series of suggestions with the aim of providing resource,
Care of the Critically Ill and
Injured During Pandemics
and Disasters
Groundbreaking Results from the
Task Force on Mass Critical Care
Christian E. Sandrock, MD, MPH, FCCP
Sacramento, CA
The critically ill are a unique group of patients in a
disaster response setting because they require resource-
intensive care, advanced and costly therapies, and
specialized settings and providers to deliver this care.1,2
They can present as a sudden surge of patients over a
short period of time, pushing the limits of the health-
care facility, or they can present over a sustained period
of time, such as was the case of the 2009 influenza
A(H1N1) pandemic, straining the larger regional health
system. In many disasters, such as the London bomb-
ings, the critically ill can present as both an immediate
surge and as a sustained intensive response, thus
presenting varying response needs throughout the
disaster.2,3 This variability with the most critically ill
creates uncertainty in health-care response because
local, regional, and national health-care systems may
have resource limitations, a paucity of medical expertise,
and structural compromise of health-care clinics and
hospitals at any given moment. The current Ebola
outbreak in West Africa best highlights the difficulties
surrounding critically ill patients in a very resource-
limited environment. However, regardless of the type of
disaster and the extent of the critically ill, planning for
this uncertainty in mass critical care is paramount to
ensuring good patient outcomes.3-5
In 2008, the American College of Chest Physicians
(CHEST) Task Force for Mass Critical Care published a
AFFILIATIONS: From the Intensive Care Unit, Division of Pulmonary
and Critical Care, Division of Infectious Diseases, University of
California, Davis School of Medicine.
FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported
to CHEST that no potential conflicts of interest exist with any
companies/organizations whose products or services may be discussed
in this article.
CORRESPONDENCE TO: Christian E. Sandrock, MD, MPH, FCCP, Inten-
sive Care Unit, Division of Pulmonary and Critical Care, Division of
Infectious Diseases, University of California, Davis School of Medicine,
4150 V St #3400, Sacramento, CA 95817; e-mail: cesandrock@ucdavis.edu
© 2014 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of
this article is prohibited without written permission from the American
College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.14-1900
journal.publications.chestnet.org
logistic, and patient-flow planning for mass critical care
in a disaster.1 Since the release of these documents,
disasters and pandemics, most notably the 2009 influenza
A(H1N1) pandemic the Haiti earthquake, and most
recently the Ebola outbreak in West Africa, have
provided additional learning experiences in mass critical
care.3,5-7 Because the 2008 documents were limited in
scope, without discussion of pediatrics, trauma, critical
care in the developing world, and subspecialty critical
care, the Task Force for Mass Critical Care was recon-
vened to provide a rigorously developed set of sugges-
tions with an expanded scope and expertise to support
critical care providers, hospital administrators, public
health officials, and government planners. The result,
published in CHEST, is an unparalleled, detailed series
of 14 articles that lays the strongest foundation for
disaster planning and response to date.8
The ultimate aim of the Task Force was to provide
recommendations for the management of all adults and
children critically ill because of a disaster or pandemic,
regardless of where the care is provided. However, in the
case of disaster response, no high-quality evidence exists
from which to develop recommendations.9 Disaster
response is rapid, large scale, and nonstandardized, and
thus, the ability to develop real-time studies is extremely
difficult. Evidence, therefore, is largely restricted to
retrospective case series, provider experience, and
expert opinion. To bridge this gap, the Task Force
convened an unprecedented group of experts, from
bedside physicians with deployment experience to
medical societies to government representatives, to offer
the best suggestions. Using a modified Delphi process,
the Task Force approached all aspects of care, from the
bedside to policy development to provider education, in
both a resource-intensive and a resource-limited setting
(the developing world).8 Although the Task Force’s
14 articles span many areas, their suggestions cover five
main levels of disaster response and planning: patient
care, disaster providers and responders, health-care
systems and hospitals, local and regional governments,
and community and society.
High-quality care of the critically ill is the foundation
of all disaster response efforts.1,5,8,10 However, a disaster
alters basic care delivery to the critically ill, and if
preparedness is inadequate, this foundation can
crumble, with adverse patient outcomes. The inability
to respond to an increase in patients and resource
demand has been directly linked to poor outcomes in a
number of disasters.3,7,11,12 Therefore, the management of
881
medications, medical supplies, oxygen therapy, mechanical
ventilation, specialized services (eg, dialysis), and ICU
location is detailed extensively over these 14 articles.
Methods of conservation (particularly with scarce
medication and oxygen therapy), substitution, and triage
are a particular focus, with the goal of optimizing
patient outcomes in mass critical care. These principles
are very relevant today, where the resource limitations in
West Africa are hindering both patient care and
outbreak management. For example, minimal ventilator
requirements are described to ensure both lung-protective
strategies and that high positive end-expiratory pressure
can be delivered in cases of ARDS. Antibiotic and
antiviral substitutions for certain disease states are
suggested, along with the minimal resources needed
to manage a highly contagious disease among the
critically ill. With this process, the Task Force sugges-
tions create the strongest foundation of care delivery
for the individual critically ill patient during a mass
critical care.
