Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicines Task Force for intensive care unit triage during an influenza epidemic or mass disaster



# Introduction
In 2007, the European Society of Intensive Care Medicine established a Task Force for Intensive Care Unit (ICU) Triage during an Influenza Epidemic or Mass Disaster to develop recommendations and standard operating procedures (SOPs). At that time worldwide intensive care, infectious disease/microbiology and pulmonary societies sent representatives to participate. Based on a literature review and expert opinion, a Delphi process was used to define the essential topics. This review provides the recommendations and SOPs of the Task Force focusing on the ICU and H1N1. Key points for each of these topics are noted in [fig_ref] Table 1: Key points 1 [/fig_ref]. The information should also be helpful for other hospital areas and other mass casualty events (MCEs). Preliminary information regarding H1N1 patients is available. Approximately 8% of H1N1 patients are hospitalized [bib_ref] Infection and death from Influenza A H1N1 virus in Mexico: a retrospective..., Echevarria-Zuno [/bib_ref] (23 per 100,000 population) , and 6.5-25% of these require being in the ICU [bib_ref] Critically ill patients with 2009 Influenza A (H1N1) in Mexico, Dominguez-Cherit [/bib_ref] (28.7 per million inhabitants)for a median of 7-12 days [bib_ref] Intensive care adult patients with severe respiratory failure caused by Influenza A..., Rello [/bib_ref] with a peak bed occupancy of 6.3-10.6 per million inhabitants; 65-97% of ICU patients require mechanical ventilation [bib_ref] Infection and death from Influenza A H1N1 virus in Mexico: a retrospective..., Echevarria-Zuno [/bib_ref] [bib_ref] Intensive care adult patients with severe respiratory failure caused by Influenza A..., Rello [/bib_ref] , with median ventilatory duration for survivors of 7-15 days [bib_ref] Critically ill patients with 2009 Influenza A (H1N1) in Mexico, Dominguez-Cherit [/bib_ref] [bib_ref] Intensive care adult patients with severe respiratory failure caused by Influenza A..., Rello [/bib_ref] ; 5-22% require renal replacement therapy [bib_ref] Intensive care adult patients with severe respiratory failure caused by Influenza A..., Rello [/bib_ref] , and 28-day ICU mortality is 14-40% [bib_ref] Critically ill patients with 2009 Influenza A (H1N1) in Mexico, Dominguez-Cherit [/bib_ref] [bib_ref] Intensive care adult patients with severe respiratory failure caused by Influenza A..., Rello [/bib_ref]. Search terms used for the literature review are in Appendix [fig_ref] Table 1: Key points 1 [/fig_ref]. The authors' first-hand experience with emergency responses is found in Appendix [fig_ref] Table 2: Essential medical equipment, pharmaceuticals and supplies triple, double and single lumen for... [/fig_ref].

## Surge capacity and infrastructure considerations
The type of MCE is a major determinant of the demands on a hospital. The proportion of ICU beds occupied by patients with H1N1 varies. In Australia and New Zealand, it peaked at 9-19%, but in Mexico they were overwhelmed, and many patients required ventilation outside ICUs [bib_ref] Critically ill patients with 2009 Influenza A (H1N1) in Mexico, Dominguez-Cherit [/bib_ref]. Critical care capacity is a key element of hospital surge capacity planning. Critical care physicians and staff should be involved with the development of SOPs for their institution and understand their roles during a response.
Surge capacity spans a continuum of care across conventional (usual spaces, staff and resources), contingency (functionally equivalent care using non-traditional patient care space, staff and resources) and crisis (sufficiency of care in a scarce resource setting) [bib_ref] Refining surge capacity: conventional, contingency, and crisis capacity, Hick [/bib_ref]. The institutional plan should account for the provision of care across this surge capacity spectrum so that the maximum number of patients can be treated during each phased response appropriate to the demands. Hospitals should be able to increase their ICU beds to the maximal extent by expanding ICUs and other areas with appropriate beds and monitors. Increases beyond 25% over usual capacity are unlikely with the current H1N1 virus. Future mutations, outbreaks or MCE may require maximum feasible expansion of capacity. This maximal feasible number will vary between institutions and countries, and be determined by the number of excess ICU patients, the usual ICU bed proportion of the total population and the maximum feasible expansion. One group has recommended a 300% expansion target, but many facilities may not be able to reach this target and should consider phased expansion to double capacity [bib_ref] Summary of suggestions from the Task Force for Mass Critical Care summit, Devereaux [/bib_ref].
Designated locations for expansion should be prioritized by expanding existing ICUs, using postanesthesia care units and emergency departments to capacity, then step-down units, large procedure suites, telemetry units and finally hospital wards [bib_ref] Definitive care for the critically ill during a disaster: medical resources for..., Rubinson [/bib_ref]. Hospitals should balance ICU needs and the potential decreasing benefits of increasing ICU capacity due to excess workload [bib_ref] Hospital mortality in relation to staff workload: a 4-year study in an..., Tarnow-Mordi [/bib_ref] with other hospital needs that may suffer more as services are depleted. During the surge of patients, stable patients may have to be transferred to other facilities [bib_ref] Summary of suggestions from the Task Force for Mass Critical Care summit, Devereaux [/bib_ref].
Worksheets and SOPs should reflect the specifics of the three phases to be easily used in an incident. The overall goal should be to place unstable and highly resource-dependent patients in usual critical care areas and move stable and less resource-dependent ICU patients to non-traditional areas until the situation improves or until patients can be transferred to other facilities [bib_ref] Definitive care for the critically ill during a disaster: a framework for..., Rubinson [/bib_ref].
Effective management of a ''surge'' of ICU patients may require mass critical care. This is dependent on the institution having the procedures, training and integrated support of a broad range of stakeholders as well as adequate space, staff and supplies. An appropriate incident management system should be utilized to gather information and make decisions about service provision, set operational objectives and define the resources that need to be obtained or the adaptations that should be made. Decision-makers should communicate with community emergency services and other local hospitals to ensure a coordinated approach to patient transfers, standards of care and resource allocation [bib_ref] Medical surge capacity and capability: a management system for integrating medical and..., Barbera [/bib_ref]. Infection control personnel should create a phased plan to accommodate larger numbers of patients with highly infectious diseases. Planning should account for ongoing support for infrastructure protection, power, water, oxygen, suction and compressed air provisions, which are also necessary. Laboratory, radiology, nutrition and other departments should help meet ICU disaster needs and be engaged in prioritization of support services (minimizing tests ordered and restrictions to essential tests).

