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This is an international website intended to remain accessible to as many people as possible. The opinions expressed here are those of the individual posters who remain solely responsible for the content of their messages.
The use of good judgement during the discussion of controversial issues would be greatly appreciated.

DRAFT Guidelines on Ventilator Allocation from NYS DOH for Public Comment

by: DemFromCT

Mon Apr 02, 2007 at 13:45:20 PM EDT


( - promoted by DemFromCT)

The NY State Department of Health is distributing this 52 page Guideline and 8 page accompanying FAQ on the use of ventilators in a pandemic for comment and feedback from the public. Note this comment from the executive summary:
The workgroup recommends that these guidelines be reviewed in public settings, including medical centers and community forums, with the explicit goals of encouraging education, comment and revision.  After such public review, NYSDOH should incorporate improvements to these recommendations, and issue the revised document as a set of voluntary guidelines for acute care facilities.

We appreciate the public health authorities who are thinking this through and asking for feedback from the public.

Please feel free to comment (and to distribute this URL for comment). Review the .ppt slides as well for context:
http://www.newfluwik...

DemFromCT :: DRAFT Guidelines on Ventilator Allocation from NYS DOH for Public Comment
From the executive summary:
A powerful strain of avian influenza has generated concern about a possible pandemic, though scientists do not know with certainty whether or when a pandemic will occur.  However, the better-prepared New York State is, the greater its chances of reducing morbidity, mortality and economic consequences.  In a pandemic, many more patients could require the use of mechanical ventilators than can be accommodated with current supplies.  A federal ventilator stockpile exists, and New York State plans to buy additional ventilators that would meet the needs of patients in a moderately severe pandemic.  In a disaster on the scale of the 1918 influenza pandemic, however, stockpiles would not be sufficient to meet need.  Even if the vast number of ventilators needed for a disaster of that scale were purchased, a sufficient number of trained staff would not be available to operate them.  If the most severe forecast becomes a reality, New York State and the rest of the country will need to confront the rationing of ventilators.

An ethical framework must guide recommendations for allocating ventilators in a pandemic.  Key ethical concepts are the duty to care for patients and the duty to use scarce resources wisely.  Maintaining a balance between these two sometimes competing ethical obligations represents the core challenge in designing a just system for allocating ventilators.

The workgroup recommends an ethically and clinically sound system for allocating ventilators in a pandemic, containing the following elements:

1) Pre-triage requirements: Facilities must reduce the need for ventilators and expand resources before instituting ventilator triage procedures.

2) Patient categories for triage: All patients in acute care facilities will be equally subject to triage guidelines, regardless of their disease category or role in the community.

3) Implications of triage for facilities: State-wide consistency will prevent inequities; chronic care facilities will maintain different standards from acute care facilities.

4) Clinical evaluation: Clinicians will evaluate patients based on universally applied objective criteria, and offer time-based trials of ventilator support.

5) Triage decision-makers: Supervising physicians will take responsibility for triage decisions. Primary care clinicians will care for patients and will not determine ventilator allocation.

6) Palliative care: Palliative care will play a crucial role in providing comfort to patients, including those who do not receive ventilator treatment.

7) Appeals process: Physicians and patients require a means of requesting review for triage decisions; ethics committee members and others should be prepared to assist in the appeals process.

8) Communication about triage: Government and clinicians need to provide clear, accurate and consistent communication about triage guidelines.  Data gathering and public comment can help improve the triage system.

The workgroup recommends that these guidelines be reviewed in public settings, including medical centers and community forums, with the explicit goals of encouraging education, comment and revision.  After such public review, NYSDOH should incorporate improvements to these recommendations, and issue the revised document as a set of voluntary guidelines for acute care facilities.

Here is an example of the content of the accompanying FAQ:

Q:  Why is it necessary to have a policy on ventilator allocation in a severe pandemic?

A:  One critical factor when planning for a severe (1918-like) pandemic is the shortage of life-sustaining equipment such as mechanical ventilators. Although New York State continues to purchase additional ventilators for our Medical Emergency Response Cache, and plans are in place to request additional ventilators from the Strategic National Stockpile, a severe pandemic would quickly outstrip the available supply.  A severe pandemic would also result in a shortage of staff trained to operate ventilators, forcing hospitals to decide which patients will and will not be provided ventilator support.  There must be clear guidance in place ahead of time to ensure that these decisions ultimately will be made in a way that is fair and equitable and will provide the greatest benefit to as many patients as possible.

This is a draft, and the intent is to distribute for review and comment. The NYS public health folks will be reading what you write with interest. Again, thanks to them for sending this out for review, and for working on the problem in the first place.
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following up on the CDC communications post
(see Communications, Leadership, Flu Wiki and CDC), it is heartening to see the community forums on line used for draft distribution and comment of policy. This is a role we have been hoping for. What better way to involve the public with public health issues?

