Special Populations: Defining Special Populations for Mass Critical Care

We suggest the definition of special populations for mass critical care be those patients that may be at increased risk for morbidity and mortality outside a fully functional critical care environment or those patients that present unique challenges to providers when a full complement of supportive services is not available. We include the chronically ill and technologically dependent as the fragility of their baseline health puts them at significant risk for progression to a higher level of medical need. http://medicine-against-diabetes.net/
Many definitions of special, vulnerable, or at-risk populations have been proposed. According to the US Department of Health and Human Services, the definition of special population, in the context of the National Response Framework and All Hazards Preparedness Act, is based on additional needs around the incident in one or more of the following areas:
(1) maintaining independence, (2) communication, (3) transportation, (4) supervision, and (5) medical care. Governmental agencies often include children, elderly individuals, people with physical or emotional disabilities, individuals who live in institutionalized settings, poor people, or individuals with limited English proficiency. However, this broad definition does not lend itself to mass critical care. A special population as we have defined it for mass critical care is a vulnerable population that may be at increased risk for morbidity and mortality outside the norm of a critical care environment or those patients who present unique challenges when a full complement of supportive services is not available (Table 2). Other populations germane to mass critical care would include those with significant chronic medical conditions and who depend on technology (Table 3). Our definition of special populations does not include the general pediatric population because children are a core component of all communities affected by pandemics and disasters in proportion to their presence in the local population. However, children who have special needs and depend on technology are included here.

Table 2 – Community Populations Susceptible to Decompensation to Critical Illness in Disaster Environments and Potential Barriers to Successful Disaster Care

Special Population System Involved Example Preparation/Communication In Shelters
Potential Barriers to Success Possible Solutions Potential Barriers to Success Possible Solutions
Respiratory OxygendependentCOPD

OSA

Severe asthma Cystic fibrosis

Lack of patient and caregiver disaster planning Lack of primary care provider disaster planning support Backup medications may not be covered by insurance Backup oxygen tanks may not be covered by insurance Patient and caregiver disaster planning education Engagement of primary care providers and home health professionals in identification of at-risk patients and support of disaster planning Identification of appropriate shelters beforehand Consider reservoir nasal cannulae to preserve oxygen Need for oxygen delivery and supply Personnel knowledgeable with basic oxygen tank handling and changing Personnel knowledgeable in care of noninvasive positive pressure ventilation devices such as CPAP and NIV Need for electricity and recharging of devices Personnel knowledgeable in use of nebulized medications Basic training of shelter personnel in oxygen tank handling Engage respiratory therapists in disaster planning Consider shelter coverage by respiratory therapists
Cardiac Chronic heart failure LVADPermanentpacemakers

Intracardiac

defibrillator

Hypertension

Lack of patient and caregiver disaster planning Lack of primary care provider disaster planning support Backup medications may not be covered by insurance Additional batteries may not be covered by insurance Patient and caregiver disaster planning education Engagement of primary care providers and home health professionals in identification of at-risk patients and support of disaster planning Identification of appropriate shelters beforehand Need for strict medication regimens Specialized medications not readily available Restricted or specialized diet Physical limitations Inability to lie flat on shelter cotsLVAD battery recharging Frequent laboratory monitoring necessary for electrolytes and anticoagulation Routine telephonic interrogation of implanted pacemaker and defibrillator Adhere to patient’s home medication regimen Use bolsters to elevate headLocate bed close to bathroom Ensure electrical outlets are available Ensure pacemaker and ICD implant cards are kept with patient Identify consultant resources Determine hospital admission criteria Modify general diets to meet dietary restrictions
Renal Chronic renal insufficiency Dialysis Lack of patient and caregiver disaster planning Lack of primary care provider disaster planning support Backup medications may not be covered by insurance Closure of usual dialysis unit Patient and caregiver disaster planning education Engagement of primary care providers and home health professionals in identification of at-risk patients and support of disaster planning Identification of appropriate shelters and dialysis centers Restricted or specialized diet Frequent laboratory monitoring necessary for electrolytes Need for sterile conditions and aseptic technique for care of indwelling catheters Coordination of and transportation to dialysis centers Adhere to patient’s home medication regimen Identify consultant resources and disaster dialysis centers Determine hospital admission criteria Modify general diets to meet dietary restrictions Determine means of electrolyte monitoring
Hepatic Cirrhosis Lack of patient and caregiver disaster planning Lack of primary care provider disaster planning support Backup medications may not be covered by insurance Patient and caregiver disaster planning education Engagement of primary care providers and home health professionals in identification of at-risk patients and support of disaster planning Identification of appropriate shelters beforehand Restricted or specialized diet Need for intermittent paracentesis Adhere to patient’s home medication regimen Identify consultant resources Determine hospital admission criteria Modify general diets to meet dietary restrictions
Endocrine Diabetes Lack of patient and caregiver disaster planning Lack of primary care provider disaster planning support Backup medications may not be covered by insurance Patient and caregiver disaster planning education Engagement of primary care providers and home health professionals in identification of at-risk patients and support of disaster planning Identification of appropriate shelters beforehand Restricted or specialized diets Frequent glucose monitoring Possible frequent medication adjustments Aseptic technique for medication administration Possible long-term wound care Adhere to patient’s home medication regimen Identify consultant resources Determine hospital admission criteria Modify general diets to meet dietary restrictions Have emergency glucose sources
Neurologic StrokeParalysisMyasthenia