## Coordination and collaboration with interface units
During a MCE ICUs should effectively collaborate with their hospital coordinating structure, other hospitals and regional resource authorities to ensure the best possible patient care. A detailed SOP for coordination and collaboration should be formulated and components tested by simulation during the pre-crisis phase, implemented when the crisis occurs, updated as the crisis evolves and evaluated and improved in the post-crisis phase. While a general SOP can serve as a guide, situational knowledge is key to the preparation of the detailed systems and guidelines.
A communication, coordination and collaboration system should be developed between the ICU and key departments, such as central hospital administration, clinical departments (e.g., internal medicine, surgery, operating rooms, emergency department), nursing, infectious diseases, laboratory services and supporting services such as radiology, physiotherapy, housekeeping and medical supplies [fig_ref] Figure 1: Schematic algorithm describing key lines of authority [/fig_ref].
Each region should establish an Incident Management System (IMS) with Emergency Executive Control Groups at facility, local, regional/state or national levels to exercise authority and direction over resources. Each IMS includes five functional areas-command, operations, planning, logistics and finance/administration [bib_ref] Emergency preparedness: what every healthcare worker needs to know, Christian [/bib_ref]. Within the regional IMS is a Central Triage Committee of experts with broad situational awareness, capacity to develop and modify protocols, monitor outcome and coordinate responses. Cooperation and communication between various levels are essential [bib_ref] Development of a triage protocol for critical care during an influenza pandemic, Christian [/bib_ref]. with Emergency Executive Control Groups at facility, local, regional/state or national levels to exercise authority and direction over resources Developing fair and equitable policies may require restricting ICU services to patients most likely to benefit Usual treatments and standards of practice may be impossible to deliver ICU care and treatments may have to be withheld from patients likely to die even with ICU care and withdrawn after a trial in patients who do not improve or deteriorate Triage criteria should be objective, ethical, transparent, applied equitably and be publically disclosed Critical care triage protocols for mass casualty events should only be triggered when critical care resources across a broad geographic area are or will be overwhelmed despite all reasonable efforts to extend resources or obtain additional resources Triage of patients for ICU should be based on the likelihood for patients to benefit most or a 'first come, first served' basis Critically ill patients will be assessed by a triage officer who will apply inclusion and exclusion criteria to determine their qualification for ICU admission When resources permit, emergency triage should cease in a graduated fashion by altering prioritization criteria and then exclusion thresholds 8. Medical procedures Specify high risk procedures (aerosol-generating procedures) Determine if certain procedures will not be performed during a pandemic Develop protocols for safe performance of high-risk procedures that include appropriateness, qualifications of personnel, site, PPE, safe technique and equipment needs Ensure adequate training of personnel in high-risk procedures Procedures should be performed at the bedside whenever possible Ensure safe respiratory therapy practices to avoid aerosols Provide safe respiratory equipment (i.e., adequate filters, closed suctioning, etc.) Determine criteria for cancelling and/or altering elective procedures 9. Educational process Preparation will depend on adequate training and education of ICU, ward staff and those co-opted to perform new roles Training should begin as soon as possible with demonstrations followed by supervised practice The staff should be educated about the disease, its ramifications and treatment The hospital command structure should be trained in crisis management procedures Subjects to be taught include medical management, personal protection techniques, environmental contamination, laboratory specimens, alert lists, training of non-ICU staff pre-determined tasks, ethical issues, dealing with the deceased and families of dying patients and visitors restrictions Mortality, although inevitable during a disaster or influenza outbreak, can be reduced by adequate preparation including education and training The administration should identify the staff to participate in training programs, verify that they participated and evaluate their knowledge annually SOP standard operating procedure It is important to clearly identify key functions requiring coordination and collaboration. The most important functions are manpower, resource utilization and re-allocation of personnel, equipment and physical space. Clinical information should be shared through a unified hospital database.
Guidelines for the systematic management of patient admission and discharge to the hospital and between hospital departments (particularly the ICU) should be developed. Appropriate personnel to function as interdepartmental contacts, such as an ICU Triage officer, Infection Control Officer, Emergency Department Admissions and/or Patient Transfer Officer should be identified. Inter-departmental contact methods (creating and promulgating master contact lists) should also be developed.
Creating systems and guidelines is not sufficient. The roles and responsibilities of key individuals necessary for the implementation of the guidelines should be defined. These individuals should be properly trained to perform their duties [bib_ref] Healthcare worker competencies for disaster training, Hsu [/bib_ref] [bib_ref] Effectiveness of hospital staff masscasualty incident training methods: a systematic literature review, Hsu [/bib_ref] [bib_ref] The effectiveness of disaster training for health care workers: a systematic review, Williams [/bib_ref]. Not only should operational guidelines be developed, but the availability of sufficient equipment should be ensured and an adequate physical environment to allow staff to properly implement the guidelines and function optimally should be implemented. Hospitals should utilize this approach with cooperation at the local, regional and national levels . As ICU resources are frequently limited and vary in quantity and complexity from hospital to hospital, direct coordination with a regional ICU authority is recommended to share information regarding availability of vital equipment, manpower and pharmaceuticals.
Clinicians should join regional databases with a common global registry of ICU H1N1 patients to gain important, timely information for treating severe H1N1 patients. Information can help to evaluate triage decisions and provide data to areas not yet affected by a pandemic. Randomized controlled trials testing treatment strategies should be expedited with rapid Investigational Review Board approvals [bib_ref] Clinical research ethics for critically ill patients: a pandemic proposal, Cook [/bib_ref]. provides the Hospital EECG with information such as ICU functionality, capacity, projected staff and supply requirements, and preferred triage and discharge policies. The ICU EECG ensures that relevant policies agreed upon and endorsed by the HEECG are implemented within the ICU. It is made up of at least the ICU director, a deputy, the head nurse and deputy, and one or more triage officers. In the case of multiple ICUs in a hospital under different administrative authorities, each ICU should have an independent ICU EECG. An additional combined ICUEECG may be considered desirable. Other potentially important interfaces are shown

