Clinical Review Allocating Ventilators During Large Scale Disasters Problems Planning and Process
Number 726 (Replaces Committee Stance Number 555, March 2013. Reaffirmed 2021)
Commission on Obstetric Practise
This Commission Opinion was adult by the American Higher of Obstetricians and Gynecologists' Committee on Obstetric Practice in collaboration with committee member Alfred 1000. Robichaux, MD; the American Academy of Pediatrics' Council on Environmental Wellness, liaison member Nathaniel DeNicola, MD, MSc; and Richard H. Beigi, MD.
Abstract: Large-scale catastrophic events and infectious disease outbreaks highlight the demand for disaster planning at all community levels. Features unique to the obstetric population (including antepartum, intrapartum, postpartum and neonatal care) warrant special consideration in the event of a disaster. Pregnancy increases the risks of untoward outcomes from various infectious diseases. Trauma during pregnancy presents anatomic and physiologic considerations that often tin can require increased use of resources such as higher rates of cesarean delivery. Contempo show suggests that floods and human-influenced ecology disasters increase the risks of spontaneous miscarriages, preterm births, and low-birth-weight infants amid significant women. The potential surge in maternal and neonatal patient volume due to mass-casualty events, transfer of high-acuity patients, or redirection of patients considering of geographic barriers presents unique challenges for obstetric care facilities. These circumstances require that facilities plan for additional increases in necessary resources and staffing. Although emergencies may exist unexpected, hospitals and obstetric commitment units can ready to implement plans that volition best serve maternal and pediatric care needs when disasters occur. Clear designation of levels of maternal and neonatal care facilities, along with establishment of a regional network incorporating hospitals that provide motherhood services and those that practice not, will enable rapid ship of obstetric patients to the advisable facilities, ensuring the right care at the right time. Using mutual terminology for triage and transfer and advanced knowledge of regionalization and levels of care volition facilitate disaster preparedness.
The American College of Obstetricians and Gynecologists (ACOG) makes the following recommendations:
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Hospitals that provide maternity services should implement a standing perinatal subcommittee (likely to include obstetrics, pediatrics, and anesthesia) in accuse of disaster preparedness, which can be mobilized apace in the event of an emergency.
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All hospitals should be familiar with the ACOG and Society for Maternal–Fetal Medicine (SMFM) levels of maternal care designations and should have integrated regional referral networks based on these levels.
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Hospitals with maternity services should develop specific strategies for stabilizing and transporting obstetric patients, managing surge chapters and the demand for consultative services, sheltering-in-place, and incorporating regional facilities that exercise non provide motherhood services.
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Hospitals providing care for maternal and neonatal patients should communicate using a common terminology, such every bit OB-TRAIN (Obstetric Triage by Resource Resource allotment for Inpatient), to facilitate and prioritize transport based on acuity of intendance.
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Disaster preparedness may include a designated obstetric team that can exist called upon in an emergency setting or implemented as function of a planned evacuation.
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Communication strategies should include redundancy circulate systems—in the outcome of loss of telephone communication—that take advantage of new engineering science, such as telemedicine, that can function over the internet and nevertheless may exist accessible when other lines of communication take been cutting off.
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Obstetric units should have a designated safe location for laboring patients who cannot be transported because of imminent commitment. This programme should include an identified alternative site for commitment if the labor and delivery unit is damaged and a organization to ensure the necessary equipment can exist transported quickly to the alternative site.
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Ensuring that the adult female and her infant are transported together is a vital element of disaster planning. This situation may require additional coordination in the outcome that the woman or her infant needs care at a specialized facility and may exist initially transported separately.
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Hospitals should ready for power outages and lack of admission to electronic medical records. This scenario may include providing difficult copies of the medical tape at the fourth dimension of patient send or using mobile devices that can access a patient's medical record through online patient portals.
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Obstetricians and other obstetric intendance providers should consider the option of altering obstetric services to office with less resource use. Examples include early on hospital discharge after delivery and enhanced employ of telephone and telemedicine triage, with attention to documentation requirements.
