No data directly prove that transitioning to a crisis standard of care is the preferred method for preserving limited resources for special needs populations. Several publications discuss the general issues surrounding the use of crisis standards of care when resources are limited, but these discussions do not directly address outcomes, such as morbidity or mortality.
An example of implementation of a crisis standard of care occurred on the US Naval Ship Comfort during the aftermath of the Haitian earthquake on January 12, 2010. Having the only dialysis capability for the country after the earthquake, the influx of patients with renal failure and crush injuries stretched the dialysis capabilities onboard the 1,000-bed hospital ship. This prompted a dialyzer reuse protocol. Patient-designated dialysis filters were cleaned between treatments and reused for each patient. Priority was given to those with oliguric renal failure. Hyperkalemia was treated with bicarbonate-based IV fluids, oral binding agents, IV calcium, insulin, and glucose. Dual-lumen catheters were not available; therefore, separate central venous cannulae were used. There did not appear to be any long-term sequelae of this approach. It would be advantageous to have professional societies and stakeholders in the care of the special populations outlined in this article develop crisis standard of care guidelines based on the Institute of Medicine’s tenets. More info
There is a paucity of research evidence to direct care for special populations during mass critical care, leaving recommendations based on expert opinion and small case series. Patients on dialysis appear to have an advantage in disaster planning because hemodialysis is done in registered centers and long-term patients can be tracked. This has allowed governmental, professional, and advocacy groups to develop a proactive and reactive support network during disasters. A central data bank of patients with chronic diseases who require homogenous treatment, such as oxygen supplementation, would help governmental, advocacy, and professional society stakeholders to streamline care during a disaster as would the development of crisis standard of care guidelines for mass critical care of special populations.
Medically fragile and chronically ill patients need to be preidentified and considered during disaster planning. Preparation on all levels is necessary to mitigate a disaster’s impact on this population who will likely decompensate and may need scarce critical care resources. The model offered by KCER is a template that may prove useful in other special populations.