Other triage protocols exist, including that from the Canadians discussing ICU beds, which can be found here. A draft discussion from the Respiratory Therapy Working Group that covers personnel is here. This is a welcome addition to existing literature and thought, even in draft form.

Tough decisions follow. This community, and the other online flu communities, should be no stranger to the idea that there's no easy solution. But only by thinking though in advance how to do this can we come to equitable solutions.

PS Keep in mind that hospital O2 and other medical gasses are a commodity and needs to be replenished, as is noted on page one of the Guideline:

Pandemic planning must address potential shortfalls in many resources, including staff, protective equipment, and medications, including oxygen. 
Delivery services may not be able to keep up with demand, particularly if all hospitals are needing resupply at once.

oh, and since oxygen is a commercial JIT supply issue
it should be considered as part and parcel of planning. This is where a public-private collaboration is needed, so local hospitals at least have some idea of what to expect.

[ Parent ]
Ox, Consumables. repair
DemFromCT,

  Any comments on stockpiling consumables like filters and masks.

  What about technitians and spare parts? Valve metering and timing (inhale v.s. exhale) need calibration from time to time. I'm looking at this as a long term, multi wave effort.

  These things all run on Electricity - right?

Kobie



[ Parent ]
Sent this on to my cousin...who is a RN. Thanks. n/t


I am not like other birds of prey....

[ Parent ]
I also posted this at flutrackers, PFI and current events
[ Parent ]
too late: ventilators for a handful (cfr is very bad) and no one bought safe PPE for the staff
so, let them jump to more practical points.

Buying PPE for the staff the "deciders" themselves would be willing to give bedside care to H5N1 patients in 12-24 hours shifts in?

Being honest right now, and telling the hcw and support staff at hospitals to stock their families up at home for months of disruptions? They know they are being treated as expendable; don't blame them if they will not go along with plans that ammount to self-destruct missions. Any of the top chains of command going to be exposed to what hcw are expected to be?

Has the NY state Health Dept bothered to tell the citizens of NY that their municipalities need to have PPCCs?
http://www.pandemicf...
People would volunteer, to have truely "all"-stakeholder committees; if they understood this is life or death that it get done for their communities and families.

Bothering to communicate to the public, now, a pandemic year really has been hanging over their heads, a plane ride away when it starts, no antivirals nor vaccines for the public this year, and federal and state and local officials will not meet the needs of those homebound by illness or quarantine; send 'em to the prep pages of the 'Wiki?
What authorities have purchased, and have on hand locally, Palliative care meds?? Be more worried about reaction to rationing, or needing to have to use, those, and start the public's adjustment reation now; waiting will make it worse.


hi, crfullmoon
cheerful and upbeat reply ;-)

Your comments are welcome and will be read, I hope, by everyone.

My town has a PPCC (pandemic flu coordinating committee) - except we call it a task force. The state DOH did urge this and, more importantly, is pushing drills, tabletops and exercises to reach to regional/local level. We're far from prepared, mind you, but the point is that the vent triage protocol is in addition to everything else that needs to be done, not instead of.


[ Parent ]
Refuse treatment or vent
DemFromCT,

  I did not see where the document address what to do when a patient refuses treatment.

  They wish to give up their ventilator "to help another due to the shortage"

  It may sound far fetched but people do it - not just guys.

Kobie


I call Kobies ventilator! n/t


Carry the torch, not to light the way, but to set your peers on fire!

[ Parent ]
:o) ha ha ha.
Hi,

  That is funny.

  Seriously while taking a group on tour one person got sick. In the hospital she started refusing treatment "so she could die in the holy land." People may decide its better to go than stick around for the disaster. There is a teenage suicide problem now that may only get worse.

  I think I know one individual who would give up her spot for another. She is a mother of two but also has health problems. Regretably she can not see that her friends think more highly of her than each other.

  Who knows what people may do. I think the real HCW have stories to tell.

Kobie


[ Parent ]
only read the faq's so far
I am very surprised to see them say that age and social worth would not be considered in who gets a ventilator.  First off why not, why have triage at all, isn't that a factor?  It all goes back to if 80% are going to be dead we need a surviving population to continue the species and rebuild, not be too old to contribute or infants.  In reality I would bet you age and social worth will be considered.  All I can say is that I am glad I dont have children because I can only imagine the violence that's going to insue when people cant get the treatment they need.  I liked, "will there be an appeal process?"  I can see a lot of appeal processes happening at the end of a .45  Plans are great but I just cant see anyone needing a vent getting the attention someone on a vent needs to actually survive, be it from lack of caregivers to just plane lack of all other supplies.  Maybe after I read the whole 60 some pages I'll have a different opinion but I doubt it.

Carry the torch, not to light the way, but to set your peers on fire!

this is a draft
and requires input.

The canadian suggestion from CMAJ calls for age to be considered. You are excluded in the Canadian plan if age > 85:

http://www.cmaj.ca/c...


[ Parent ]
the guidelines were driven by hospitals
wanting to have something to work with. Note:

More on this guideline can be access at:

http://www.nyhealth....

