Background
Public health emergencies involving large numbers of ill or injured people place significant strain on the healthcare system's ability to respond. In mass care situations that affect a large region, basic healthcare resources may become scarce, especially if resupply is not an option and patients cannot be transferred to other hospitals.
Core clinical strategies form what is considered basic and necessary medical care during an emergency. These consist of approaches to maintaining access to resources in seven key areas: oxygen, staffing, nutritional support, medication administration, hemodynamic support and IV fluids, mechanical ventilation/external oxygenation, and blood products.
Specific issues
- Life-sustaining medical equipment may not be available for all people who need it during a large public health emergency.
- Different regions and hospitals may experience equipment shortages to various degrees, leading to geographic inequalities in healthcare provision during a widespread emergency.
The practice
The Minnesota Department of Health (MDH) developed a framework that hospitals and clinics can use to manage and extend medical resources for patient care during an emergency.
MDH created a decision support tool that recommends steps for continuing core clinical strategies when resources are scarce. The tool is intended to standardize responses to resource shortages when staff are operating under the Incident Command System and have a firm grasp of ethical decision-making during emergency situations. Healthcare facilities using the framework would contact the state public health agency if actions to address scarcity would span more than 24 hours without the option of obtaining resources or transferring patients to another institution.
The tool serves a number of purposes for clinicians and administrators working in a scarce-resource, emergency setting, including:
- Defining criteria that may help hospitals and clinics realize when they are facing a situation in which medical resources are/may become scarce
- Connecting with subject matter experts who have specialized knowledge about the extent of the problem and potential solutions
- Predicting need for scarce resources, the length of time scarcity would be an issue, and any available sources from which supplies could be obtained
- Recommending strategies to address resource scarcity or providing the necessary structure and guidance to develop thorough strategies that conform to the needs of the hospital
- Maintaining a consistent response to scarce resources across multiple healthcare facilities in a region
The framework consists of two parts: 1) strategies and recommendations for the seven core clinical strategies, and 2) resource reference cards addressing shortages in specialized healthcare services (eg, pediatrics, burn therapy, palliative care).
Information on the seven core clinical strategies address recommendations for the following:
- Oxygen, including use of inhaled medications, high-flow applications, air-oxygen blenders, oxygen conservation devices, oxygen concentrators, and oxygen reallocation
- Staffing, including focusing staff time and expertise on core clinical needs and assigning supplemental personnel
- Nutritional support, including enteral and parenteral nutrition
- Medication administration, including caching or increasing supplies, using equivalent medications, and reducing or modifying medication use based on the situation
- Hemodynamic support and IV fluids, including minimizing the use of invasive monitoring, administering oral or nasogastric rather than intravenous hydration, substituting epinephrine for other vasopressors, and reusing supplies after sterilizing and disinfecting them
- Mechanical ventilation/external oxygenation, including stockpiling ventilators, identifying alternative supply sources for ventilators and other equipment, reusing ventilator circuits, and assigning ventilators to patients most likely to benefit in situations where other options have been exhausted
- Blood products, including recommendations for using packed red blood cells, fresh frozen plasma, and platelets
The resource reference cards provide specific recommendations for specialized healthcare areas. As of April 2012, only a reference card providing recommendations for renal replacement therapy is available. Cards describing strategies for burn therapy, pediatrics, and palliative care environments are forthcoming.
What made this practice possible?
- Subject matter experts. The MDH Science Advisory Team developed the framework in close collaboration with a variety of subject matter experts, ensuring that strategies and recommendations were based on practical and ethical information.
Results
Numerous ethical frameworks exist for allocating care to large numbers of patients during an emergency. Guidelines for extending medical resources, however, focus decision-making on how equipment can be stockpiled and/or used equitably without jeopardizing care for most patients in a large-scale emergency.
Notes
Because the cards were developed in Minnesota, some of the content may need to be examined for its applicability and relevance to other states.