## Manpower
During disasters staffing may be limited due to staff absenteeism, illness and closure of child care facilities. Planning to coordinate and increase staff is necessary for continued and expanded ICU care. This includes increasing intensivists and expanded practice for non-critical care personnel. Roles and responsibilities of key individuals expanding the work force should be defined before the disaster. Education, preparation and communication are required to ensure a well-protected and prepared workforce. Coordinated manpower expansion should include adequate psychosocial and family support and adequate rest and support. The number of trained staff is the dominant rate-limiting step to increasing surge capacity. The following groups may be able to provide staff to work in the ICU: medical and nursing staff, respiratory care practitioners/therapists, pharmacists, administrators, ancillary staff (assistants, transport, social services, clergy, housekeeping, clerks), support therapists (occupational, physical and speech), clinical infectious disease and microbiology laboratory support, radiology, surgical and other equipment specialists, infection control and health care epidemiologists, dieticians, volunteers, retirees and physical and environmental support. The ICU needs should be balanced against other hospital service needs.
The scope of practice for non-critical care personnel should be expanded to provide critical care. These personnel may include hospital-based specialists, primary care physicians, surgical sub-specialists, medical/surgical nurses, respiratory therapists, medical and nursing students, veterinarians, dentists and other health professionals. Only clinical staff should provide care to patients. Credentialing and training should be provided by the hospital in coordination with regulatory authorities.
Manpower needs should be assessed by the operations, logistics and planning sections of the Hospital Emergency Executive Control Group. They coordinate all clinical and non-clinical staffing requirements and determine the ICU and hospital's daily needs including a sick and no-show list. A central inventory of all clinical and non-clinical staff with their current roles along with potential emergency re-training possibilities should be maintained. Staffing needs (housing, food, family support and childcare) and appropriate protective measures (vaccinations, protective equipment and antivirals) along with the appropriate training should be provided. Staffing ratios may have to be altered to compensate for working in a unfamiliar environment, use of less skilled staff and time to don personal protection equipment (PPE). Once hospital manpower needs are exceeded, the local authority followed by regional or national authorities may provide support for health care facilities.
Recommendations for increasing the labor pool and their functions include:

## Essential equipment, pharmaceuticals and supplies
Hospitals should ensure that adequate essential medical equipment, pharmaceuticals and other important supplies hereafter referred to as resources are available during a disaster. As resources are depleted local/regional/state/ country authorities may have to provide additional support. They should let hospitals know in advance what resources will be potentially available. The Hospital Emergency Executive Control Group should liase with key personnel within various departments to determine the required resources, order and stockpile adequate numbers and judiciously distribute them. Depending on sources of supply, which may vary in different countries, ICU, hospital and regional stockpiles may have to be increased by weeks or even months.
Essential medical equipment, pharmaceuticals and supplies are shown in [fig_ref] Table 2: Essential medical equipment, pharmaceuticals and supplies triple, double and single lumen for... [/fig_ref]. Prompt medical treatment should include neuraminidase inhibitors as survivors were more likely to have received treatment, although this was only one study with a low level of evidence [bib_ref] Critically ill patients with 2009 Influenza A (H1N1) in Mexico, Dominguez-Cherit [/bib_ref].
During MCEs, hospitals may have to consider restricting interventions that (1) have demonstrated an improved survival and without which death is likely, (2) require extraordinarily expensive equipment and (3) consume extensive staff or hospital resources [bib_ref] Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations..., Rubinson [/bib_ref].
Most hospitals cannot double the number of ventilators required during a disaster and will have to attempt to procure new ones [bib_ref] Definitive care for the critically ill during a disaster: medical resources for..., Rubinson [/bib_ref]. Additional ventilators should have as many of the following attributes as possible: be portable, provide adequate gas exchange for a range of clinical conditions, function with low-flow oxygen without high pressures (important with a loss of high-pressure oxygen supply due to expansion outside conventional hospital settings or failure of delivery), provide volume and pressure control ventilation, be safe for patients (disconnect alarms) and safe for staff (reduce staff time in patients' rooms) [bib_ref] Summary of suggestions from the Task Force for Mass Critical Care summit, Devereaux [/bib_ref] [bib_ref] Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations..., Rubinson [/bib_ref]. If sufficient ventilators are not available, manual ventilation is usually not recommended because of operator fatigue, patient hypoventilation and high risk for disease transmission. Each facility should determine whether manual ventilation will be considered based on availability of personnel, equipment and safety for staff. Some H1N1 ICU patients have experienced severe hypoxemia requiring advanced ventilatory support and rescue therapies including high levels of inspired oxygen and positive end-expiratory pressure (PEEP), pressure control ventilation, inhaled nitric oxide, highfrequency ventilation, prone positioning ventilation and ECMO [bib_ref] Critically ill patients with 2009 Influenza A (H1N1) in Mexico, Dominguez-Cherit [/bib_ref] [bib_ref] Intensive care adult patients with severe respiratory failure caused by Influenza A..., Rello [/bib_ref]. If hospitals cannot provide such services, they should consider transferring patients with severe disease to regional centers [bib_ref] Preparing for the sickest patients with 2009 influenza A (H1N1), White [/bib_ref].
As resources are depleted:
1. Pharmacies may need to make drug substitutions, decrease medication frequency, change parenteral to oral or enteral administration, restrict medications, extend drug shelf-life and authorize certain medical personnel to prescribe scarce medications. 2. If sufficient resources are not available for all patients, triage of scarce resources should be based on those who are likely to benefit mostor on a 'first come, first served' basis.