All guideline comments can be emailed to panflu@health.state.ny.us



costs
what costs a ventilator ?
how many has New York state ?
when they buy more, does that reduce their budget
on other items like masks etc. ?

ask experts for their subjective
panflu death expectation values
and report the replies


gs, costs are always a factor....
and the purchase of anything that is not going to directly benefit, or improve the outcome of a patient is very difficult to justify. (I should add... or also protects the healthcare worker). 

Ventilators are not a "one size fits all" so the prices vary. and they can cost anywhere from 10,000.00 to 50,000.00... when I checked about 2 years ago. 

BUT, the numbers of ventilators needed is not the only issue. How can you justify buying them, if there is no immediate need for them?  Where will they be kept? Are the locations where they would be used built with the equipment needed, and all of they mechanical necessities needed to care for a patient, O2 outlet, suction set up, monitoring equipment, etc.  (Not to mention again, the supply of O2 and compressed air.)

Then you have to think about the personnel who will care for these patients.  Existing Health Care Facilities are already short staffed for nurses, critical care staff, etc.

Medicare & Medicaid (CMS) is moving toward a pay for performance platform which will surely cut the governments costs , but will place hospitals, physician, therapist, and other qualitifed individuals at even a greater risk for losing money, in a time when it costs more to care for patients. (heaven forbid that insurance companies follow this model as they have in the past with DRG's) Operating on a shoestring is an understatement.

There are several hospitals in New York, which are closing their doors........ They may be the smaller hospitals, but they still served their community well.  Hospitals no longer have the funds to remodel, or upgrade because of the costs that are being mandated by congress....  Electronic medical records by 2010 (Last date I had heard, and very unrealistic, this may have changed.)

A supply of extra ventillators would be a nice addition and safety net.  But, I do not think any hospital will be able to stockpile them.... just in case.

Never believe that a few caring people can't change the world. For, indeed, that's all who ever have. ~ Margaret Mead


[ Parent ]
$10000
I think there are better ways to invest in panflu preparation
actually. For one ventilator you can buy hundredths of
antiviral treatments or vaccines or PPE.
These have larger expected benefit for the possible recipients.
If I were NY, I would not spend more than a few percent
of my panflu-prepping budget on ventilators.

ask experts for their subjective
panflu death expectation values
and report the replies


[ Parent ]
Back of the envelope calcuations.
Input.

Hmmmm.

I can be logical.

Or I can be irrational.

Let's try logical.

Lets assume 10,000 vents available in NY.  Lets also assume all supplies and trained personel available for the duration of a pandemic.

Lets also assume that the current amount of vent availability is 10% (from what I understand that number is too high, but lets be generous.)

Lets also assume that vent demand from other non pandemic illnesses fall 10% due to pandemic SIP and social isolation protocols (again too high, but hey, these are assumes.

That means that in the first days of a pandemic, 2,000 vents are available for pandemic victims.

Lets further assume only a 30% infection rate spread out over 6 months. 

Lets further assume only 10% of infected need a vent.

For new york, population of 19 million, that means that 5.7 million get sick, 570,000 need a vent, spread over 6 months that is about 100,000 people need a vent per month.  If the average time a person is on a vent is 2 weeks, then only 50,000 vents are needed in a month.

In this very generous mild pandemic scenario, 1 out of 25 is going to get access to a vent.  Any triage scenario must be created that excludes 24 out of 25 potential recepients. I wish you luck.

The other 24, because they need a vent and do not get it, will need morphine to ease the pain of their deaths.  I suggest spending lots of money for those morphine shots.  That or get the US to work with the Afganistan taliban for some heroin shipments.

Just rolling along, making waves and causing trouble...


The goal of implementing NPIs is to reduce the infection rate
ISn't it?

So as long as you are assuming so many optimistic things, go ahead and assume that the NPIs have been adopted very early by 60% of the population, and that they are working to reduce the attack rate.

So (if I understand correctly) it is possible that 30% AR could be lowered greatly, perhaps to 3%?

(I'm not sure though -- if that also requires use of Tamiflu given to contacts of infected people as well, to get it that low -- if so, it would require that Tamiflu was effective.)

So -- I'm not so good at math -- but IF the AR were down to 3% (one tenth what you originally suggested) that would mean in your example, you would need only 5,000 vents in a month, not 50,000.

If 2,000 were available, then there'd be 2.5 people competing for 1 vent.  (Assuming it worked for them in the first place.)

I'm not sure if I have this all right; I'm trying to understand how the NPIs are supposed to work -- so correct me if I'm wrong.


GetPandemicReady.org - non commerical website with practical ways for families to prepare.


[ Parent ]
50k vents - just one state in just one country,
Pablo,

  Sobering numbers.

  Even if a manufacture the Govenrment asked GM or Westinghouse where to mass produce different ventilators at cost - where do you store them afterwards?  That really is a problem.

