care.
T11 1529-1820 Sentence denotes Mass critical care events, though, have garnered increasing attention 2 and stimulated new interest in critical care disaster preparedness. [3] [4] [5] [6] [7] [8] [9] In 2004, an analysis 10 of US critical care disaster response identified major limitations to respond to serious epidemics.
T12 1821-1977 Sentence denotes In light of the increasing consternation about a potential influenza pandemic, 11, 12 an updated review of critical care response capabilities is warranted.
T13 1978-2083 Sentence denotes Authorities continue to call for development of comprehensive guidance for managing mass casualty events.
T14 2084-2253 Sentence denotes 13 A number of efforts are underway to meet this need, but detailed guidance regarding how to provide critical care for large volumes of patients remains underdeveloped.
T15 2254-2367 Sentence denotes 5, 14 To this end, the Task Force for Mass Casualty Critical Care (hereafter called the Task Force) was convened.
T16 2368-2539 Sentence denotes The Task Force steering committee members (listed in the Appendix) were fairly certain that current critical care surge capacity for disasters had a number of limitations.
T17 2540-2717 Sentence denotes However, the specific strengths and weaknesses of critical care response capabilities must be delineated to best inform development of novel strategies to augment critical care.
T18 2718-2981 Sentence denotes This manuscript summarizes the current US and Canadian critical care disaster response capabilities, and provides the rationale and context for the guidance of the Task Force for critical care surge capacity and allocation of scarce life-sustaining interventions.
T19 2982-3066 Sentence denotes Disaster medical management has focused primarily on the response to trauma victims.
T20 3067-3268 Sentence denotes 5, 15 Victims who suffer critical injuries frequently die immediately or before rescue, so the vast majority of those who survive to receive hospital-based treatment have non-life-threatening injuries.
T21 3269-3413 Sentence denotes 16 -18 Disaster plans have assumed that critical care resources will be available when needed, 5 and generally this assumption has been correct.
T22 3414-3636 Sentence denotes However, with the anticipation of large volumes of critically ill patients in future disasters, some believe that hospital capacity, and in particular critical care capability, will be a major limiting factor for survival.
T23 3637-3764 Sentence denotes 15, 19 Numerous authorities have forecast scenarios that will result in large numbers of critically ill and injured casualties.
T24 3765-3846 Sentence denotes Table 1 summarizes scenarios developed by the US Department of Homeland Security.
T25 3847-3983 Sentence denotes Eleven of the 15 scenarios predict numbers of critically ill patients ranging from hundreds to tens of thousands in a metropolitan area.
T26 3984-4169 Sentence denotes If such events occur, the demand on critical care resources will be multiple orders of magnitude greater than previous emergencies experienced in the past half century in North America.
T27 4170-4379 Sentence denotes The experience with the severe acute respiratory syndrome in Toronto, although not a mass casualty event, stands as example where critical care can prevent deaths even for a disease lacking specific treatment.
T28 4380-4512 Sentence denotes In the absence of critical care, the case fatality rate in Toronto would have been more than triple (20%) the observed rate of 6.5%.
T29 4513-4596 Sentence denotes 20 This lesson may have profound import were a serious influenza pandemic to occur.
T30 4597-4748 Sentence denotes Further, the effectiveness of community mitigation as well as the utility and availability of antivirals to forestall serious illness remain uncertain.
T31 4749-4874 Sentence denotes 21, 22 Many people, particularly high-risk groups, may have critical illness 23 and without critical care will assuredly die.
T32 4875-5105 Sentence denotes If critical illness directly or indirectly resulting from influenza is not uniformly fatal with essential critical care services, then availability of life-sustaining interventions may have a profound impact on community survival.
T33 5106-5182 Sentence denotes 24 The need to augment critical care is not unique to an influenza pandemic.
T34 5183-5402 Sentence denotes Illness developing after exposures to chemicals, 25 infection with serious pathogens, and exposure to radiologic materials are all likely to result in life-threatening clinical conditions, such as severe sepsis or ARDS.
T35 5403-5530 Sentence denotes Natural catastrophes, such as earthquakes 26 -28 and tsunamis, 29 can also generate many victims with severe organ dysfunction.
T36 5531-5991 Sentence denotes In the United States and Canada, severe sepsis and acute respiratory failure, including ARDS, are commonly treated in ICUs 30 -32 ; and importantly, at least half of patients survive with aggressive ICU care. [33] [34] [35] [36] [37] [38] Unlike the duration of surge demands on emergency departments (EDs) in mass casualty incidents, which are often measured in units of minutes or hours, the critical care response may need to be sustained for days to weeks.