## Protection of patients and staff
It is important to clarify the potential safety issues for health care staff during a pandemic. Plans to provide the best achievable care for as many patients as possible will be predominantly dependent on staff availability. Information from major events suggests that advanced preparation for maintaining staff confidence and morale helps to maintain response systems created for such circumstances [bib_ref] Summary of suggestions from the Task Force for Mass Critical Care summit, Devereaux [/bib_ref] [bib_ref] Infection control and anesthesia: lessons learned from the Toronto SARS outbreak, Peng [/bib_ref]. Patient and staff protection requirements can be broadly divided into two main areas: clinical and nonclinical risks. Clinical risks relate to potential disease transmission for which infection control and occupational health policies are important as well as adequate equipment and manpower. Non-clinical risks predominantly relate to staff members, the most concerning being those that may undermine confidence. Lack of confidence may influence attendance and willingness to undertake challenging additional responsibilities and hence impact on patient care. Therefore, in the presence of uncertainty, staff protection should start at the highest level and then be gradually reduced. Institutions should prepare formal reassurance plans for legal protection and for assisting staff working outside their normal domain. Debriefing and communication may reduce psychological stress for both staff and patients. Given the medical-legal implications of many decisions, comprehensive documentation is essential. Support of relevant professional organizations and medical/nursing authorities will also benefit members working outside their normal areas of expertise.
Risks include
- risks of infection or contamination (work-acquired, family transmission, community/travel acquired), - work implications (compromised care standards, treatment limitations or withdrawal, excessive working time, disagreement on decisions, working outside normal domain) - personal/psychological (anxiety about personal and family risks, distress on triaging, death of family members/ friends, potential errors caused by excessive/inappropriate workload, antisocial relatives' reactions, fatiguerelated anxiety, lack of confidence in employer support), - potential litigation (triaging, care compromised by working outside area of expertise, excessive workload) - security (triage decisions may lead to threats or violence)
Handwashing, wearing gloves and gowns and use of N95 respirators reduces the transmission of epidemic respiratory viruses [bib_ref] Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic..., Jefferson [/bib_ref]. The low rate of nosocomial transmission among ICU patients during the recent H1N1 flu outbreak [bib_ref] Critically ill patients with 2009 Influenza A (H1N1) in Mexico, Dominguez-Cherit [/bib_ref] may be because of following the robust infection control procedures proven to reduce the risk of contracting severe acute respiratory syndrome (SARS) from patients [bib_ref] Transmission of SARS to healthcare workers: the experience of a Hong Kong..., Gomersall [/bib_ref]. For diseases with high rates of transmission, the risk to staff versus the benefit to patients should be weighed. Although wearing surgical masks may provide similar benefits [bib_ref] Surgical Mask vs N95 respirator for preventing influenza among health care workers:..., Loeb [/bib_ref] , there are still concerns that masks may not be sufficiently protective for the number of aerosol-generating procedures in the ICU. Staff training in PPE use (e.g., fit-testing for N95 respirators, avoiding contamination when placing/ removing, environmental cleaning, etc.) is essential [bib_ref] Increase in methicillin-resistant Staphylococcus aureus acquisition rate and change in pathogen pattern..., Yap [/bib_ref]. The use of negative pressure isolation rooms with adequate ventilation facilities is also recommended although they may be limited in many ICUs and expanded areas. The possibility of reducing the risk of airborne pathogens by modifying ICU design [bib_ref] Factors involved in the aerosol transmission of infection and control of ventilation..., Tang [/bib_ref] may also be of benefit.

## Critical care triage
MCEs generate many critically ill patients that can overwhelm health care resources [bib_ref] Definitive care for the critically ill during a disaster: current capabilities and..., Christian [/bib_ref]. Triage is used to guide the prioritization of limited resources following disasters [bib_ref] Pandemic influenza threat and preparedness, Fauci [/bib_ref] [bib_ref] Comparative analysis of multiple-casualty incident triage algorithms, Garner [/bib_ref] [bib_ref] Pediatric triage: a system to JumpSTART your triage of young patients at..., Romig [/bib_ref] [bib_ref] Evolution of triage systems, Robertson-Steel [/bib_ref] [bib_ref] Triage in medicine, part I: concept, history, and types, Iserson [/bib_ref] [bib_ref] Triage in medicine, part II: underlying values and principles, Moskop [/bib_ref]. In severe circumstances insufficient ICU bed availability may result in the occurrence of potentially avoidable deaths, which may be influenced by compulsory triaging decisions. Triage protocols for ICUs have been developed based on the probability that needs during a disaster are greater than availability [bib_ref] Summary of suggestions from the Task Force for Mass Critical Care summit, Devereaux [/bib_ref] [bib_ref] Development of a triage protocol for critical care during an influenza pandemic, Christian [/bib_ref] [bib_ref] Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations..., Rubinson [/bib_ref] [bib_ref] Definitive care for the critically ill during a disaster: a framework for..., Devereaux [/bib_ref] [bib_ref] Allocation of ventilators in a public health disaster, Powell [/bib_ref]. Ideally triage plans should be developed at a national or regional level.
Developing fair and equitable policies for ''the greatest good for the greatest number'' of patientsmay require restricting services to patients likely to benefit from ICU care. Usual treatments and standards of practice may be impossible to deliver. ICU care and treatments may have to be withheld from patients likely to die even with ICU care and withdrawn after a trial in patients who do not improve or who deteriorate [bib_ref] Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations..., Rubinson [/bib_ref]. In an influenza pandemic, hospitals should expect the greatest surge of ICU patients approximately 4-6 weeks after the first confirmed winter ICU admission and extra workload and resource use lasting several weeks.
Triage criteria should be objective, ethical, transparent, applied equitably and publically disclosed. ICU triage protocols include inclusion criteria that identify patients who may benefit from ICU admission [fig_ref] Table 3: Inclusion criteria for admission to critical care during a mass casualty event [/fig_ref] and exclusion criteria that identify patients who are not candidates for ICU admission including patients: (1) with a poor prognosis despite ICU care, (2) requiring resources that cannot be provided, (3) whose underlying illness has a poor prognosis with a high likelihood of death and (4) who are ''too well'' [bib_ref] Development of a triage protocol for critical care during an influenza pandemic, Christian [/bib_ref].
ICU triage protocols for pandemics should only be triggered when ICU resources across a broad geographic area are or will be overwhelmed despite all reasonable Hypotension (SBP \90 mmHg or relative hypotension) with clinical evidence of shock (altered level of consciousness, decreased urine output or other end organ failure) refractory to volume resuscitation requiring vasopressor/inotrope support efforts to extend resources or obtain additional resources [bib_ref] Definitive care for the critically ill during a disaster: a framework for..., Devereaux [/bib_ref]. The triage of patients for ICU care remains controversial. Experts have recommended accepting patients likely to benefit most from ICUor on a 'first come, first served' basis. Each institution should determine its own triage criteria using senior clinicians in a transparent fashion. All critically ill patients will be assessed by a triage officer who should apply inclusion and exclusion criteria together possibly with a prioritization tool to determine qualification for ICU admission [bib_ref] Development of a triage protocol for critical care during an influenza pandemic, Christian [/bib_ref] (Tables 3, 4, 5 are one example to consider adapting to the situation). The [fig_ref] Table 5: Triage prioritization tool [/fig_ref] prioritization tool utilizes the sequential organ failure assessment (SOFA) score [bib_ref] Serial evaluation of the SOFA score to predict outcome in critically ill..., Ferreira [/bib_ref] [bib_ref] The sepsis-related organ failure assessment (SOFA) score to describe organ dysfunction/failure. On..., Vincent [/bib_ref]. The tool has limitations and has not yet been validated. Although SOFA day-1 scores have been shown to be significantly associated with 28-day and overall mortality in H1N1 patients, little improvement in SOFA scores between admission and day 3 casts doubt on the usefulness of re-assessing patients on day 2 [bib_ref] Critically ill patients with 2009 Influenza A (H1N1) in Mexico, Dominguez-Cherit [/bib_ref].
Patients not meeting inclusion criteria remain on the ward and can be re-evaluated. All ICU patients at the time of the MCE will also be assessed for eligibility based on the same criteria. Patients admitted to the ICU should subsequently be reassessed and re-categorized. When resources permit, emergency triage should cease in a graduated fashion by altering prioritization criteria and then exclusion thresholds.