  Also - if we mass produce them now, does that not destroy the ventilator market for several years due to the glut of suprplus machines?

  As the draft report says - so what if you have enough machines. You need qualified people to run them. To not over inflate the lungs or avioli.

Kobie

 


[ Parent ]
Not enough vents now
Once a pandemic comes and goes, and there are tons of vents on the market, it just means that more and more hospitals and secondary-care hospices will have easier access to the equipment they already need. As it is now, there's a major shortage of ventilators out there...

[ Parent ]
Excellent Article on this topic
RT for Decision Makers in Respiratory Care

Emergency Care

Issue: March 2007
  Normal Version

Avian Flu Pandemic: Will We Be Prepared?
by Carol Daus

The impending avian flu pandemic has experts wondering how to ensure that there will be enough ventilators and a sufficient number of well-trained RTs to care for the possibly millions of victims....

http://www.rtmagazin...


ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


thanks!
Mayo's Hick believes that the most important thing an individual hospital can do to prepare adequately for a flu pandemic is to completely understand its work processes. "Hospitals need to have a concrete plan in place that addresses how difficult decisions should be made concerning who should and who should not be given a respirator at a time when resources are scarce," he says. "This involves understanding what thresholds the hospital feels are ethically acceptable."

Currently, there is tremendous inconsistency among hospitals in terms of their level of preparedness. Hick recommends that respiratory care professionals be included as members of hospital emergency preparedness committees, since they have a strong understanding of what will be needed during an influenza outbreak. Branson concurs: "I think therapists have to be involved in planning and education, as well as in the selection of equipment." One of Branson's concerns is that many hospitals have purchased inexpensive disposable ventilators that are not appropriate for patients with acute respiratory disease. In determining which ventilators to purchase, hospitals should refer to the AARC guidelines, which describe the capabilities and features needed in ventilators for a flu pandemic.

Here (NYS DOH) is a proactive approach to the issue.


[ Parent ]
Well, if vents are not that helpful to H5N1 patients
(which so far that hasn't been proven for certain, but it doesn't look good) then why not simply keep the vents for patients with other medical emergencies?  People will still have heart attacks, accidents, babies, emergency surgery, strokes.  Is a vent more likely to save a 20yo car accident victim or a 55yo H5N1 patient? 

The problem is that if CFR is even remotely greater than 1918, there simply won't be enough vents to go around.  End of story.  The public doesn't even know this.  They assume "modern medicine" will keep PI from being like 1918 (or worse with current CFR).  Thanks to ER and other shows they just assume a few machines and a determined doctor can pull you out of a crisis.  It doesn't work that way!

And hospitals better figure out what they are going to do in such a crisis.  Other things like masks, medicines, IV drips, etc. will go further in saving lives of the "less sick" than possibly saving the life of ONE gravely ill H5N1 patient.  Even if these items are stockpiled they will likely still face allocation issues and difficult choices that few are mentally prepared to make.


yes, true...
and this one set of discussions doesn't substitute for that kind of planning.

These companion articles from UPMC, one on "what hospitals will face" and the other on "what alternate care facilities really should be" are required reading.

  1. What Hospitals Should Do to Prepare for an Influenza Pandemic
  Toner E, Waldhorn R. Biosecurity and Bioterrorism. 2006;4(4).

http://www.upmc-bios...

  2. The Prospect of Using Alternative Medical Care Facilities in an Influenza Pandemic
  Lam C, Waldhorn R, Toner E, Inglesby TV, O'Toole T. Biosecurity and Bioterrorism. 2006;4(4).

http://www.upmc-bios...


[ Parent ]
NYS DOH first 34 page reaction
DemFromCT,

  Wow tough read.

  I felt bad that HCW did not get access to ventilators but after the draft I can understand why.

  The leagal aspects are scary as this could be far worse than Katrina. It is not at the  "war crimes" level but can see people questioning descisions.

  The SOFA and MQS look like good candidates for determing who should be on a vent. MQS protocol may need expasion.

  The idea of taking an eight year old off a vent for a 20 year old with fewer organ failurs is hard to swallow but logical.

  The draft speaks as if the hospital is in good working order. Nothing is said the hospital may be crippeled running on emergency power.

  People may also try brining in their generators to run equipment.

  Yes I do expect the rich to have purchased vents and people to run them. Nurse can work in a crowded hospital with sick or make more money staying in a clean $14mil mansion with pool privliges. Hmm, which would one pick??

Kobie


DemFromCT, NYSDOH final review.
  After finishing the document my feelings are low. I do not mean this

  I felt it was better than the 1950 nuke strike plans of "just give morphine"

  It read like a leagal CYA. document on "How to leagaly let most people die and not fear litigation" Which if there are not enough ventilators - that is what will likely happen.

  One question - I understand the DNR request but if someone is removed from a vent for another and then a vent becomes available, why not put them back on it if they are a good candidate. The document reads like you have one shot, and one shot only. Did I mis-read something??

