Hospitals Should Streamline Intensive-Care Routines to Enable Treating More Bioterror Victims, Experts Say

By Joe Fiorill
Global Security Newswire

WASHINGTON — Hospitals should continue to provide ventilators and intravenous fluids to victims of a biological attack but should suspend many other intensive-care interventions in order to help a larger number of patients, an expert working group on the subject says (see GSN, Oct. 21).

In response to what the group calls a lack of guidelines for managing a bioterrorism-related surge in critically ill patients, the researchers say in a new paper that critical care should be initially limited to a small number of broadly useful interventions and may ultimately have to be refused to patients deemed least likely to survive.

“There are going to be some very difficult ethical decisions that hospitals, regionally, need to be articulating,” working-group member Jennifer Nuzzo, a public-health analyst at the University of Pittsburgh Medical Center’s Center for Biosecurity, said this week.

The Center for Biosecurity and the Society of Critical Care Medicine convened the 33-member working group, which included ex officio members such as smallpox-eradication pioneer D.A. Henderson and representatives of the Centers for Disease Control and Prevention and other federal agencies.

The group calls on hospitals and regions to lay out clear emergency plans and criteria for the decisions in consultation with the public and the federal government, in order to facilitate work during an attack and to limit liability repercussions.

“More lives could be saved if a circumscribed set of key critical-care interventions were offered to a larger number of patients rather than if maximal critical-care interventions, with all their incumbent human and material resource requirements (i.e., usual U.S. standards of critical care), could only be provided to a smaller number,” the group writes.

“Usual critical care-triage processes,” the experts add, “are not intended to prioritize or arbitrate ICU admission decisions for a group of patients who all clearly will require critical-care interventions, as would be the case of large bioterror attacks or in the midst of a serious epidemic.”

The group says its recommendations “might double, triple or perhaps even further augment” the critical-care capacity of hospitals that implement them during bioterrorism.

“The feedback that we’ve gotten is that this has been a fairly novel paper,” Nuzzo said. “It certainly represents sort of a shift in the way of thinking.”

Lead author Lewis Rubinson, an intensive-care specialist with the biosecurity center, said practitioners in his field have not had enough input into government and hospital disaster plans.

Many planners, Rubinson said yesterday, assume that critical care would be discontinued entirely during bioterrorism or would be provided as normal but only until the usual intensive care beds are filled.

“A lot of folks are going to get sick, and this idea of writing all of those people off or of first-come, first-served, in my mind, makes me a little queasy,” Rubinson said.

“For the most part,” he said, “it’s still off of most people’s radar screens, as either too difficult or, ‘Why would we want to take care of critically ill patients in the face of a disaster?’”

Rubinson said there is a “multitude” of reasons, including an inability to face up to large-scale bioterrorism as a potential reality, behind the planning problem.

“Part is clearly the psychology. It’s hard to wrap your hands around it,” he said.

At the same time, Rubinson said, “A lot of the people who are responsible for making these decisions do not understand what critical care or what definitive inpatient care is.”

While emergency-care specialists have had frequent input into government-organized disaster planning, he said, intensive-care doctors have not — a situation that has led to a failure to address intensive care in many terrorism-response plans.

“We all generally feel that we have had very little voice in structuring and controlling this aspect of the response to disasters,” Rubinson said. “We really have not been able to break into the very, very high-level planning on these kinds of things.”

Countering some of the planning assumptions deplored by Rubinson, the working group says in the paper that intensive care “will play an essential role in decreasing morbidity and mortality rates” during bioterrorism and that, as a result, clear, advance plans are needed.

Federal assistance — whether in the form of dispatched disaster-response teams or of supplies from the Strategic National Stockpile of countermeasures — should not be counted on for the first few days of an outbreak, so hospitals and regions should begin developing their own plans for managing that early period, the group says. Primarily, say the experts, that means scaling back normal operations in order to help more people.

Intensive-care units need clear “criteria to trigger a shift” to the emergency mode, which should be developed with government input to better anticipate the “substantial ethical, political, legal, regulatory and logistic ramifications” that could arise, the group says. New laws may be needed to address liability in such situations, the experts add.

Critical-care interventions in hospitals are typically available to all patients who might benefit from them, but staff and supply shortages during bioterrorism could quickly make many disease-specific interventions untenable, the group writes.

“At a minimum,” the group says, hospitals should plan to maintain basic ventilators, intravenous fluids, antibiotics and certain measures to prevent health problems that can be contracted in intensive-care units.

Even while offering a limited set of interventions, the group continues, intensive-care units may find themselves with “insufficient resources to treat all seriously ill patients,” necessitating tough life-and-death decisions.

“The most ethical way to help the greatest number of critically ill people survive in such dire conditions,” the group says, “is to give such interventions first to the people deemed most likely to survive.”

“Triage decision-makers … could be forced to withhold essential elements of critical care from the patients categorized as most likely to die,” the experts say, or could “choose to give all patients a trial of essential elements of critical care and to withdraw critical care from those who do not clinically improve after a set period of time.”

Nuzzo expressed hope that the recommendations would aid hospitals in saving more patients in the days immediately during a bioterrorist attack.

“We felt as though that could make or break a hospital, at least while they’re waiting for outside help,” she said.

One reason such plans are not already in place, she added, could be exaggerated expectations on the part of hospitals about the speed and content of federal aid.

“I think that’s highly possible,” she said. “There may be a disconnect between local and federal perceptions of just who’s doing what.”

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