## Medical procedures
Judicious planning for performance of procedures and monitoring during a pandemic is necessary to optimize outcomes in ICU patients. Adequate resources should be

## Procedures
Procedures that constitute a high risk for disease transmission [aerosol generating procedures (AGPs)] when performed on infected or potentially infected patients should be specified in advance [bib_ref] ICU management of severe acute respiratory syndrome, Lapinsky [/bib_ref]. Each facility should determine if certain AGPs will not be performed during a pandemic. Protocols should be developed for safe performance of high-risk procedures that address the following issues [bib_ref] Expanding ICU facilities in an epidemic: recommendations based on experience from the..., Gomersall [/bib_ref] : appropriateness of high-risk procedures, qualifications of clinicians performing high-risk procedures, required use of PPE during and following a high-risk procedure, optimal site for performing high-risk procedures, essential personnel and exposure time during high-risk procedures, room entrance and exiting during procedures and safe disposal of or adequate sterilization of utilized equipment. Appropriate equipment needs should be determined, and adequate training of personnel should be provided for high-risk procedures. Procedures should be performed at the bedside whenever possible, and appropriate safety precautions should be taken if patients are transported outside the ICU.
Respiratory/aerosol issues Safe practices and safe respiratory equipment are needed to minimize aerosol generation when caring for patients with influenza. These include minimizing disconnecting the ventilator circuit and using bag-mask ventilation, putting the ventilator on 'stand-by' mode before disconnecting the patient, and avoiding Venturi masks and nebulized medications. Respiratory equipment optimizing safety includes closed suction systems if available, high-quality bacterial/ viral filter attached to the expiratory port of ventilators, high-quality bacterial/viral heat and moisture exchanger and filter (HMEF) attached to the endotracheal tube/tracheostomy tube and a bacterial/viral filter attached to the expiratory port of the bag-mask ventilation device with another filter between the mask and valve. Use of heated humidifiers on ventilators should be avoided.

## Elective procedures
Each facility should determine criteria for cancelling and/ or altering elective procedures when resources are limited. The safety of areas (environment and equipment) used for elective procedures should be assessed to prevent exposure of uninfected patients to influenza.