  Over all it did not read badly. Might need more examples so people know they are removing a 8 year old with liver damage to give the ventilator to a 22 year old convicted felon who has no organ failure.

  That someone will have the vent pulled because they are not making sufficient progress for a unknown person who has not been on a vent and may or may not make progress.

  In the abstract it looks good. In reality .... well it was hard. Unless one puts faces and names with the abstract it is all easy.

  If it is going to be implimented we need more clergy and grief experts. No recommendation is made for staffing.

  I will try and check out the power point files.

  I need a five or ten min break.

Kobie

 


[ Parent ]
the ppt files really put this in context
do look at them!

[ Parent ]
Will do. Did you think I read anything incorrectly?? n/t


[ Parent ]
only that it's more than lawyer CYA
the need for the clinicians to have this is well spelled out in the ethics piece. it's heartfelt, not bs.

[ Parent ]
DemFromCT - end of the road
DemFromCt,

  I apologize for any thought the paper is BS.

  What scares me is that this could be a solution.

  An ethical protocol for dispersing limited supplies worried me that more supplies will not be agrresivly fought for. The simple soulution of sedation seems so tempting when no other means are at hand.

  I am scared to buy into this. While I believe that if you told the workers on the GM or Ford assmebly line what was going to happen to their family and they had permission to take what ever action was they thought nescessary you would see the place re-tooled over night and thousands of ventilators rool off the assembly line.

  Brute force is not always the answer. The big hurdle is traind technitions. Even with ventilators there needs to be trained people to run them.

  Yes, I feel clinicians and HCW will not find any of easy. "I was only following orders" does not fly like it used to.

Kobie


[ Parent ]
they are not mutually exclusive
An ethical protocol for dispersing limited supplies worried me that more supplies will not be agrresivly fought for.

These are necessary decisions that must be handled, and best handled ahead of time, than in the midst of the turmoil of mass casualty pandemic.



All 'safety concerns' are hypothetical.  If not, they'd be called side effects...


[ Parent ]
SusanC-not mutualy exclusive
SusanC,

  I agree with you 100%. Discuss and deicide now when cooler heads can prevail.

  It is better to figure out what one needs before leaving or starting than after wards or in mid step.

  Purchasing/securing ventilators, consumable and training people seems like it can be done. Yes it is a huge expense for a one time event.

  Huge amounts have been spent on putting a man on the moon, building the Concord, The Normandy wall and a one time wharehouse to process fuel for the Atomic bomb.

Counter Point:

  Training and certifing ventilation technitions post haste has problems. The new trainees may kill several people as they will be working under adverse conditions.

  Ventilation does not guarentee a cure.

  Can that number be predicted? To make up numbers: "With a surge of 2,000 people per week - 1,200 to 1,700 will be helped with ventilation."

Kobie



[ Parent ]
sounds like it would help more to prevent cytokine storm. n/t


[ Parent ]
more specifically, this is for
the clinicians in the trenches. They do not have the option of ignoring the issue, but should not be the ones deciding policy. See especially the ethics .ppt presentation.

http://newfluwiki2.c...


[ Parent ]
DemFromCT,
DemFromCT,

  I do not want to end the week on a bad note.

  My laymans opinion is that more work needs to be done on The appeals process, re-testing/evaluation of SOFA rating and several senarios.

  The written senarios should walk clinicians through the difficult descisions that will be made. Some questions do not come up untill later.

  A section on home health care in case the person wants to die at home. I assume a person is allowed to leave the hospital with BF and die at home. Too dangerouse for me, but some may want to. 

  There was no section on euthenasia. Would the protocals be any different?  When doing some work on teen suicide prevention there where alot of warning about sleeping pills causing brain damage due to Oxygen starvation.

Kobie


[ Parent ]
there are no guidelines on that which is illegal
Forget about euthanasia. That will not be included in this guideline or in print anywhere.

As far as leaving against medical advice (also known as leaving AMA), there are already existing policies for that in every hospital in the country.

This is a limited-in-scope policy not designed to deal with everything bird flu, but about one thing and one thing only... how to triage vents in the ICU. Anything else is separate policy, including home care.

BTW, as far as home care goes, remember your diary on the topic:

http://www.newfluwik...

and see

http://www.health.go...

for CA's advice... over 400 pages.


[ Parent ]
DemFromCT - Canada
DemFromCt,

  Thanks for the Canada web site. I have not read it all yet. Its interesting to see how it is a work in progress from one year to another.

  Yea, I remeber my diary but forgot what was in it. I can not see leaving the hospital with BF. My boss, and boss boss understand that and say we will not be called in unless "they need to bull doze a neighborhood for a mass grave. In which I may be putting some of my family." My response was "it could be cathertic (sp?) as I would at least be doing something. Starting closoure." There where no jokes nor grins - even to break the tension. Well I did say "I have this bad neighbor two blocks over....."

  No I do not know how I would really react in real life.