gravis

Multiple

sclerosis

Lack of patient and caregiver Patient and caregiver disaster disaster planning planning education Lack of primary care provider Engagement of primary care disaster planning support providers and home health Backup medications may not professionals in identification be covered by insurance of at-risk patients andsupport of disaster planning Identification of appropriate shelters beforehand Mobility and communication deficits Swallowing difficulties requiring dietary modification and feeding assistance Decubitus ulcer prevention and care Early recognition of decompensation Adhere to patient’s home medication regimen Identify consultant resources Determine hospital admission criteria Modify general diets to dysphagia Provide suction
Cancer Patientsreceivingchemotherapy

Patients

receiving

brachytherapy

Lack of patient and caregiver disaster planning Lack of primary care provider disaster planning support Backup medications may not be covered by insurance Patient and caregiver disaster planning education Engagement of primary care providers and home health professionals in identification of at-risk patients and support of disaster planning Identification of appropriate shelters beforehand Immunosuppression Need for continued treatments Care of mediports and indwelling catheters Possible low-level radiation exposure to susceptible populations, such as pregnant women and children Adhere to patient’s home medication regimen Identify consultant resources Determine hospital admission criteria Provide area away from pregnant women and children aged <2 у Provide area of isolation for patients with neutropenia
Immunosuppressed TransplantRheumatoidarthritis Lack of patient and caregiver disaster planning Lack of primary care provider disaster planning support Backup medications may not be covered by insurance Patient and caregiver disaster planning education Engagement of primary care providers and home health professionals in identification of at-risk patients and support of disaster planning Identification of appropriate shelters beforehand Susceptibility to infections Frequent drug monitoring, which may not be readily available Adhere to patient’s home medication regimen Identify consultant resources Determine hospital admission criteria Provide area away from contagion Provide masks
Pregnancy Lack of patient and caregiver disaster planning Lack of primary care provider disaster planning support Patient and caregiver disaster planning education Engagement of primary care providers in identification of at-risk patients and support of disaster planning Identification of appropriate shelters beforehand Susceptibility to infections Higher risk of premature labor after disaster Mobility issues in later trimesters Identify consultant resources Determine hospital admission criteria Provide area away from contagion Provide masks Provide basic education of shelter personnel in care of pregnant women
Technologydependent Home ventilator Total parenteral nutrition Tube feeding Dialysis: peritoneal andhemodialysis Lack of patient and caregiver disaster planning Lack of primary care provider disaster planning support Backup medications may not be covered by insurance Backup dextrose-containing solution may not be covered by insurance Patient and caregiver disaster planning education Engagement of primary care providers and home health professionals in identification of at-risk patients and support of disaster planning Identification of appropriate shelters beforehand Personnel knowledgeable of machines Electricity and battery recharge Refrigeration needed for parenteral nutrition Need for sterile conditions and aseptic technique for care of indwelling catheters and peritoneal dialysate exchanges Coordination of and transportation to dialysis centers Provide consistent electricity Engage respiratory therapists in disaster planning Consider shelter coverage by respiratory therapists Engage nutritionist and pharmacist in disaster planning for these patients Provide refrigeration Provide dextrose-containing IV fluids Provide area for sterile preparation of indwelling catheters

Table 3 – Critical Care Patient Populations That May Be Vulnerable When Full Critical Care Services Curtailed or Not Available

Special Population Example Potential Barriers to Success
Hospitalized critical care patients vulnerable when full critical care services not available Equipment and personnel needed may not be available
Advanced intervention Severe ARDS or IRDS Advanced modes of mechanical ventilation required High PEEP Prone positioning Nitric oxide Inhaled epoprostenol HFOV ECLS
Renal failure CRRT
Circulatory failure Postcardiac arrest LVAD, IABP, ECLS Active hypothermia
Neurologic failure Continuous EEG
Status epilepticus
Intractable ICP
High nursing demand Large burns Complex wounds Open abdomen Frequent and time-consuming dressing changes
Specialized equipment Morbid obesity Neonates Highly infectious Bariatric beds, high-capacity lifts IncubatorsPersonal protective equipment PAPRsNegative pressure rooms
High support staff demand Patients with uncontrolled psychiatric conditions Patients with language barriers Prisoners One-to-one sittersInterpretersSecurity
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