T37 5992-6037 Sentence denotes Several recent examples highlight this issue.
T38 6038-6279 Sentence denotes Following the Rhode Island nightclub fire, the emergency department (ED) response lasted only hours, yet 47 critically ill patients admitted to a single hospital resulted in 406 ICU patient days with an average ICU length of stay of 21 days.
T39 6280-6483 Sentence denotes 39 Similarly, following the 2005 London bombings, the major incident lasted in the ED lasted 3 h and 14 min, yet the average length of stay for the critically injured was 12.4 days (range, 6 to 22 days).
T40 6484-6682 Sentence denotes 16, 40 Complications seen in the critically ill or injured, such as ARDS, prolong recovery times in ICU 16, [41] [42] [43] and should be anticipated in planning for future mass critical care events.
T41 6683-7079 Sentence denotes Within an effective command and control system to coordinate regional response, 10 surge capacity in critical care depends on three crucial elements: (1) "stuff," medical equipment and supplies; (2) "staff," appropriately trained health professionals to competently care for critically ill and injured patients; and (3) "space," the physical location suitable for safe provision of critical care.
T42 7080-7263 Sentence denotes Although a rather simplistic conceptual approach, one can confidently state that a system that fails to meet any one of these requirements will not be able to cope with a large surge.
T43 7264-7574 Sentence denotes Medical response to disasters, including the critical care response, is dependent on a number of nonclinical medical institution services (eg, logistics and procurement, environmental services, food services) and external services (eg, transportation, consistent functional utilities, commerce infrastructure).
T44 7575-7653 Sentence denotes For expediency, this article will focus on critical carespecific capabilities.
T45 7654-7797 Sentence denotes Mechanical ventilators are unique to the critical care environment, and they are essential equipment for the management of respiratory failure.
T46 7798-7849 Sentence denotes There are no realistic substitutes for ventilators.
T47 7850-8238 Sentence denotes Proposals to train hundreds of volunteers to provide manual ventilation to patients during a pandemic are naïve and fraught with serious logistical and scientific shortfalls, such as the lack of staff or volunteers during bioevents as well as the risk of secondary transmission to the caregivers who must remain at the bedside and the adverse consequences of prolonged manual ventilation.
T48 8239-8344 Sentence denotes Estimates of the total number of full-feature ICU ventilators available in the United States vary widely.
T49 8345-8555 Sentence denotes One study 12 reported 105,000 ventilators (35 ventilators per 100,000 population); other published studies and unpublished data place the estimate between 53,000 44 and 70,000 (17 to 23 per 100,000 population).
T50 8556-8655 Sentence denotes These devices are distributed among the 72,000 to 87,500 non-federal ICU beds in the United States.
T51 8656-8800 Sentence denotes 45 47 in Los Angeles found that 71% of hospitals in the Los Angeles area had fewer than six ventilators available for immediate use at any time.
T52 8801-9021 Sentence denotes If several local hospitals require additional ventilators, rental supplies may be insufficient to meet need, as it is common for vendors to contract to provide the same finite pool of ventilators to several institutions.
T53 9022-9215 Sentence denotes Data from the National Healthcare Safety Network 48 show that the majority of ICUs have, on average, Ͻ 70% of their occupied beds filled with patients receiving invasive mechanical ventilation.
T54 9216-9362 Sentence denotes Based on these data, at least 10,000 full-feature ventilators are likely available across the United States at any time for use during a disaster.
T55 9363-9495 Sentence denotes This predicted available national mechanical ventilator quantity may at first seem reassuring, but it also has potential to mislead.
T56 9496-9592 Sentence denotes Numerous logistic hurdles will hamper immediate distribution to areas of need during a disaster.
T57 9593-9779 Sentence denotes Thousands of ventilators may be available at hospitals nationwide, yet an affected community requiring just hundreds of additional devices may not be able to get them in a timely manner.
T58 9780-10004 Sentence denotes Also, published and unpublished models of varying sophistication portend there will still be a large gap between the total number of ventilators required during the peak of a serious influenza pandemic and available devices.
T59 10005-10117 Sentence denotes 23,49 -51 In all models, the predicted need will far exceed even the tens of thousands of available ventilators.