  There are no official guidlins on what is illegal. I can not find the book or a web site off hand but the book was by a british doctor telling teens not to even attempt suicide as it is very dangerouse.

  Having ones lungs fill up and slowly sufficating sound like such a bad way to go. Yes I took a bio-ethics class in college. At that time doctors where forbidden from giving anything that would not sustain life.

  400 pages - wow. Good. I hope the document gets passed around to other states - like mine. Not sure I want to read it.

  Wish I could add something helpful. If things get bad there will be alot of confused layman trying to take this all in. Trying to understand what is going on in a very short time without the normal "second or third opinion."

  I'll stick to somethign simple like computers and wires.

  Have a good weekend.
Kobie


[ Parent ]
you too, Kobie
people all over the world are genuinely trying.

[ Parent ]
DemFromCT-Of vents and power.
DemFromCT,

  Please tell where guidlines for running a hospital under duress are?

  What are the guidlines for deciding which systems to run as power, water and fule fail.

Kobie


all hospitals have emergency power generators
short of flooding, as in Katrina, these would suffice for short periods (hours and not days). With complete power failure, RTs 'bag' patients by hand. You make do with what you have. But hospitals would likely run out of oxygen and supplies, as well as personnel, before they ran out of power.

If a system for coverage with full power could be developed that would be fantastic! Alas, as all the articles show, we are not there. Doing so with less than full power is harder and easier (in the sense that if you can't, you can't). Same is true for food and water.


[ Parent ]
DemFromCT,
Hi,

  Our local hospital has a generator - but not one that can run the hospital.

  They lost power for three days only to find out the AC system was *not* covered. I got this from the electrician at the hospital who was there.

  In order to conserve fuel a Hospital may not want to run the generator at full tilt.

  If we run out of supplies and HCW, would family not bring in what they had? 

  Are you saying there are no protocols for running a hospital and half or 1/4 power?

Kobie
"We have a long way to go and a short time to get there.
For we're going to do what they say can't be done."


[ Parent ]
generally, plans include
emergency use only plugs. Rooms have a red emergency plug and regular plugs. Vents and monitors are plugged into the red plug. That means that the generators run the 1/4 of the hospital that HAS to be run, the rest we do without.

In a hurricane emergency, or if a tornado hit, we'd evacuate. In a pandemic that would not work.


[ Parent ]
DemFromCT 1/4 power
DemFromCT,

  Ok, now I understand.

  It takes alot of power for AC, elevators, X-Ray equipment, laundry and dish washers.
  Hopefuly the records and admin computers are kept up.

  I assume each hospital can run for a few days if power is lost. Not just from flooding like Katrina or Grand forks but other problems.

  BTW, the Navy and some IT departments run three genny's. One can handle most of the load, Two are normaly run while one rests. Later they start up the third and shut down the first. This continues untill power is restored.

  There is a one generator solution called a MUSE, but they are very limited in number.

http://www.navy.mil/...

https://portal.navfa...

Kobie


[ Parent ]
bagging
One blizzardy night local substation went down. Genny did not kick in. Spent 6 hours bagging our 1 vent patient. We rapidly found out that 10-15 min. was the max before our hands cramped. Before we finally got power even had the janitor take his turn.Small 20+ bed hospital, with 3 ICU beds.
  I`ve had better nights.

There is no pleasure in having nothing to do; the fun is in having lots to do and not doing it." -Mary Wilson Little

[ Parent ]
you needed a nurse or a RT with
forearms like Popeye. And they're in short supply.

[ Parent ]
Genny did not kick in.
Cactus,

  You are not alone.

  "Fuel? Contract is in purchasing waiting on negotiation.
  No fuel in the tank per-se. "
  "Oh, that's *our* genny our there"
  "Where is the key"
  "We think the batteries dead"
  "We have not had to use it before

  "Its not hooked up" - transfer switch was not installed right and never tested. Its only a switch, how complicated could it be??

  "Customer supplies hookup" - this was funny. Contractor put in power but the Navy ran the hook up. Secure building, contractors not allowed inside.  Contractor was going to sue the Navy for not finishing on time. From what I heard they ran the pipe and used two jeeps to pull the wire from the far side of the building.

  "We have portable genny. 20KW!" Seriously for the city's IT building. No Joke. 20KW would not have run all the lights. Yes it was also locked - bad neighborhood. No, in the year I was there we did not actually find the key nor did we test it.

  This one is was kinda sad.
  "We don't need a generator. Power company runs two lines to the water treatment plant."  - Which they did. Both lines cam from the same sub-station and power plant.

  Our local hospital has a genny. When the power went out for three days they found out the AC unit was *not* included. Its hot and humid in the south near the water - nuff said when the windows will *not* open (safety feature I'm told).

  The building I work in now tests the Genny every Wednesday. Not only does it page four different people it runs but has a computer built in that keeps a record. Start, run-up, transfer to gen, timed test, transfer back, cool down, shutdown. If overcrank, failure, low oil or error happens it records it.

