Objective: The Sequential Organ Failure Assessment (SOFA) score has been recommended for triage during a mass influx of critically ill patients, but it requires laboratory measurement of 4 parameters, which may be impractical with constrained resources. We hypothesized that a modified SOFA (MSOFA) score that requires only 1 laboratory measurement would predict patient outcome as effectively as the SOFA score.

Methods: After a retrospective derivation in a prospective observational study in a 24-bed medical, surgical, and trauma intensive care unit, we determined serial SOFA and MSOFA scores on all patients admitted during the 2008 calendar year and compared the ability to predict mortality and the need for mechanical ventilation.

Results: A total of 1770 patients (56% male patients) with a 30-day mortality of 10.5% were included in the study. Day 1 SOFA and MSOFA scores performed equally well at predicting mortality with an area under the receiver operating curve (AUC) of 0.83 (95% confidence interval 0.81-.85) and 0.84 (95% confidence interval 0.82-.85), respectively (P = .33 for comparison). Day 3 SOFA and MSOFA predicted mortality for the 828 patients remaining in the intensive care unit with an AUC of 0.78 and 0.79, respectively. Day 5 scores performed less well at predicting mortality. Day 1 SOFA and MSOFA predicted the need for mechanical ventilation on day 3, with an AUC of 0.83 and 0.82, respectively. Mortality for the highest category of SOFA and MSOFA score (>11 points) was 53% and 58%, respectively.

Conclusions: The MSOFA predicts mortality as well as the SOFA and is easier to implement in resource-constrained settings, but using either score as a triage tool would exclude many patients who would otherwise survive.

(Disaster Med Public Health Preparedness. 2010;4:277-284)

Objective: The supply and distribution of mechanical ventilation capacity is of profound importance for planning for severe public health emergencies. However, the capability of US health systems to provide mechanical ventilation for children and adults remains poorly quantified. The objective of this study was to determine the quantity of adult and pediatric mechanical ventilators at US acute care hospitals.

Methods: A total of 5752 US acute care hospitals included in the 2007 American Hospital Association database were surveyed. We measured the quantities of mechanical ventilators and their features.

Results: Responding to the survey were 4305 (74.8%) hospitals, which accounted for 83.8% of US intensive care unit beds. Of the 52 118 full-feature mechanical ventilators owned by respondent hospitals, 24 204 (46.4%) are pediatric/neonatal capable. Accounting for nonrespondents, we estimate that there are 62 188 full-feature mechanical ventilators owned by US acute care hospitals. The median number of full-feature mechanical ventilators per 100 000 population for individual states is 19.7 (interquartile ratio 17.2–23.1), ranging from 11.9 to 77.6. The median number of pediatric-capable device full-feature mechanical ventilators per 100 000 population younger than 14 years old is 52.3 (interquartile ratio 43.1–63.9) and the range across states is 22.1 to 206.2. In addition, respondent hospitals reported owning 82 755 ventilators other than full-feature mechanical ventilators; we estimate that there are 98 738 devices other than full-feature ventilators at all of the US acute care hospitals.

Conclusions: The number of mechanical ventilators per US population exceeds those reported by other developed countries, but there is wide variation across states in the population-adjusted supply. There are considerably more pediatric-capable ventilators than there are for adults only on a population-adjusted basis.

(Disaster Med Public Health Preparedness. 2010;4:199-206)

This article applies developing concepts of mass critical care (MCC) to children. In public health emergencies (PHEs), MCC would improve population outcomes by providing lifesaving interventions while delaying less urgent care. If needs exceed resources despite MCC, then rationing would allocate interventions to those most likely to survive with care. Gaps between estimated needs and actual hospital resources are worse for children than adults. Clear identification of pediatric hospitals would facilitate distribution of children according to PHE needs, but all hospitals must prepare to treat some children. Keeping children with a family member and identifying unaccompanied children complicate PHE regional triage. Pediatric critical care experts would teach and supervise supplemental providers. Adapting nearly equivalent equipment compensates for shortages, but there is no substitute for age-appropriate resuscitation masks, IV/suction catheters, endotracheal/gastric/chest tubes. Limitations will be encountered using adult ventilators for infants. Temporary manual bag valve ventilation and development of shared ventilators may prolong survival until the arrival of ventilator stockpiles. To ration MCC to children most likely to survive, the Pediatric Index of Mortality 2 score meets the criteria for validated pediatric mortality predictions. Policymakers must define population outcome goals in regard to lives saved versus life-years saved. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S166–S171)