T60 10118-10218 Sentence denotes Hence, strategies for rational augmentation of positive pressure ventilation capacity are necessary.
T61 10219-10316 Sentence denotes In the United States and Canada, stockpiles of ventilators are available from government sources.
T62 10317-10495 Sentence denotes 52, 53 Currently the strategic national stockpile in the United States 54 has approximately 4,600 ventilators, and there is a stated intention to purchase additional ventilators.
T63 10496-10595 Sentence denotes 44 Furthermore, some local institutions, municipalities, and states are also developing stockpiles.
T64 10596-10786 Sentence denotes For some events, these devices, together with staff augmentation strategies, may allow for many additional patients to survive (see "Definitive Care for the Critically Ill During a Disaster:
T65 10787-10906 Sentence denotes A Framework for Optimizing Critical Care Surge Capacity" and "Definitive Care for the Critically Ill During a Disaster:
T66 10907-10946 Sentence denotes Medical Resources for Surge Capacity").
T67 10947-11241 Sentence denotes For more catastrophic events, these additional ventilators may be beneficial but still insufficient to serve all in need; in such cases, scarce mechanical ventilators will need to be allocated to those patients who are prioritized (see "Definitive Care for the Critically Ill During a Disaster:
T68 11242-11313 Sentence denotes A Framework for Allocation of Scarce Resources in Mass Critical Care").
T69 11314-11525 Sentence denotes The "just-in-time" supply chain management systems used by many hospitals creates a significant threat to successful disaster response as many hospitals maintain only a minimal store of medical supplies on site.
T70 11526-11724 Sentence denotes 55 Of the typically "consumable" medical supplies required for the provision of critical care some may have the potential for limited disinfection and reuse in a disaster when no alternative exists.
T71 11725-11831 Sentence denotes There are a variety of inotropes and vassopressors that are interchangeable again increasing availability.
T72 11832-11939 Sentence denotes However, oxygen remains a critical consumable resource which has a limited supply and distribution network.
T73 11940-12000 Sentence denotes Most hospitals rely on large storage tanks of liquid oxygen.
T74 12001-12068 Sentence denotes If this source runs low, oxygen must be trucked in from a supplier.
T75 12069-12210 Sentence denotes The number of suppliers of medical grade oxygen in North America is limited as are the number of tanker trucks available to transport oxygen.
T76 12211-12404 Sentence denotes Portable oxygen supplies for use during an infrastructure failure or in 12S off-site critical care facilities are very limited, inefficient and not included in the strategic national stockpile.
T77 12405-12544 Sentence denotes 44 Staff Like many areas of health care, critical care units face shortages of various team members 56 required for critical care delivery.
T78 12545-12687 Sentence denotes 44, 50, [57] [58] [59] [60] [61] Data from Ontario show that 49% of critical care units had nursing vacancies and 20% had physician vacancies.
T79 12688-12807 Sentence denotes 50 ICUs facing staffing shortages are routinely forced to cancel surgeries and divert ED admissions to other hospitals.
T80 12808-12936 Sentence denotes 50 The need to resort to such actions even in non-surge periods bespeaks the limited surge capacity in the critical care system.
T81 12937-13023 Sentence denotes In the past, staff shortages have not typically been a major problem during disasters.
T82 13024-13152 Sentence denotes 62 However, a report 7 revealed that staffing can be a problem, with staff absenteeism during a disaster ranging from 10 to 60%.
T83 13153-13403 Sentence denotes The authors 7 described disasters that were prolonged, were of a type rare for the community, or impacted the personal lives of employees (ie, school closures, day-care closures, or elder-care issues) were associated with higher rates of absenteeism.
T84 13404-13478 Sentence denotes Estimated absenteeism for future bioevents is predicted to be even higher.
T85 13479-13895 Sentence denotes 63, 64 In bioevents, staff may fail to report for duty for a variety of reasons, including fear of infection or infecting their families. [63] [64] [65] [66] Although volunteers often converge on disaster-stricken communities, 67,68 rarely do these volunteers possess the skills necessary to provide critical care; and even if they do, rapidly verifying credentials during a disaster can be logistically challenging.
T86 13896-13983 Sentence denotes It is important that the staff available to respond have adequate preparation to do so.
T87 13984-14078 Sentence denotes Critical care physicians in general are poorly prepared to respond to mass casualty disasters.
T88 14079-14324 Sentence denotes 3, 4, 69 A study 70 of other physician groups report that preparedness for bioterrorism or public health emergencies are particular areas of weakness, and deficiencies in training to respond to mass casualty events are not limited to physicians.