  Yes, the gen runs the building both primary and secondary AC, as well as both refridgerators (food-its a guy thing :) We only have one deparment coffeepot but multiple back up units in differnt offices.

  Cactus - I hope they fix your generator. I hope they put in a heater plug to keep the engine block warm. Mostly I just hope it runs.

  My apologies if this was too long or too full of vinigar. I get frustrated not amused.

Kobie
 


[ Parent ]
Kobie
The genny issue was several years ago, in a different state. That town now has brand new hospital, and run their genny every week.
  It takes about 20-30 sec. after power goes out for backup to kick in. I hold my breath every time, now. Arizona small towns (and larger ones,too) tend to loose power every monsoon season for a short while.So, I get to practice my breath holding skills every summer.

There is no pleasure in having nothing to do; the fun is in having lots to do and not doing it." -Mary Wilson Little

[ Parent ]
Cactus-genny,
I hope the genny situation gets better.

  Some of the quotes where from the early 1990's, the 20KW was from 1999. The wendays test is current. We have three people who understand Genny's and pushed to have weekly tests.

  Our Court building and Jail have them but as far as I know they have not been tested. Weird to me. People go out and start their cars once a week.

  I guess genny's are magical - they will start and work perfectly without care or maintenace. Kinda like the three year old flashlight left in the closet. Hmm a genny is bit more expensive to replace than a flashlight or car.

  Sorry my emotions still run deep.

Kobie


[ Parent ]
...
big ones aren't magical...  they get run every week for test, but also to keep the battery charged and the seals intact.  and vendor onsite maintenance at least once a year.  no run, no run.

[ Parent ]
C3Jmp - you knw that. I know that. There seems to be a whole group who thinks they are magical n/t


[ Parent ]
if you have the chance, review the .ppt slides
Framework
http://www.nyhealth....
   
Quote:
The 1918 pandemic was among the most deadly events in recorded human history, with an estimated 50-100 million deaths world wide and three quarters of a million deaths in the US.  New York experienced about 10% of these deaths, or roughly 68,000.  A proportional number of deaths today in New York would be about 150,000.  By comparison, the 1957 and 1968 pandemics were much less severe.  Many of the control measures which I will describe would probably not be needed in pandemics of this lesser magnitude.  The 1918 pandemic was the "once in a century storm" that we have to plan for.


Ethics

link

   
Quote:
Doctors must focus on providing best available care for individual patients; the clinician treating the patients cant also make triage decisions

Even when patients will not be treated with ventilators, they will still receive care.

DOH is collaborating with palliative care experts to devise palliative care surge capacity for mass casualty scenarios

A useful ethical system will also strive to minimize the number of times that doctors and others are forced to make the most agonizing decision, in this case the decision to deny initial or later access to a ventilator.



Next Steps

link

   
Quote:
To provide input on the draft guidance document presented today, please submit feedback to:


  panflu@health.state.ny.us


  We want your feedback



Give them the feedback, including on ethics.


Power Point Presentaion - not bad
DemFromCt,

  Slide #3 most telling. Most laymen think *we* have a normal mortality rate, not one that has been vastly improved.

  Slide #7 - missing comman change '1400 flu deaths' to '1,400 flu deaths'

  No mention of vent maintenace or repairs.

  Are most ventilators run 24x7x365 ??  During a pandemic I assume we will be running the ventilators harder.

Kobie

 


[ Parent ]
for the most part
they are generally used for weeks at a time with little servicing except on the spot. They will be used for 6 weeks, not 365 days, and not likely worked harder than usual.

[ Parent ]
6 weeks? I thought we would get multiple waves? n/t


[ Parent ]
the next wave is
'starting over' recurrent use, not continuous use, as far as the equipment goes.

[ Parent ]
interesting to look at pandemic timing from the POV of a piece of hardware


You arm yourself to the teeth just in case.  You don't leave the gun near the baby's hand.

[ Parent ]
DemFromCt, wow what a wrinkle.
DemFromCt,

  The pandemic really is suppose to be that short. Hmm. Puts a new wrinkle on things.

  I'm still uncomfertable with the feelings "we can not do it becasue it costs too much"

  Solution - Ask people on their NY state tax form if they would add $3 to go in a special fund to buy Ventilators, pandemic supplies.

  I hate adding taxes as they do not go away. They just ended long distance telephone tax to pay for the Spanish/American war. There are others.

  DemFromCT I guess it is me and my perspective.

Kobie

 


[ Parent ]
sometimes you get what you pay for
re taxes, that is. still, buying more boxes doesn't help if there's no personnel (respiratory therapists, nurses, etc). You can't buy your way out of this, alas.

[ Parent ]
No buy outs - hmm - you are right there. Need people. Will it
really be only six weeks?

  With so many babies and young kids who could not be vaccinated it seems like it will be longer.

  History says it will be short. 1918 pandemic lasted from March to December - that is end to end.
Source
http://www.pbs.org/w...

