Infectious Disruptor Events And Early Warning For Critical Care Units

In a recent article by Sprung et al in the journal Intensive Care Unit, the European Society of Intensive Care Medicine presented their summary recommendations for intensive care unit triage during an influenza epidemic or mass disaster.  I offered a response to the authors based on our experience during the emergence of pH1N1 in Mexico:

I read your paper titled “Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster“ with great interest.

Attached please find a paper we published a couple of months prior to the H1N1 pandemic.  We provided warning of the Mexico crisis to CDC and WHO and later created a near-real time situational awareness feed for the Society of Critical Care Medicine and the Critical Care Medicine- and Virtual PICU Listservs (CCM-L and vPICU) during the subsequent pandemic waves.

Your recommendations were spot-on except for one crucial point: an adequate early warning system for intensive care units.  Infectious disease crises and disasters must be detected, warned, and proactively acted upon by those members of the medical community most impacted.  I have also attached the experience of Vancouver versus Toronto during SARS- a tale of cities that presents an important perspective about the value of forewarning.

It was long our considered assessment the emergency department-intensive care unit axis of a hospital in developed nations represents the single most important part of the medical infrastructure.  And most specifically, it is the intensive care unit we were most concerned about.  This reasoning was due to

1. Hospital corporate liability related to an ability to manage critical or potentially critically ill patients in the face of exceeded ICU / ventilator bed capacity.  
2. The fragile nature of multiple ICUs functioning as a grid in the urban environment- and how easily it may be overwhelmed.
3. Public expectation for uninhibited access to a given standard of care and changes in social anxiety levels once it is known the local capacity for critical care treatment has been grossly exceeded- especially in the pediatric setting.
   

The socio-economic disruption related to loss of a critical care facility in an urban setting was apparent in Hong Kong and Toronto during SARS.  We in the United States have been fortunate to have so many “near misses”.

Infrastructure resiliency is directly related to forewarning and length of forewarning coupled to a practiced understanding of what to do upon receiving a warning.  Our experience during the 2009 H1N1 influenza pandemic showed both the Society for Critical Care Medicine (SCCM) and the critical care community writ large to be impressively responsive, proactive, and quite willing to share information for the benefit of all involved as we assessed the changing features of the pandemic crisis.  They represented the highest standard of biosurveillance information sharing we observed during the crisis among all (20+) of the professional disciplines we approached.  I cannot commend the international critical care community more highly for their selfless actions to support situational awareness.

I recommend building upon these valuable lessons learned and capitalizing on the powerful strengths of this unique community of physicians to marry effective infectious disease crisis and disaster warning to response to protect this critical component of our medical infrastructure: the intensive care unit.

Sincerely,

James M. Wilson V, MD

Download 1968 pandemic final published paper

Download Vancouver Response to SARS