T89 14325-14453 Sentence denotes Hospital administrators, who are often called on to lead the response in a health-care facility, also lack appropriate training.
T90 14454-14456 Sentence denotes 71
T91 14457-14637 Sentence denotes Critical care requires specific functionalities, including electricity, oxygen, suction, medical gas, monitoring equipment, and physical space for equipment and patient management.
T92 14638-14808 Sentence denotes As a result, there are limited areas in which critical care can be provided on a routine basis outside of current critical care areas (ICU, postanesthesia care unit, ED).
T93 14809-14942 Sentence denotes As with staffing, some hospitals face shortages of critical care spaces, 46,71-73 although occupancy varies across the United States.
T94 14943-15068 Sentence denotes In Ontario in 2006, there were 1,789 critical care beds, 1,057 of which were capable of accommodating mechanical ventilation.
T95 15069-15121 Sentence denotes 74 The occupancy rate for these beds approaches 90%.
T96 15122-15245 Sentence denotes 50 Demands on critical care resources are expected to increase in both the United States and Canada as the populations age.
T97 15246-15424 Sentence denotes 75 On a day-to-day basis, additional capacity can be created in the critical care system by expanding critical care to areas of the hospital such as the postanesthesia care unit.
T98 15425-15517 Sentence denotes However, this expansion is still limited by the issues of stuff and staff discussed earlier.
T99 15518-15779 Sentence denotes Therefore, even though the bed spaces may be available to use for critical care, if the hospital rents its ventilators and has no more on site, the ability to expand critical care remains limited unless specific advanced planning and preparation are undertaken.
T100 15780-16129 Sentence denotes Finally, although it is possible to convert off-site locations 17, 53 (ie, hotels, gymnasiums, sports fields) into medical treatment facilities, the ability to convert such areas to critical care facilities on a large scale is curtailed because of the functional requirements and logistical challenges, such as large-volume portable oxygen supplies.
T101 16130-16330 Sentence denotes While unlimited stockpiles of medical equipment could mitigate the shortfall of critical care resources during a disaster, this is not a realistic solution in part because of the costs of stockpiling.
T102 16331-16527 Sentence denotes Extrapolating from even an incomplete list of equipment required to care for critically ill patients 53 results in an estimated cost of $1,789,876 to manage 100 critically ill patients for 3 days.
T103 16528-16701 Sentence denotes This cost does not take into account the cost of the financing to purchase the stockpile or the potential returns from alternative investments those funds could be used for.
T104 16702-16796 Sentence denotes This considerable expense also does not include the cost of maintaining and storing equipment.
T105 16797-16922 Sentence denotes Furthermore, the period of treatment being considered is very short and not representative of the typical length of ICU stay.
T106 16923-17021 Sentence denotes Thus the cost is substantial, imposing significant fiscal limitations on the ability to stockpile.
T107 17022-17141 Sentence denotes Therefore, a balance must be struck between service provision today and preparation for potential events of the future.
T108 17142-17199 Sentence denotes Finally, stockpiling does not resolve the staffing issue.
T109 17200-17363 Sentence denotes One option most health-care facilities consider when they are overwhelmed is to seek help from outside, either by transferring patients out or having help sent in.
T110 17364-17625 Sentence denotes 14 Generally, if a health-care facility elects to transport a patient to another hospital for ongoing treatment because it does not have the ability or resources to manage that patient, it is the responsibility of the sending facility to arrange transportation.
T111 17626-17750 Sentence denotes However, this is often difficult to do during a disaster when ambulances are occupied with the ongoing prehospital response.
T112 17751-17946 Sentence denotes Moreover, most areas will not have a sufficient number of dedicated critical care transport teams to evacuate large numbers of critically ill; thus, regular critical care staff would be required.
T113 17947-18163 Sentence denotes This would take critical care staff away from the hospital during transport and would be an inefficient use of valuable staff (ie, 2:1 or 3:1 registered nurse/respiratory technician/ medical doctor-to-patient ratio).
T114 18164-18470 Sentence denotes If local resources are insufficient for patient evacuation, the US Department of Health and Human Services maintains contracts with a private ambulance service for ground transport coordination, and the Department of Defense is responsible for evacuation within the National Disaster Medical System (NDMS).