  But we are more densly populated and, in my laymans opinion, we are more connected to remote pools of infection.

  I am not trying to make a mountain out of a mole hill. Six weeks just seem so short.

Kobie


[ Parent ]
1918 lasted 18 months
with three waves of 6-8 weeks each, not 18 months of consecutive illness in a given community.

Do we know how long a wave will last, or how many wave sfor the next one? No.


[ Parent ]
DemFromCT, 3 waves of 6-8 weeks
DemFromCT,

  Thanks - that changes my preception.

  With the lond distances people commute for work, single income households, JIT delivery, intra country trade for food, fuel, goods and spare parts along with the densely populated cities I still see things as being far worse than 1918.

  Low cost shipping, buried infrastructure and assembly line manufacture has allowed for greater centralization of porcessing at locations that are far more distant from the consumer.

  It is good that there should be a respit.

kobie


[ Parent ]
Draft Document
Let's say the decision has been made by the appropriate staff, that a pt. is to be extubated.  The physician or nurse walks in and just says to the patient "Okay, you're not getting any better, and we're going to take you off the respirator.  We're pretty sure you're going to die, respirator or no respirator, and someone who's healthier needs the equipment."  (Or some words to that effect.) 

Very practical questions, but I think important:  How long will the patient/family be given to adjust to this new situation, before they're actually extubated? 

If the patient wants to appeal, that appeal, per the protocol, should involve more than one person--this seems like it would be a time-consuming process.  The proper reviewers have to be contacted, set up a meeting, review patient's chart, etc. 

What if during this process, patient B, who was supposed to be getting the respirator gets worse and no longer has a qualifying SOFA score?  Do you then tell pt. A, "Well, your appeal was denied, but now it's a moot point, and we'll leave you on."?  How many times do you do that to someone?

Or how about if the appeal takes longer than a day, and the patientA/family wants the blood tests re-run...do you do it?

If the pt/family still disagrees, after an appeal, with the decision to extubate, is the patient physically tied down for extubation, because don't you think they'll resist?  Or are they too sick to resist?

Second, assume a pt. arrives with an endotrachial tube that was inserted in an ambulance.  Do ambulances have ventilators?  Would the pt. already be on a respirator?  If so, and a decision has to be made whether to continue it or not, the SOFA scoring requires blood tests that even if done STAT (and w/hospital overwhelmed, that's not likely), it's going to be a few hours before the results are in.  So is the pt. being bagged in the meantime, or just left laying in the ER gasping for air?

Sorry, but I'm a very practical person.  The plan seems very vague in the most critical areas. 

I agree somewhat with Kobie.  If it's not a CYA exercise, due to liability exposure, then it needs to be more detailed.


...
um...  unless things have changed drastically pre-hospital...  if someone codes in a mass casualty, they're not critical, they're dead.  i wouldn't look for too many med units to be bringing codes in during an mci/mce.  by all means - if things have changed, please correct me. 

if ems does continue to work codes, i wouldn't expect them to do so for very long - running o2 at 15 L/min bvm, you get maybe 2 or 3 codes in before having to swap tanks on the truck.  that's just o2.  if ems can't re-supply drugs because they're not available or in limited supply...  it'll be mostly bls pretty quick, not als, where it occurs at all.

med units aren't magical either.


[ Parent ]
...
and that assumes ems has fuel.  the E-350's we used to run got 4-6 mpg on gasoline, and a pretty steady 8 mpg on diesel. they're not run for their fuel economy, and fuel will be a problem.  i don't think we'll have ems for long in a pandemic - not the ems folks have become accustomed to.

[ Parent ]
Gas mileage - off topic drift
I just purchased my 10th and 11th Sprinters last week. 

Made by mercedes, sold and serviced by dodge.

We get 20 mpg out of them.  Very stable, very powerful, and absolutely the best replacement for E-250 and E-350 modifications. 

I highly reccommend you investigate them in your next fleet purchase.

PE

Just rolling along, making waves and causing trouble...


[ Parent ]
...
sweet - and i did get off topic..  definitely something for ems folks to look into, tho, if they're looking at new units or balancing refurb costs..  whatever will make those limited resources go further..  ;-)

[ Parent ]
Good question - Who do they appeal to?
SoCal,

  Hi. Very good point.

  Who to appeal to?

  Will there be enough appeals people around - or will they be sick?

  Why appeal? If I read the document correctly once you are disqalified that is it. The person is not re-assesed.
I got the impression there will be such an inrush of paitients there is a good possibility they will have a better SOFA score. The new people will outstrip the supply of ventilators.

  Will the police or HCW wrestle the tube from the patient and family?

  BTW, I have to agree with the HCW. In wilderness first aid we where taught "help the ones you can and make comfertable the ones you can not. In this way you have done all that you can. Even Dr. McCoy could not save them all"

  I'm just not ready to accept "it can not be done"

Kobie 


[ Parent ]
Discussion continues ...
http://www.newfluwik...

ITW(Joel J)
Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain
 


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