An influenza pandemic can overwhelm the capacities of hospitals, clinics, nursing facilities, and emergency services. The likelihood is that most of the individuals who are stricken will be cared for at home, and there is strong evidence that in-home caregivers bear a disproportionate risk of becoming infected. We reviewed the scientific literature after 2000 to identify steps that in-home caregivers can take to reduce the chances that they and other household members will become infected in the home. Personal hygiene, common masks, and technologies including air filters and UV light each offer incremental benefits, and in combination are expected to reduce a portion of the risk that household members face when caring for a member who has become infected. In pandemics and even seasonal epidemics, seemingly small steps can literally mean the difference between life and death, especially for in-home caregivers.

(Disaster Med Public Health Preparedness. 2011;5:266–271)

Background: In a public health emergency, many more patients could require mechanical ventilators than can be accommodated.

Methods: To plan for such a crisis, the New York State Department of Health and the New York State Task Force on Life and the Law convened a workgroup to develop ethical and clinical guidelines for ventilator triage.

Results: The workgroup crafted an ethical framework including the following components: duty to care, duty to steward resources, duty to plan, distributive justice, and transparency. Incorporating the ethical framework, the clinical guidelines propose both withholding and withdrawing ventilators from patients with the highest probability of mortality to benefit patients with the highest likelihood of survival. Triage scores derive from the sepsis-related organ failure assessment system, which assigns points based on function in 6 basic medical domains. Triage may not be implemented by a facility without clear permission from public health authorities.

Conclusions: New York State released the draft guidelines for public comment, allowing for revision to reflect both community values and medical innovation. This ventilator triage system represents a radical shift from ordinary standards of care, and may serve as a model for allocating other scarce resources in disasters. (Disaster Med Public Health Preparedness. 2008;2:20–26)

Objective: A pediatric triage tool is needed during times of resource scarcity to optimize critical care utilization. This study compares the modified sequential organ failure assessment score (M-SOFA), the Pediatric Early Warning System (PEWS) score, the Pediatric Risk of Admission Score II (PRISA-II), and physician judgment to predict the need for pediatric intensive care unit (PICU) interventions.

Methods: This retrospective cohort study evaluates three illness severity scores for all non-neonatal pediatric patients transported and admitted to a single center in 2006. The outcome of interest was receipt of a PICU intervention (mechanical ventilation, acute dialysis, depressed consciousness, or persistent hypotension). Predictive ability was assessed using receiver operating curves (ROCs).

Results: Of 752 patients admitted to the hospital, 287 received a PICU intervention. Median scores for all tools were significantly higher for children receiving an intervention than for those who did not. ROCs showed PEWS had the least discriminatory ability, followed by PRISA-II and pediatric M-SOFA. No value of the pediatric M-SOFA produced both positive and negative predictive values better than clinician judgment.

Conclusions: No score had a clinically acceptable discriminate ability to predict patients who required a PICU intervention from those who did not. Physician judgment outperformed all three triage scores.

(Disaster Med Public Health Preparedness. 2012;6:126–130)

Background: Drive-through mass vaccination clinics are an increasingly popular component of public health emergency response plans. One potential disadvantage, however, is the exposure of clinicians, volunteers, public health responders, and the public to carbon monoxide (CO) from vehicle exhaust emissions when clinics are held within garages or other enclosed structures.

Methods: CO levels were monitored during indoor drive-through clinics held on the same day at 2 separate locations in a rural upstate New York county. Each clinic was operated for 2 hours during which seasonal influenza vaccines were administered to county residents as they remained within their vehicles. At each location, vehicle engines remained operating indoors within multiple lanes of traffic. No mechanical ventilation was used, but wind speeds through the buildings were relatively strong and consistent. CO was measured at breathing-zone height throughout the clinic sessions using direct-reading instruments.