With a strong foundation of patient care established,
health-care providers for the critically ill need additional
support to ensure adequate, high-quality care.11,12 As
disasters evolve, treatments may change, thus requiring
rapid education of providers.4 When resources are
scarce, staff may need to triage those limited resources
among many patients, therefore requiring an ethical
system to determine resource use.1,2 An ICU subspe-
cialist, such as a burn surgeon, may have a limited ability
to cover large geographic areas. The Task Force sugges-
tions place a particular emphasis on the use of tech-
nology and telemedicine, particularly surrounding an
expanded scope of practice in some specialist-limited
areas (eg, burns and trauma).8 Baseline education and
just-in-time training, along with mental health support
during difficult decision-making, is also designed to
allow providers to deliver the best care without the
impact larger resource decisions would have. With these
suggestions, the health-care worker will be fully sup-
ported to deliver the best care possible at the bedside,
with a structured framework for triage and clinical
decision support, specialist support, and just-in-time
education for difficult-to-treat illnesses.
To optimize provider support and patient outcomes in
mass critical care, the Task Force offered a series of
suggestions aimed at hospitals and health-care systems.
The disaster literature focuses largely on patient-care
delivery and provider support, and the Task Force
realized that bedside care will suffer if health-care
communities are not prepared.1,2,9 The transition from
882 Editorials
daily patient care, such as elective surgery, to disaster
response and mass critical care is difficult, and if carried
out poorly or late, can lead to poor patient outcomes.4,13
Most health systems require little storage with real-time
delivery, and if not prepared with additional supplies,
patient care can suffer with even smaller surges of
critically ill patients.2,4,13 The disaster may involve the
health system itself, and business operations may need
relocation, thus affecting the continued ability to
provide both structure and supplies.13 The Task Force
recommendations of a 20% increase in surge within the
health system resources to a 200% surge with regional
and national resource support sets an international
benchmark for health system preparedness. These
suggestions, together with continuing operations
planning and disaster team structure, provide the
disaster response framework for a health system that can
ensure optimal critical care delivery during a disaster.
In a disaster, the health-care system can deliver optimal
critical care for a limited time, but eventually, regional
and national governments must provide support. With
mass critical care, the response system is stretched
immediately, with resources, staffing, and patient flow
impacted at the regional level.2,10,13 The suggestions of
the Task Force, most notably the coordination of patient
flow and resources, have not been described elsewhere
in the literature or in other disaster planning documents.
In a disaster, the traditional method of directly transfer-
ring a critically ill patient from a smaller, more remote
hospital to a larger, tertiary center cannot occur indepen-
dently of local and regional governments.1,2,4 If a
tertiary center is impacted, public health and govern-
ment officials must have the ability to triage patients
and coordinate flow to a less impacted area.4,14 This
process will require local and regional providers to
understand the needs of mass critical care, including
the ability to triage and recommend care substitutions,
rather than to rely on local providers in the field to
make these decisions.
In addition, the Task Force outlines these issues in more
resource-limited settings, such as the developing world
and areas without government support (nongovernmental
organizations).8 Thus, during a spectrum of response by
a government and health-care system, the progression of
triage from conventional to conservation and contin-
gency to crisis care has been fully aligned with this work.8
The Task Force’s vision of a large, central coordination of
patient flow, resources, and critical care expertise sets a
high but necessary benchmark for public health and
government officials.
[ 146#4 CHEST OCTOBER 2014 ]
However, the most important aspect of the Task Force’s
suggestions concerns the community and society. A
large-scale disaster can leave both small and large
populations without structure and government, and in
the absence of a planned and timely response, health-
care inequities can expand rapidly.1,14 These inequities
can undermine any government or nongovernmental
organization response, particularly within the popula-
tions most displaced and at risk, thus directly impacting
patient outcomes.14 Perhaps the Task Force’s greatest
contribution in these 14 manuscripts is when it dis-
cusses complex care delivery in an ethical and equal
fashion to critically ill patients. Political careers have
failed and governments have fallen when response to a
disaster has been inadequate.14 If one resource is limited
with adverse patient outcomes in one region while it is
freely available in another region, patient care will be
grossly inequitable. Despite excellent care delivery in
these settings, population mistrust of health-care
providers will occur and the high-quality response of
front-line critical care providers will be greatly under-
mined.1,14 This mistrust will herald a larger collapse of
the health system and eventually of the community.
These principles are currently prevalent in West Africa,
where the health-care community is seen as the source
of the Ebola spread, and governments and health-care
institutions are deemed inept, ineffectual, and a hin-
drance to good care. Thus, patients avoid the health-care
system, further carrying and spreading disease. The
effort of the Task Force to address inequity during
disaster response, from resource allocation triage to care
of special, vulnerable populations, is a massive step
toward correcting these inequities at times of greatest
stress on the health-care system.
While tackling the broad subject of mass critical care in
a disaster, the Task Force perfectly balanced the indi-
vidual with society, ultimately supporting the impor-
tance of justice. Any government official, politician,
public health expert, or policy expert should incorporate
these recommendations into disaster planning to ensure
optimal patient outcomes in an equitable fashion. John
Rawls,15 in A Theory of Justice, describes how individuals
who make choices about society (eg, politicians) should
consider resources concretely, because these resources,
such as income, wealth, liberty, and opportunity, are
ultimately the social basis for self-respect. Every person,
journal.publications.chestnet.org
regardless of circumstances, should have an equal right
to the most extensive system of liberties. From an
extreme paucity of evidence-based medicine, the Task
Force has ultimately created a foundation of disaster
response for the critically ill that provides justice to the
most adversely affected patients. In the current litera-
ture, there is no guideline, recommendation, study, or
consensus statement that can claim such a feat, and thus,
the work of the Task Force is unparalleled.
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