Skip to main content

Table 4 Sample process for healthcare facility response during resource-poor situation

From: Clinical review: Allocating ventilators during large-scale disasters – problems, planning, and process

• Incident commander recognizes that systematic changes are or will be required to allocate scarce facility resources and that no regional resources are available to offset demand.
• Planning chief gathers any guidelines, epidemiologic information, resource information, and regional hospital information.
• Clinical care committee reviews facility/regional situation and examines the following:
   - Alternate care sites – Can additional areas of the building or external sites be used for patient care? (This should be planned in advance.)
   - Medical care adaptations (for example, use of non-invasive ventilation techniques, changes in medication administration techniques, and use of oral medications and fluids instead of intravenous).
   - Changes in staff responsibilities to allow specialized staff to redistribute workload (for example, floor nurses provide basic patient care in the intensive care unit while critical care nurses 'float' and troubleshoot) [5] and/or incorporate other health care providers, lay providers, or family members where practical.
   - Triage plan describing how the use of scarce resources at the facility (emergency department [ED] resources, beds, operating rooms, and ventilators) will be allocated. (What level of severity will receive care? What tool or process will be used to make decisions when there are competing demands for the same resource?)
   - Community/regional strategies to cope with the situation and how the institutional response contributes to those efforts.
   - Committee summarizes recommendations for next operational period and determines meeting and review cycles for subsequent periods (may involve conference calls or similar means to avoid face-to-face meetings during a pandemic).
• Incident commander approves committee recommendations as part of incident action plan. Plan is operationalized. Public information officer communicates updates to staff, patients, families, and the public.
• Current inpatients, patients presenting to the hospital, and their family members are given verbal and printed information (ideally by the triage nurse in the ED or, for inpatients, by their primary nurse or physician) explaining the situation and that resources may have to be reallocated, even once assigned, in order to provide care to those who will most benefit. A mechanism for responding to patient/family questions and concerns should also be detailed.
• Security and behavioral health response plans should be implemented.
• Triage plan (which may affect all units equally or some more than others) implemented:
   - ED/outpatient screening of patients (and denial of service to patients either too sick or too well to benefit from evaluation/admission) based on guidance disseminated by the clinical care team.
   - Tertiary triage team (ideally NOT the physicians directly providing the patients' care and ideally two physicians of equal 'rank' in the institution) considers situations in which there are competing patient demands for a scarce resource. The resource should be assigned as follows:
When two patients have essentially equal claim to the resource, a 'first-come, first-served' policy should be used.
When, according to guidelines or the triage team's clinical experience, the claim to the resource is clearly not equal, the patient with a more favorable prognosis/prediction shall receive the resource.
   The triage team should ask for and receive whatever patient information is necessary to make a decision but should NOT consider subjective assessments of the quality of the patients' life or value to society and, in fact, should ideally be blinded to such information when possible.
• A 'bed czar' (under the Hospital Incident Command System, this is the inpatient unit leader) should be appointed to make final decisions on bed assignments. This individual should have access to real-time inpatient and outpatient system status and, when needed, patient clinical information.
• Whenever a decision is made to reallocate a ventilator or similar critical resource, the treating physician and family should be provided with the grounds for the decision (which should be documented for the record at the facility) and a rapid appeals process if there is additional or new information that the family or a treating physician feels would affect the decision.