Mechanical ventilation in disaster situations: A new paradigm using the AGILITIES Score System

Authors

  • Eric P. Wilkens, MD, MPH
  • Gary M. Klein, MD, MPH, MBA

DOI:

https://doi.org/10.5055/ajdm.2019.0347

Keywords:

triage, mechanical ventilator, disaster, influenza, death, resource, pandemic

Abstract

Background: The failure of life-critical systems such as mechanical ventilators in the wake of a pandemic or a disaster may result in death, and therefore, state and federal government agencies must have precautions in place to ensure availability, reliability, and predictability through comprehensive preparedness and response plans.

Methods: All 50 state emergency preparedness response plans were extensively examined for the attention given to the critically injured and ill patient population during a pandemic or mass casualty event. Public health authorities of each state were contacted as well.

Results: Nine of 51 state plans (17.6 percent) included a plan or committee for mechanical ventilation triage and management in a pandemic influenza event. All 51 state plans relied on the Centers for Disease Control and Prevention Flu Surge 2.0 spreadsheet to provide estimates for their influenza planning. In the absence of more specific guidance, the authors have developed and provided guidelines recommended for ventilator triage and the implementation of the AGILITIES Score in the event of a pandemic, mass casualty event, or other catastrophic disaster.

Conclusions: The authors present and describe the AGILITIES Score Ventilator Triage System and provide related guidelines to be adopted uniformly by government agencies and hospitals. This scoring system and the set of guidelines are to be used in disaster settings, such as Hurricane Katrina, and are based on three key factors: relative health, duration of time on mechanical ventilation, and patients’ use of resources during a disaster. For any event requiring large numbers of ventilators for patients, the United States is woefully unprepared. The deficiencies in this aspect of preparedness include (1) lack of accountability for physical ventilators, (2) lack of understanding with which healthcare professionals can safely operate these ventilators, (3) lack of understanding from where additional ventilator resources exist, and (4) a triage strategy to provide ventilator support to those patients with the greatest chances of survival.

Author Biographies

Eric P. Wilkens, MD, MPH

Assistant Professor, Department of Anesthesiology, Columbia University Medical Center, New York City, New York

Gary M. Klein, MD, MPH, MBA

Chief Medical Officer, mEDhealth Advisors, LLC, Vienna, Virginia

References

Castro C, Persson D, Bergstrom N, et al.: Surviving the storms: Emergency preparedness in Texas nursing facilities and assisted living facilities. J Gerontol Nurs. 2008; 34(8): 9-16.

Curiel TJ: Murder or mercy? Hurricane Katrina and the need for disaster training. N Engl J Med. 2006; 355: 2067-2069.

CBS Broadcasting: 60 Minutes segment “Was It Murder?”; September 24, 2006.Available at www.cbsnews.com/stories/2006/09/21/60minutes/main2030603.shtml?tag=contentMain;contentBody. Accessed July 27, 2010.

CDC website: 2009 H1N1 flu situation update. Available at www.cdc.gov/h1n1flu/update.htm. Accessed July 27, 2010.

Super G: START: A Triage Training Module. Newport Beach, CA: Hoag Memorial Hospital Presbyterian, 1984.

United States Census Bureau, Population Division: 2008 Population Estimates; December 22, 2008. Available at http://www.census.gov/popest/national/files/NST-EST2008-alldata.txt. Accessed October 1, 2009.

Vincent JL, Moreno R, Takala J, et al.: The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996; 22(7): 707-710.

Virginia Department of Emergency Management: Commonwealth of Virginia Pandemic Influenza Plan. Vol. VI. Norfolk, VA: Virginia Department of Emergency Management, 2009.

Mississippi State Department of Health: Plan for receiving, distributing, and dispensing strategic national stockpile assets, Mississippi State Department of Health Public Health Emergency Preparedness and Planning Program, Jackson, MI, January 15, 2010.

Iowa Department of Public Health Division of Acute Disease Prevention and Emergency Response: An ethical framework for use in a pandemic, Report of the Iowa Pandemic Influenza Ethics Committee, Des Moines, IA, 2007.

New York State Department of Public Health: Pandemic Influenza Plan. Albany, NY: New York State Department of Public Health, 2008.

Utah Hospitals and Health Systems Association for the Utah Department of Public Health: Utah Pandemic Influenza Hospital and ICU Triage Guidelines, Version 2. Salt Lake City, UT: Utah Hospitals and Health Systems Association for the Utah Department of Public Health, 2009.