Results: CO levels remained below detection for the majority of the clinic sessions. Short-term, high CO exposures, however, were found to be associated with a small number of individual vehicles that were in apparent disrepair.

Conclusions: The findings from this study indicate that CO exposures may be minimized by identifying and separately processing problematic vehicles before they enter the clinic. Direct reading CO monitors can help to identify these vehicles. (Disaster Med Public Health Preparedness. 2009;3:158–162)

The prospect of a severe influenza pandemic poses a daunting public health threat to hospitals and the public they serve. The event of a severe influenza pandemic will put hospitals under extreme stress; only so many beds, ventilators, nurses, and physicians will be available, and it is likely that more patients will require medical attention than can be completely treated. Triage is the process of sorting patients in a time of crisis to determine who receives what level of medical attention. How will hospitals sort patients to determine priority for treatment? What criteria will be used? Who will develop these criteria? This article formulates an answer to these questions by constructing a conceptual framework for anticipating and responding to the ethical issues raised by triage in the event of a severe influenza pandemic. (Disaster Med Public Health Preparedness. 2008;2:114–118)

Objective: The novel H1N1 influenza pandemic renewed the concern that during a severe pandemic illness, critical care and mechanical ventilation resources will be inadequate to meet the needs of patients. Several published protocols address the need to triage patients for access to ventilator resources. However, to our knowledge, none of these has addressed the pediatric populations.

Methods: We used a systematic review of the pediatric critical care literature to evaluate pediatric critical care prognosis and multisystem organ failure scoring systems. We used multiple search engines, including MEDLINE and EMBASE, using a search for terms and key words including including multiple organ failure, multiple organ dysfunction, PELOD, PRISM III, pediatric risk of mortality score, pediatric logistic organ dysfunction, pediatric index of mortality pediatric multiple organ dysfunction score, “child+multiple organ failure + scoring system. ” Searches were conducted in the period January 2010-February 2010.

Results: Of the 69 papers reviewed, 22 were used. Five independently derived scoring systems were evaluated for use in a respiratory pandemic ventilator triage protocol. The Pediatric Logistic Organ Dysfunction (PELOD) scoring system was the most appropriate for use in such a triage protocol.

Conclusions: We present a pediatric-specific ventilator triage protocol using the PELOD scoring system to complement the NY State adult triage protocol. Further evaluation of pediatric scoring systems is imperative to ensure appropriate triage of pediatric patients.

(Disaster Med Public Health Preparedness. 2012;6:131–137)

Objective: National security special events occur yearly in the United States. These events require comprehensive advance planning for health and medical contingencies in addition to law enforcement concerns. The planning for and impact of the Republican National Convention (RNC) on the City of St Paul and the Minneapolis–St Paul metropolitan area is described.

Methods: Descriptive analysis of events was provided by the authors based on their planning and operational experiences. Daily data were gathered from area hospitals, emergency medical services agencies, the National Weather Service, federal medical teams, and the Minnesota Department of Health to capture the impact of the RNC on emergency department activity, nonemergency surgery, emergency medical services run volumes, patient visits to onsite and offsite medical clinics, and general hospital occupancy in the metropolitan area.

Results: There were no epidemiological signal events. Weather was not extreme. Confrontations between protestors and law enforcement resulted in frequent use of riot-control agents. Protestors sought medical care from “street medics” and their affiliated free clinics in preference to usual medical facilities. Emergency departments close to the event venue reported decreased patient volumes. Hospitals close to the venue reported significantly decreased nonemergency surgical case volumes. Local hospitals implemented access controls and in 1 case, shut down ventilation systems due to riot-control agent deployment in the streets outside. Emergency medical services volumes were near average, with the exception of St Paul Fire Department on the day of a major protest march.

Conclusions: Planning and operational response for the RNC consumed large amounts of time and resources. The RNC had minimal patient impact on the health care system and in fact caused significant volume decreases at hospitals proximate to the venue. Although contingencies available for a mass casualty event were not needed, they must continue to be available for all such events. Health and medical preparedness and funding is not adequately detailed in the planning framework for national security special events, and this should be a focus for future events. (Disaster Med Public Health Preparedness. 2009;3:224–232)