David Weber, MD, professor of medicine, pediatrics, and epidemiology at the University of North Carolina at Chapel Hill, recently stated that predicting the next influenza pandemic is much like predicting an earthquake in San Francisco—it isn’t a question of if but rather when and how big. Despite the unknowns, it is clear that such a pandemic would seriously impair hospitals and the public health system. One of the most troubling concerns is the probable ventilator shortage for patients. Whether it is an avian flu pandemic, a re-emergence of SARS, or a bio-terrorism incident, victims of a mass casualty event will likely need to be treated for an obstructive airway or an inhalation injury. Some government experts have predicted that an avian flu pandemic similar to the 1918 flu epidemic could result in approximately 750,000 patients nationwide requiring mechanical ventilation.
Currently, hospitals throughout the country do not have sufficient numbers of reserve ventilators needed to meet the demands of a pandemic flu or a disaster. The expense of purchasing and storing critical care equipment has prevented many institutions from stockpiling additional emergency ventilators. Furthermore, even most manufacturers of ventilators admit that they do not have excess capacity that could be used in a pandemic.
“Although none of us know how bad such a pandemic will be, we do know that it won’t take much to push us over the edge,” says John Hick, MD, a disaster medicine expert and professor of emergency medicine, Mayo Medical School, Rochester, Minn. In a recent drill at his hospital, Hennepin County Medical Center in Minneapolis, Hick discovered that when trying to locate vendors who could supply additional ventilators, only one manufacturer had available ventilators that were similar to those in the hospital. “Others were available, but our RTs would have had to be trained on them, which doesn’t work well when you’re stretched to capacity,” Hick says. “Drills like this teach us that we need to be making plans now for allocating scarce resources for patients in the event of a pandemic.”
The Threat of H5N1
Attention has been focused on the increasing likelihood of a flu pandemic primarily because of the avian influenza strain, H5N1, which has spread in domestic poultry and wild birds across 38 countries in Asia, Africa, and Europe and has killed 157 people since 2003, according to the World Health Organization.
Planning for Disaster
In November 2006, the US Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) published a planning guide for hospitals and local governments: www.ahrq.gov/research/mce/.
The American Association for Respiratory Care has published guidelines for the acquisition of ventilators during an influenza pandemic: www.aarc.org/resources/vent_guidelines.pdf.
Hick points out that pandemic influenza usually comes from avian influenza strains, but there is no guarantee that H5N1 is going to be the strain that mutates enough to allow sustained human to human transmission. “The reason we’re so concerned about H5N1 is that when those cases are in humans, it causes very severe disease,” he says. “There’s a 60% mortality rate with this strain, which is unlike any avian influenza virus that’s been seen in modern history.” This concern has caused many experts to draw comparisons to the 1918-1920 influenza pandemic, which killed 50 to 100 million people globally.
In the December 2006 issue of The Lancet,1 researchers reported that 62 million people could die in a year throughout the world if a similar pandemic were to occur today, based on mortality data from the 1918-1920 pandemic.
Since staggering numbers of people will suffer from acute respiratory failure during an influenza pandemic, the American Association for Respiratory Care (AARC)2 has developed patient care guidelines and recommendations for ramping up equipment and human resources to prepare for a crisis. Some of the major points include:
- Expand the federal government’s Strategic National Stockpile program by 5,000 to 10,000 ventilators. This should include approximately 1,500 ventilators with capabilities that can support patients with acute respiratory failure.
- Standardize ventilators when possible in order to make it easier to train support staff and maintain the necessary support resources, such as circuits.
- Consider ease of use and training when making ventilator purchases.
- Increase human resources to assist RTs and physicians.
- Develop a distribution plan for ventilators on both the local and national level.
- Recommend intubation for patients with acute respiratory failure, because ventilation by mask may increase the risk of infection to staff and other patients.
- Prepare for power outages.
Due to the detailed nature of these AARC guidelines, many states’ respiratory care organizations have used them in developing their own tools for disaster preparedness.3 For example, the Florida Society for Respiratory Care has been working with state health officials since 2003 to train RTs on the use of ventilators purchased for emergency situations in Florida and is developing a 1-hour continuing education course that it hopes will be made mandatory by the Florida Board of Respiratory Care in 2007. The Minnesota Society for Respiratory Care has participated in emergency preparedness exercises and has conducted a ventilator inventory in the Twin Cities and statewide.
State governments also have become more active in their efforts to prepare for an influenza pandemic. A year ago, former Massachusetts Governor Mitt Romney proposed a $36.5 million bill to fund the purchase of ventilators, antiviral medications, and other supplies to be stockpiled in the event of a major outbreak. North Carolina public health officials have requested more than $12 million in state and federal money to plan and prepare for pandemic flu. States have even begun to stockpile their own ventilators, recognizing that the Strategic National Stockpile program is simply not adequate. New York recently purchased 871 ventilators, and Ohio bought 540.
The federal government has been fairly proactive in the past couple of years in preparing for a flu pandemic. The Centers for Disease Control and Prevention (CDC) has stored 5,000 mechanical ventilators under the Strategic National Stockpile program. The two different ventilators selected for the program can meet the clinical requirements of both adult and pediatric patients in mass casualty situations. Furthermore, these ventilators allow for patient transport, are intuitive to use, have audible alarms, do not require medical gases for operation, and have strong reliability records.