Texas Department of State Health Services: Pandemic Influenza Plan Operational Guidelines, Version 2.1. Austin, TX: Texas Department of State Health Services, 2008.

Hawaii Department of Health: Pandemic Influenza Preparedness and Response Plan,Version 08.1. Honolulu, HI: Hawaii Department of Health, 2008.

North Carolina Institute of Medicine: Prioritization and use of limited resources during and influenza epidemic. In: Stockpiling Solutions: North Carolina’s Guidelines for an Influenza Epidemic. Morrisville, NC: North Carolina Institute of Medicine, 2007: Chapter 5.

Washington State Department of Health: Pandemic Influenza Planning Overview.Washington, DC:Washington State Department of Health, 2005.

Wisconsin Department of Public Health: Wisconsin Pandemic Influenza Operations Plan: All Priorities and Appendix A. Madison, WI:Wisconsin Department of Public Health, 2007.

Minnesota Department of Public Health Office of Emergency Preparedness: Mechanical Ventilation Strategies for Scarce Resource Situations. St. Paul, MN: Minnesota Department of Public Health Office of Emergency Preparedness, 2008.

Alabama Department of Public Health: Pandemic Influenza Operational Plan. Montgomery, AL: Alabama Department of Public Health, 2009.

CDC: CDC FluSurge 2.0 Excel Spreadsheet Software. Available at http://www.cdc.gov/flu/tools/flusurge/. Accessed July 27, 2010.

CNNMoney.com: Corporate Katrina gifts could top $1B. Available at http://money.cnn.com/2005/09/13/news/fortune500/katrina_donations/. Accessed July 27, 2010.

Kaiser Family Foundation: Total hospitals, 2008. Available at http://www.statehealthfacts.org/comparetable.jsp?ind=382&cat=8&sub=94&yr=63&typ=1&sort=a. Accessed July 27, 2010.

Jacobson v Commonwealth of Massachusetts, 197 US 11 (1905). 24.New York State Workgroup on Ventilator Allocation in an Influenza Pandemic, NYSDOH Task Force on Life and Law: Allocation of Ventilators in an Influenza Pandemic: Planning Document, Draft for Public Comment, March 15, 2007.

Ardagh M: Criteria for prioritising access to healthcare resources in New Zealand during an influenza pandemic or at other times of overwhelming demand. N Z Med J. 2006; 119(1243): U2256.

New Jersey Department of Health and Senior Services: Influenza Pandemic Plan. Trenton, NJ: New Jersey Department of Health and Senior Services, 2009.

Joint Commission: Specifications Manual for Joint Commission National Quality Core Measures (2010B). Oakbrook Terrace, IL: The Joint Commission, 2010.

Maurya PK, Kalita J, Paliwal VK, et al.: Manual AMBU ventilation is still relevant in developing countries. QJM. 2008; 101(12): 990-991.

Teasdale G, Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974; 2: 81-84.

U.S. Department of Homeland Security: Pandemic Influenza Preparedness, Response, and Recovery Guide for Critical Infrastructure and Key Resources.Washington, DC: U.S. Department of Homeland Security, 2006.

Hick JL, O’Laughlin DT: Concept of operations for triage of mechanical ventilation in an epidemic. Acad Emerg Med. 2006; 13(2): 223-229.

Knaus WA, Draper EA,Wagner DP, et al.:APACHE II: A severity of disease classification system. Crit Care Med. 1985; 13(10): 818-829.

Knaus WA,Wagner DP, Draper EA, et al.: The APACHE III prognostic system, risk prediction of hospital mortality for critically ill hospitalized adults. Chest. 1991; 100(6): 1619-1636.

Le Gall JR, Lemeshow S, Saulnier F: A new simplified acute physiology score (SAPS II), based on a European/North American Multicenter Study. JAMA. 1993; 270: 2957-2963.

Published

10/01/2019

How to Cite

Wilkens, MD, MPH, E. P., and G. M. Klein, MD, MPH, MBA. “Mechanical Ventilation in Disaster Situations: A New Paradigm Using the AGILITIES Score System”. American Journal of Disaster Medicine, vol. 14, no. 4, Oct. 2019, pp. 311-26, doi:10.5055/ajdm.2019.0347.