## Educational process
The quality of health services depends upon an informed, committed and confident staff [bib_ref] Definitive care for the critically ill during a disaster: a framework for..., Devereaux [/bib_ref]. Training should begin as soon as possible followed by supervised simulations to ensure optimal use of available facilities and to minimize infections [bib_ref] SARS transmission among hospital workers in Hong Kong, Lau [/bib_ref]. PP techniques and reduction of environmental contamination should preferably be taught by infection control staff with assistance from ICU directors [bib_ref] Disaster preparedness lessons learned and future directions for education: results from focus..., Rebmann [/bib_ref]. Interventions aimed at changing clinical practice show that outreach visits, posted reminders, interactive educational meetings and other multifaceted interventions were Patients not meeting inclusion criteria remain on the ward and can be re-evaluated. Patients who are triaged as 'red' are given priority for ICU followed by those triaged as 'yellow'. Patients categorized as 'blue/black' remain on the ward and receive palliative care with active medical therapy at the discretion of the primary care physician with patient and/or family input. Patients admitted to ICU should be reassessed at days 2 and 5 and re-categorized. Decisions beyond ICU day 5 will be dependent upon resource availability. Although this triage procedure is based only on expert opinion [bib_ref] Development of a triage protocol for critical care during an influenza pandemic, Christian [/bib_ref] , an ICU trial with reappraisal at day 5 has proved useful in mechanically ventilated cancer patients [bib_ref] The ICU trial: a new admission policy for cancer patients requiring mechanical..., Lecuyer [/bib_ref]. It should be noted, however, that ventilated H1N1 patients had a median ventilatory duration in survivors of 7-15 days [bib_ref] Critically ill patients with 2009 Influenza A (H1N1) in Mexico, Dominguez-Cherit [/bib_ref] [bib_ref] Intensive care adult patients with severe respiratory failure caused by Influenza A..., Rello [/bib_ref] so reevaluation may have to be delayed effective, but time constraints and potential lethality of the disease were limiting factors [bib_ref] Closing the gap between research and practice: an overview of systematic reviews..., Bero [/bib_ref]. Seminars, on-site demonstrations, problem-based learning and simulations are valuable when time is of the essence. In the SARS epidemic, use of a simulator allowed effective training of 275 workers in 2 weeks [bib_ref] Infection prevention and control learning preferences of nurses sampled at a teaching..., Cheng [/bib_ref] [bib_ref] Using problem-based learning for pandemic preparedness, Marshall [/bib_ref] [bib_ref] Using simulation for training and to change protocol during the outbreak of..., Abrahamson [/bib_ref]. Teleconferencing involving clinicians and representatives from public health, infection control, infectious diseases, hospital administration and government together with website dissemination of instructional materials (http://www.eunid.eu/) is a useful tool for updating knowledge during a pandemic [bib_ref] Expanding ICU facilities in an epidemic: recommendations based on experience from the..., Gomersall [/bib_ref] [bib_ref] Severe acute respiratory syndrome and critical care medicine: the Toronto experience, Booth [/bib_ref].
Knowledge and compliance with PP protocols are poor, and consequently knowledge should be re-evaluated frequently [bib_ref] Evaluating the effectiveness of an emergency preparedness training programme for public health..., Wang [/bib_ref]. Although an element of coercion is frequently necessary [bib_ref] The use of personal protective equipment for control of influenza among critical..., Daugherty [/bib_ref] [bib_ref] Factors associated with critical-care healthcare workers' adherence to recommended barrier precautions during..., Shigayeva [/bib_ref] , reasons for poor compliance should be addressed. These include availability of appropriate equipment, quality of leadership and an organizational culture that promotes safety [bib_ref] Determinants of healthcare workers' compliance with infection control procedures, Yassi [/bib_ref]. These factors also reduce psychological stress by inspiring confidence [bib_ref] Psychological effects of the SARS outbreak in Hong Kong on high-risk health..., Chua [/bib_ref].
Areas requiring teaching and training are:
1. Personal protection techniques [bib_ref] Surgical Mask vs N95 respirator for preventing influenza among health care workers:..., Loeb [/bib_ref] Hand washing pre-and post-patient contact, procedures for donning and removing gowns, gloves, protective glasses, hoods, N95 respirators and powered air purifying respirators (including proper facial seal), personal hygiene (protected coughing, avoidance of touching the face, eyes or masks), proper disposal of contaminated materials and correct techniques for high-risk procedures such as mechanical ventilation, intubation, suctioning, tracheostomy and endotracheal tube care.
2. Medical management [bib_ref] WHO Rapid Advice Guideline Panel on Avian Influenza (2007 WHO Rapid Advice..., Schunemann [/bib_ref] Drug treatment (anti-virals and other typical drugs with doses and administration), mechanical ventilation and respiratory rescue strategies and palliative care.

## Environmental contamination
The use of correct specification pleated filters at the catheter mount and exhalation port [bib_ref] Mechanical ventilation of SARS patients: safety issues involving breathing-circuit filters, Anonymous [/bib_ref] , appropriate and safe disposal of organic and inorganic waste, and decontamination of floors, beds and respiratory equipment.