The Department of Health and Human Services (HHS) also has worked recently with the AARC in developing a national disaster response program, which is designed to provide scarce resources during an influenza pandemic. HHS plans to initially recruit a minimum of 200 RTs around the country to become specialists in responding to disasters such as a flu pandemic. As the project takes shape, the HHS will recruit even greater numbers of RTs.
In November 2006, HHS also released a comprehensive document, “Providing Mass Medical Care with Scarce Resources: A Community Planning Guide,”4 which provides community planners, as well as other individuals at the institutional, state, and federal levels, with valuable information that will help their efforts to plan and respond to a mass casualty event, such as an influenza pandemic.
Hospitals Take Action
Many hospitals have also begun developing models for staffing and isolating infected patients, but these efforts will not be adequate unless they work closely with other hospitals in their areas, their local public health departments, and state governments. “An individual hospital acting in isolation can really do very little,” stresses Richard Branson, RRT, FAARC, associate professor of surgery, University of Cincinnati. “It is the coordinated plan involving a city, municipality, and state that is most important.”
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.
Hick agrees that the practice of stockpiling cheap ventilators is a major problem. “There’s a paradox here because when you have an overwhelming number of patients you need to ventilate, you actually need ventilators with more alarms and features because therapists will not be able to keep a close eye on individual patients,” he says. “Many of these so-called disposable ventilators are very limited in utility because they’re pressure-cycled and can’t be used for patients with ARDS or pulmonary edema.” The best contingency ventilators, notes Hick, are transport ventilators with many features that can be used on a routine basis in different locations within the hospital but also can be used in the event of an influenza pandemic.
Considerations for Stockpiling
Foster (Duke) Johns III, president/CEO of New Orleans-based Medical Specialties Inc, a supplier and distributor of ventilators, believes that several considerations need to be made before stockpiling takes place. He advises hospital personnel and government officials to consider the cost of the equipment as well as its efficacy for certain disasters. “It’s also important to know whether the ventilators will be adequate for both a mass casualty event and a flu pandemic or just one or the other,” he says. “A mass casualty event such as what happened in Hurricane Katrina and a flu pandemic represent two very different scenarios and require different types of emergency planning.” For example, in the case of a mass casualty event, simple equipment that is used strictly for ventilation may be sufficient until additional help is provided in 2 or 3 days. However, in a flu pandemic—which would probably last longer—more sophisticated ventilators capable of treating patients with ARDS would be necessary.
According to Johns, the best strategy for developing effective emergency preparedness plans for any type of disaster requires cooperation between hospitals as well as all levels of the government and manufacturers. “There needs to be a total spirit of collaboration, and the liability and cost for planning should be spread equally,” says Johns. He points out that medical equipment companies have begun developing creative programs that could provide assistance in supplying ventilators and other products in the event of a disaster.
One Costa Mesa, Calif-based medical instrument company has created a ventilator reserve program for disaster situations, which helps institutions meet preparedness compliance levels without incurring all the initial costs up front. The state agencies and/or hospitals pay a nominal fee up front for acquisition of ventilators and then pay a small maintenance fee to the company to store the devices. “This might be more realistic for most states and institutions than stockpiling programs because the costs are spread out over a long period of time,” says Johns.
Branson stresses that a shortage of trained health care providers is another concern in the event of a flu pandemic. “We have to predict that some of the health care workers will be sick or will have sick family members and that employee shortages will only get worse,” he says. “Additionally, some people won’t come to work out of fear of contracting the illness.” Cross-training is needed so that other health care workers can perform simple respiratory tasks. The HHS is currently working with the AARC to train therapists in the use of stockpiled ventilators, and the Health Resources and Services Administration (HRSA) has sponsored a project known as Project EXTREME at the University of Colorado in Denver to train nontherapists to do some tasks like suctioning. The AARC is involved in that work as well.
Hick agrees that health care providers need to assess the specific responsibilities of RTs. “There are a lot of things I do on a day-to-day basis that don’t require a physician skill set and there’s a lot RTs do on a day-to-day basis that could be performed by nurses and other health care professionals,” says Hick. “During a flu pandemic, I would rather have RTs give up some of their less critical responsibilities and devote all their time to making sure the ventilators are working properly—in other words, they need to perform those tasks that only RTs are capable of doing.”
The thought of an influenza pandemic may be daunting, but progress has been made in the past few years in establishing guidelines for planning at the federal, regional, and institutional levels. “The critical step in preparing for this is having a decision-making process already in place in terms of how patients will be treated,” stresses Hick. “Only then can we make the best use of our available resources.”
Carol Daus is a contributing writer for RT. For further information, contact [email protected].
- Murray CJ, Lopez AD, Chin B, Feehan D, Hill KH. Estimation of potential global pandemic influenza mortality on the basis of vital registry data from the 1918-20 pandemic: a quantitative analysis.
- Guidelines for acquisition of ventilators to meet demands for pandemci flu and mass casualty incidents. May 25, 2006. Available at: www.aarc.org/resources/vent_guidelines.pdf. Accessed January 4, 2007.
- State-by-state involvemtn in disaster planning 2006. Available at: www.aarc.org/resources/mass_casualty/state.asp. Accessed January 2, 2007
- Providing mass medical care with scarce resources: a community planning guide, November 16, 2006. Available at: www.ahrq.gov/research/mce/mceguide.pdf. Accessed January 2, 2007.