Background
Large-scale catastrophic events and infectious disease outbreaks—including the terrorist attacks of September 11, 2001, the bombing at the 2013 Boston Marathon, the 2009–2010 H1N1 influenza pandemic, and the 2014–2016 Ebola outbreak—highlight the need for disaster planning at all community levels. Furthermore, the increased frequency of environmental natural disasters, such equally Hurricane Katrina (2005); Hurricane Sandy (2012); and the 2017 hurricanes Harvey, Irma, and Maria; and the increase in incidence of earthquakes, floods, heat waves, and severe wildfires that take directly consequences on homo wellness, demonstrate the of import function for wellness intendance providers in disaster preparedness 1.
A 2004 review suggested that disasters cause the evacuation of equally many as 20 hospitals per year ii; some other study concluded that from 2000 to 2012 natural disasters caused $ane.5 trillion in amercement worldwide and afflicted 2.9 billion people 3. Because disasters are unpredictable in nature, attention has focused on measures that can exist taken to minimize their effects and prepare citizens, businesses, health care facilities, and nations to manage the damage caused by disasters.
In recent years, new publications by ACOG and SMFM have defined specific levels of maternity intendance that provide of import direction for managing obstetric disaster preparedness. Additionally, new disaster response protocols specific to obstetric triage accept been published that assistance create uniform language for coordinating complex maternal and neonatal levels of acuity four. This document integrates these updates to provide enhanced guidance for obstetric disaster preparedness. This Committee Opinion does not specifically accost security breaches, such equally an active shooter in the infirmary, or events of bioterrorism.
The Role of Health Care Institutions in Disaster Preparedness
Given that health care institutions play an important office in responding to disasters, the discipline of hospital preparedness now occupies a central office in constructive disaster mitigation planning 5 six. Currently, many of the documents that offering guidance on infirmary preparedness are relevant to most types of medical facilities.
Every state has a disaster preparedness team directed by the Federal Emergency Management Agency and the Department of Homeland Security. Hospitals that provide maternity services should implement a continuing perinatal subcommittee (likely to include obstetrics, pediatrics, and anesthesia) in charge of disaster preparedness, which can be mobilized apace in the event of an emergency. The obstetrician–gynecologist leadership should review hospital disaster plans to ensure optimal coordination and staffing specific to the labor and delivery and postpartum units. Disaster preparedness may include a designated obstetric team that tin can be called upon in an emergency setting or implemented as part of a planned evacuation.
In some instances of disaster, the National Guard, or the Section of Homeland Security, or both, may assume the assistants of an existing infirmary or gear up up satellite medical facilities. Hospital assistants should recognize the potential for such emergency activities.
Considerations for Obstetric Care Facilities
Features unique to the obstetric population—including antepartum, intrapartum, postpartum and neonatal care—warrant special consideration in the event of a disaster. Birth is difficult to predict and obstetric units are vulnerable to a patient volume surge and unpredictable resource utilise. Recommendations for hospital disaster preparedness are summarized in Box 1. Additional obstetric-specific considerations and recommendations for disaster preparedness are summarized in Box ii.
General Considerations and Recommendations for Hospital Preparedness
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Appoint a total-time disaster coordinator for each hospital.
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Participate in regional hospital disaster planning.
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Create surge chapters planning for up to thirty% more patients.
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Augment hospital infection control practices to permit application of different measures to minimize in-infirmary spread of disease depending on the nature of each disaster. Examples of such measures include, just are not limited to, the post-obit:
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Group patients with similar affliction characteristics.
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Have all appropriate personal protective equipment available for employee use.
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Limit number of staff exposed to potentially infectious individuals.
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Have in place and enforce employment guidelines addressing employee absences when sick.
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Prioritize clinical services and develop contingency plans for canceling or minimizing elective procedures, or office visits, or both, during periods of high patient volume.
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Consider alternative care facilities to provide services during periods of loftier patient volume.
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Develop ethical algorithms for rationing limited wellness care resources in cases when demand for services exceeds supply.
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Constitute templates for altered standards of care during periods of high patient volume.
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Consider mechanisms for rapid clinical credentialing of wellness intendance providers not currently practicing to enable augmentation of work force.
Information from Toner East, Waldhorn R. What hospitals should do to ready for an influenza pandemic. Biosecur Bioterror 2006; 4:397–402. Retrieved June 6, 2017.