## Laboratory specimens
Management and transport of laboratory specimens in cooperation with the laboratory.

## Training of non-icu staff
Complete syllabi are available [bib_ref] Expanding ICU facilities in an epidemic: recommendations based on experience from the..., Gomersall [/bib_ref]. Tasks should be assigned and taught according to need. Ability to record blood pressure, pulse, respiratory rate, oxygenation, fluid intake and output, suctioning and attention to pressure sites are a minimum requirement. Palliative care and monitoring of noninvasive and mechanical ventilation should be considered.

## Alert lists
Design and instruction in clinical signs indicating deterioration potentially necessitating transfer to ICU.

# Ethical issues [68]
The duty to provide care efficiently and with compassion necessitates instruction in triage, including nonbeneficial treatments and allocation of vaccines and antiviral medicines, ventilators and ICU in resourcescarce environments.
8. Methods to deal with the deceased and families of dying patients 9. Policies for restricting visitors and mechanisms for enforcement 10. Community education Educational materials to reduce community spread should be available for distribution [CDC (http://www. cdc.gov/H1N1FLU/) and WHO (http://www.who.int/csr/ disease/swineflu/en/) websites]. The public should be informed that usual treatments may be impossible to deliver and treatments may have to be triaged but by avoiding unnecessary panic.

# Conclusions
These recommendations and SOPs have been developed to provide guidance in the preparation and management of a pandemic. This guidance should be used as a framework to guide the development of detailed systems and processes at a hospital. The detailed guidelines for Procedures with potential high risk for disease transmission Aerosol humidification Bag-mask ventilation Bronchoscopy Cardiopulmonary resuscitation Disconnection of endotracheal or tracheal tube from ventilator Extubation High-flow oxygen therapy High-frequency oscillatory ventilation Intubation Mechanical ventilation without HEPA filter on exhaust port Nasopharyngeal swabs Nasotracheal or orotracheal suctioning Nebulization of medications Noninvasive positive pressure ventilation Surgical airway HEPA high-efficiency particulate air frontline use should be a product of the SOP, local situational awareness and the specific threat faced. In the H1N1 setting, assumptions based on previous H1N1 data may change because of effective vaccinations, viral mutations and resistance to antiviral drugs. Rapidly evolving data should result in appropriate responses and changes in guidelines. Such changes will be necessary because preparations should occur as soon as possible. ''Any deaths from 2009 influenza A (H1N1) will be regrettable, but those that result from insufficient planning and inadequate preparation will be especially tragic [bib_ref] Preparing for the sickest patients with 2009 influenza A (H1N1), White [/bib_ref].''
[fig] Figure 1: Schematic algorithm describing key lines of authority (command chain) and information flow (bi-directional) during a MCE/crisis. The Hospital Emergency Executive Control Group (HEECG) is the central operations center with ''command and control'' responsibility for the overall management of the crisis. It should consist of the hospital chief, heads of all major clinical and support departments, and key supply and logistic divisions. The Hospital EECG should determine whether to open new wards, redeploy staff, suspend or redirect services (e.g., elective operations), prioritize the allocation of hospital supplies (including personal protective equipment), endorse triage policies, and formalize infection control and occupational health policies. The ICU EECG [/fig]
[table] Table 1: Key points 1. Introduction 2. Surge capacity and infrastructure considerations Hospitals should increase their ICU beds to the maximal extent by using monitored, procedure and recovery areas for critical care Hospitals should have appropriate beds and monitors for these Coordination and collaboration with interface units Regions should establish an Incident Management System withEmergency Executive Control Groups at facility, local, regional/ state or national levels to exercise authority and direction over resources A SOP provides a system of communication, coordination and collaboration between the ICU and key interface departments/ units The SOP should identify key functions or processes requiring coordination and collaboration, the most important of these being manpower and resources utilization (surge capacity) and re-allocation of personnel, equipment and physical space The framework provided by the SOP should allow smooth interdepartmental patient transfers Creating systems and guidelines is not sufficient, it is important to identify:The roles and responsibility of key individuals necessary for the implementation of the guidelines Ensure that these individuals are adequately trained and prepared to perform their roles Ensure sufficient equipment, pharmaceuticals and supplies and an adequate physical environment to allow staff to properly implement guidelines Trigger events for determining a crisis should be defined 4. Manpower The number of trained staff is the dominant rate limiting step to [/table]
[table] 1: Care should be provided by the most experienced clinicians available. 2. Assignments should be based on staff abilities and experience. 3. It may be necessary, under crisis conditions, for staff to undertake duties that are not within their usual scope [/table]
[table] Table 2: Essential medical equipment, pharmaceuticals and supplies triple, double and single lumen for central lines Catheter: regular peripheral intravenous Catheters: arterial lines Catheters: regular suction, closed-circuit suction, Yankauer suction Catheter: urinary and collection bags Catheter supplies: administration sets, flush, dressings Connector for suction catheter (finger tip) [/table]
[table] Table 3: Inclusion criteria for admission to critical care during a mass casualty event [/table]
[table] Table 5: Triage prioritization tool [/table]