T115 18471-18632 Sentence denotes 76 Although the Department of Defense is capable of transporting critically ill patients, 5,77 its ability to do so is has been estimated at 81 patients in 54 h.
T116 18633-18961 Sentence denotes Civilian ground, aeromedical rotor-wing, and fixed-wing assets may assist, if not dedicated to the on-scene major incident response, but the total number of aircraft in the United States is limited (eg, 800 civilian rotor-wing aircraft), 78 and all are designed for the transport of one to two critically ill patients at a time.
T117 18962-19198 Sentence denotes This limited capacity certainly is not sufficient to move large surges of critically ill patients; nor is it likely that these transport assets from outside regions will be available during the first 12 to 24 h of a mass casualty event.
T118 19199-19317 Sentence denotes Thus, a hospital cannot rely on immediately evacuating critically ill patients as a response to a mass casualty event.
T119 19318-19400 Sentence denotes If patients cannot go to help, then it is logical for help to come to the patient.
T120 19401-19501 Sentence denotes Depending on the situation, assistance can come from the local, regional/ state, or national levels.
T121 19502-19625 Sentence denotes Local assistance is usually facilitated by the sharing of staff in an emergency through a prearranged mutual aid agreement.
T122 19626-19829 Sentence denotes 53 This type of an arrangement can be very useful in the event of small surge situations, but is not helpful in the type of mass casualty scenario where all hospitals in a local area will be overwhelmed.
T123 19830-19940 Sentence denotes The US federal health response includes the NDMS to address medical and mental health needs during a disaster.
T124 19941-20153 Sentence denotes 79 The NDMS was created to address civilian disasters and military contingencies in which there might be a large number of casualties that cannot be accommodated by the Departments of Defense or Veterans Affairs.
T125 20154-20360 Sentence denotes 76 The NDMS is a private/public partnership that includes a number of specialized teams comprising some 7,000 to 8,000 volunteers and a network of 2,000 hospitals with a total of approximately 100,000 beds.
T126 20361-20422 Sentence denotes Similar teams are being developed elsewhere in North America.
T127 20423-20488 Sentence denotes 52 The NDMS has been a valuable resource in many prior disasters.
T128 20489-20691 Sentence denotes 80 However, there are significant concerns that the system is not equipped to respond to an event involving large numbers of critically ill patients, particularly a biological event, such as a pandemic.
T129 20692-20854 Sentence denotes 14 Disaster Medical Assistance Teams (DMATs) of the NDMS are made up of practicing clinicians who will leave their local communities and deploy to disaster sites.
T130 20855-21250 Sentence denotes While it may be possible to piece together a team or two of available volunteers from a distant unaffected area to respond to a geographically isolated event, it will be a significant challenge to find enough available DMAT members to meet the needs of many communities during a widespread event, such as an influenza pandemic or simultaneous terrorist attacks in major cities across the nation.
T131 21251-21348 Sentence denotes For disasters in which DMATs are available, another limitation is their critical care capability.
T132 21349-21515 Sentence denotes The teams are staffed primarily by members who are not trained in critical care, and the teams are not equipped to provide critical care beyond initial resuscitation.
T133 21516-21670 Sentence denotes 81 The primary responsibilities of DMATs include triaging patients, providing medical care in austere environments, and preparing patients for evacuation.
T134 21671-21865 Sentence denotes Finally, assuming that DMATs are able to be staffed and equipped to provide critical care on a large scale, they still face the issue of time, something many critically ill patients do not have.
T135 21866-21938 Sentence denotes Because of logistic issues, deployment typically may take hours to days.
T136 21939-22027 Sentence denotes 82, 83 This is not unique to DMATs but a fact for any deployable disaster response team.
T137 22028-22201 Sentence denotes 27 However, unlike many less acutely injured patients in past disasters, critically ill patients are unlikely to survive without care while awaiting the arrival of the team.
T138 22202-22384 Sentence denotes Although great strides have been made to prepare the health-care system to respond to disaster, these plans fall short for mass casualty events with a large number of critically ill.
T139 22385-22560 Sentence denotes Most countries have insufficient critical care staff, medical equipment, and ICU space to provide timely, usual critical care to a surge of critically ill and injured victims.
T140 22561-22770 Sentence denotes Were a mass casualty critical care event to occur tomorrow, many people with clinical conditions that are survivable under usual health-care system conditions might have to forgo life-sustaining interventions.
T141 22771-22847 Sentence denotes Failure to provide critical care will likely result in high mortality rates.