Boosted Obstetric-Specific Considerations and Recommendations for Disaster Preparedness
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Appoint an obstetrician to direct disaster planning for maternity services.
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Pediatrician involvement (or pediatric codirector) recommended.
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Maternity and pediatric nursing involvement also recommended.
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Consider regional patterns of obstetric care provision and disaster scenarios.
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Consider obstetric and neonatal needs with loftier obstetric patient surge.
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Establish policies for visitation and lactation that balance infection command concerns with patient and familial desires for interest in the birthing procedure.
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Foster functional working relationships with local and regional critical care clinicians.
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Have a working algorithm for ethical resource resource allotment when demand exceeds supply that considers obstetric- and pediatric-specific needs.
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Develop a surge capacity programme, realizing the challenges that pregnancy poses, to command patient volume.
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Consider temporary alterations to usual standards of obstetric care and mechanisms to optimize obstetric services with limited resource. Examples include simply are not limited to the following:
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Early on hospital discharge after delivery.
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Enhanced telephone and telemedicine triage, with attending to documentation requirements.
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Rapid credentialing of health care providers to enable delivery of obstetric care in the effect of work forcefulness limitations.
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Pregnancy increases the risks of untoward outcomes from various infectious diseases such as influenza vii 8 9 10 11. Trauma during pregnancy presents anatomic and physiologic considerations that often can require increased employ of resources such equally higher rates of cesarean delivery 12. Recent bear witness suggests that floods and human-influenced ecology disasters (such as the Earth Trade Eye collapse) increment the risks of spontaneous miscarriages, preterm births, and low-nativity-weight infants amid meaning women 13. Obstetricians and other health care providers may not exist aware of or routinely consider these risks.
Planning for Obstetric Surge Chapters
The potential surge in maternal and neonatal patient volume due to mass-casualty events, transfer of high-acuity patients, or redirection of patients because of geographic barriers presents unique challenges for obstetric care facilities. These circumstances require that facilities plan for boosted increases in necessary resources and staffing.
At that place are three subsets of surge capacity: one) conventional capacity, consistent with daily practices; 2) contingency capacity, not consistent with daily practices simply which has minimal effect on usual patient care practices; and 3) crisis chapters, not consistent with usual standards of intendance but which provides sufficient care in the setting of a catastrophic disaster 14.
Consideration also should exist given to shared needs during disaster management. The important and challenging consequence of ethical resources resource allotment when demand exceeds supply has been addressed in the general medical literature xv 16. Much of the focus has been on the distribution of limited numbers of ventilators amongst large surges of critically ill patients who require respiratory back up. These principles likewise utilise to other potentially limited resources (eg, cardiovascular back up medications, antimicrobials, and intravenous supplies). To optimize outcomes, hospital committees charged with disaster planning need to review the availability and arrangement of these of import resource before real-time disaster management is necessary.
In improver, much of the planning for full general hospital preparedness centers on the ability to control constituent procedures and visits, thereby reducing patient book and allowing for more than intensive focus on the surge of resource-intensive patients and others afflicted by the disaster. One strategy to mitigate the increase in patient volume involves preemptive management of scheduled procedures, when medically appropriate (eg, full-term induction of labor or cesarean delivery). This strategy has been employed successfully in grooming for nondisaster scenarios in which the probable strain on resources is known in advance (eg, city events with big-calibration road closures) and could exist applied in instances of disaster preparedness in which the event has a projected window of vulnerability (eg, hurricanes).
Levels of Maternal Care
The American Higher of Obstetricians and Gynecologists and SMFM'south Levels of Maternal Intendance consensus certificate calls for an integrated, regionalized network to identify when transfer of patients may exist necessary to provide adventure-advisable maternal care 17. The levels of maternal care are divers as birth heart, basic (I), specialty (2), subspecialty (III), and regional (4) 17. For each level the capabilities, types of health care providers, and required services are delineated.
The regionalized, collaborative network also could facilitate the management of surge capacity during a disaster. The established relationships and enhanced lines of communication would enable the rapid and creative response required in unexpected disasters. In such circumstances, a level III or level IV centre may be forced to stop accepting new patients or create additional capacity for critical patients by transporting or directing those requiring less specialized care to lower-level centers. Plans should exist in identify to have consultants available to provide their expertise remotely to help lower-level facilities or to facilitate obstetric care at institutions that would not otherwise provide motherhood services. An established, flexible network that incorporates coordination during an emergency response would enhance the entire region's disaster response and reduce maternal and neonatal morbidity and mortality.
In principle, hospitals without maternity services would not be designated to receive obstetric patients even during a crisis because pregnant, laboring, and postpartum patients are best served by a hospital with a maternity care designation 14 17. All hospitals should be familiar with the ACOG and SMFM levels of maternal intendance designations and should have integrated regional referral networks based on these levels. Hospitals with maternity services should develop specific strategies for stabilizing and transporting obstetric patients, managing surge capacity and the need for consultative services, sheltering-in-identify, and incorporating regional facilities that exercise not provide motherhood services. Yet, in the event of a disaster, even hospitals that do not provide obstetric services need to prepare for such patients by coordinating with a maternity hospital and preparing a program to stabilize and transfer patients when advisable.
Triage of the Obstetric Patient in Disaster Response
In one case a infirmary has determined its capacity to provide adequate maternity services, the next footstep is efficient and appropriate triage of obstetric patients. Health intendance facilities demand to consider the woman and her fetus or neonate in terms of resource allocation and surge capacity. Despite these considerations, recent research has shown that few national obstetric–gynecologic societies offer specific guidance for triage of obstetric patients in the crunch setting 18.
To approach the triage of patients in an obstetric unit, health care providers must consider antepartum, intrapartum, and postpartum care along with care plans for the newborn plant nursery and neonatal intensive care unit of measurement. Given the wide range of acuity amongst each of these groups of patients, common terminology and collaborative networks are crucial xiv.
Ane proposal for managing the multiple parallel considerations amidst maternal, fetal, and neonatal factors is the OB-TRAIN model. Hospitals providing intendance for maternal and neonatal patients should communicate using a common terminology, such equally OB-Train, to facilitate and prioritize transport based on vigil of intendance. This model categorizes an obstetric patient's acuity based on a composite scoring of specific factors with common terminology that can be used across obstetric and pediatric units. As such, the OB-Railroad train model builds upon a previously existing neonatal Railroad train arrangement that organizes pediatric patients according to their medical needs and the blazon of send required if evacuation becomes necessary fourteen. An instance of OB-Railroad train coding can be seen in Table 1.
Obstetric units should have a designated safe location for laboring patients who cannot be transported because of imminent delivery. This plan should include an identified alternative site for delivery if the labor and delivery unit is damaged and a system to ensure the necessary equipment can be transported quickly to an alternative site. Postpartum triage for the neonate is another important consideration. Ensuring that the woman and her infant are transported together is a vital element of disaster planning. This situation may require additional coordination in the event that the adult female or her infant needs care at a specialized facility and may be initially transported separately.
Special Considerations for Infectious Disease Outbreaks
Few obstetricians are trained in critical intendance, yet obstetric patients can exist affected severely by some communicable diseases outbreaks and may crave asymmetric critical care resource allocation seven 8 9 ten 11. In many facilities, adult intensive intendance units are distant from labor and delivery units. Physical separation may pose logistic barriers to the commitment of optimal intensive intendance for critically sick pregnant women. These barriers may exist exacerbated during times of overwhelming patient volume. These trends warrant thoughtful consideration and extra coordination with critical care clinicians before and during disaster mitigation. Advances in telemedicine, particularly in providing remote access to disquisitional care expertise, can aid in coming together these challenges (encounter "Remote and Altitude Care With Telemedicine" later in this document).
These considerations may be true especially when focusing specifically on influenza pandemics. Information from influenza pandemics demonstrate heightened rates of hospitalization and preterm birth associated with maternal influenza infection 8 nine ten xi 19. The increased number of newborns built-in at preterm gestations during an flu epidemic has clear implications for neonatal intensive care capacity and resource allocation that parallels increased maternal resource needs.
Two special considerations presented by the obstetric population related to infection control practices are 1) the desire for familial interest in the birthing process, and 2) the importance of lactation and early on parental bonding with the neonate. Infectious disease outbreaks often require tight restrictions on visitation procedures while the nature of the epidemic is being investigated. Isolation often is a difficult hospital practice to implement in general and is particularly challenging to enforce in the obstetric population given the need women have for support during labor, delivery, and the postpartum period. Likewise, the importance of lactation and early on parent–newborn bonding introduces infection control considerations that are not relevant to other patient populations and, therefore, warrant additional advance planning. Maternity services should coordinate with infectious disease specialists for guidance in this challenging clinical scenario.
Temporary Modifications in Standard of Care
Obstetricians and other obstetric intendance providers should consider the choice of altering obstetric services to function with less resource use. Examples include early on hospital discharge after delivery and enhanced employ of telephone and telemedicine triage, with attention to documentation requirements. Such alterations oft are necessary and benign when the volume of patients in a wellness care facility is unusually high. This concept has received considerable legal and medical attending 20 21.
The goal of these efforts is to give facilities and health care providers guidance on temporary flexibility in care standards as well as who is permitted to provide intendance. Every bit important is planning past the hospital leadership for the potential demand to speedily credential temporary obstetric intendance providers in the face of a health care provider shortage that can occur with a variety of disaster scenarios. Facility preparedness committees are encouraged to consult with their local legal colleagues to assist in interpreting state and federal guidance on this effect.
Remote and Distance Intendance With Telemedicine
In the case of an environmental disaster, pregnant and postpartum women in need of care may exist cut off from a hospital facility, medical records, and wellness care providers. Flexible infrastructure that permits expanded out-patient services by integrating "altitude prenatal care," or telephone triage, or both, may be of great value during times of overwhelming volume or inability to admission intendance locally. The Health and Medicine Division of the National Academy of Sciences, Engineering, and Medicine (formerly the Institute of Medicine) has recently considered remote and altitude care 22 and has reported on one example of the successful use of telephone triage in obstetric care 23.
If feasible, creative utilise of evolving telemedicine capabilities could enable facilities to maintain adequate patient care in the face of increased local resources demands and provide a mechanism for consultation between smaller regional facilities and larger tertiary intendance facilities. Some examples may include conducting virtual visits and remote delivery of routine testing, such as antenatal testing 24. Conversely, in emergency scenarios it frequently is necessary to provide medical intendance without the benefit of standard engineering (eg, lack of electronic medical records during a ability outage), thus reliance on newspaper records to facilitate communication during send may be necessary 25. The use of social media, specially Twitter, has provided a valuable emergency organization to denote prophylactic havens or allow electronic communication from remote areas.
Even during a disaster, documentation of all patient–wellness care provider interactions in the prenatal record remains important, equally is the ability to access those records. Communication strategies should include dorsum-up circulate systems—in the outcome of loss of telephone communication—that have reward of new technology, such every bit telemedicine, that can function over the internet and still may be accessible when other lines of advice accept been cut off. Hospitals should set for power outages and lack of admission to electronic medical records. This scenario may include providing hard copies of the medical record at the time of patient transport, or using mobile devices that tin can access a patient's medical tape through online patient portals. The possibility that admission to the electronic medical record will exist limited needs to be considered in accelerate, and mechanisms for providing patients with copies of their own medical records are recommended.
The disaster recovery phase also should be considered in accelerate equally should the institution of local mechanisms, or triggers, or both, for transitioning back to the usual standards of care. The goal is to enable a smooth recovery that optimizes care and resource use that parallels that of baseline facility function in one case the astute phase has resolved.
Determination
The discipline of hospital disaster preparedness has undergone significant advances in recent years, largely driven by the need to respond to an increase in natural and man-influenced crises. Many of the advancements provide new, specific guidance to obstetricians and other obstetric care providers at the individual and establishment levels. Although emergencies may be unexpected, hospitals and obstetric delivery units can ready to implement plans that will best serve maternal and pediatric intendance needs when disaster occurs.
Articulate designation of levels of maternal and neonatal care facilities, along with institution of a regional network incorporating hospitals that provide maternity services and those that exercise not, will enable rapid transport of obstetric patients to the appropriate facilities, ensuring the correct care at the correct fourth dimension. Using common terminology for triage and transfer and advanced knowledge of regionalization and levels of care volition facilitate disaster preparedness.
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Source: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/12/hospital-disaster-preparedness-for-obstetricians-and-facilities-providing-maternity-care
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