1. Potera, Carol


A consensus group has drafted a protocol to guide clinicians in 'rationing care.'


Article Content

If a "mass casualty event" such as an influenza pandemic or earthquake were to strike this country, critical care resources would most likely be in short supply. The United States and most other countries do not have enough specialized staff, equipment, and ICUs to cope with a large influx of critically ill or injured patients, especially if demand is expected to continue over time. Some cities, like New Orleans after Hurricane Katrina and Toronto during its severe acute respiratory syndrome outbreak, already know what that's like.


In January 2007 U.S. and Canadian health authorities convened a team of experts to develop an emergency mass critical care (EMCC) plan designed to guide providers during a catastrophe. With representatives from nursing; bioethics; response planning; infectious disease; and hospital, emergency, and military medicine, the team released its plan in May. Its intention is to allow the greatest number of victims in a catastrophe to benefit from lifesaving interventions. The guidelines are available in a supplement to the May issue of Chest (


The task force advises hospitals to triple their ICU capacity by stockpiling medical equipment like ventilators, increasing supplies of drugs like iv fluids, and designating auxiliary critical care space. It recommends that hospitals have supplies and staff for up to 10 days to meet the demands of a disaster surge.


The task force acknowledges that patients may still overwhelm available resources, and its protocol guides clinicians (a triage officer, along with a support team that includes, ideally, a critical care nurse, respiratory therapist, and pharmacist) in "rationing care" according to those most likely to survive. This would exclude those with extreme organ failure and severe chronic illnesses, such as congestive heart failure and metastatic cancer. In those cases, palliative care would be the goal. Without such guidelines, the allocation of critical care resources could be unjust. The task force cautions that the EMCC framework "should only be used for extreme mismatches between patient need and available resources," and that the decision to begin triage should be made in conjunction with local and regional authorities.

Figure. A security g... - Click to enlarge in new windowFigure. A security guard wearing protective gear patrols the closed entrance to the emergency ward at North York General Hospital May 29, 2003, in Toronto, which was the source of a second cluster of severe acute respiratory syndrome cases.

Justine Medina, a member of the EMCC task force's steering committee and director of professional practice and programs at the American Association of Critical-Care Nurses, notes that in a disaster, nurses might know more about a patient's condition than the triage officer and should speak up. "The best nurses can do is be fully competent in their job and articulate their skills," says Medina. All nurses, she says, should be aware of and understand the EMCC guidelines.


The task force also calls for protection against malpractice claims for members of a triage team, health care workers, and institutions providing care under EMCC protocols.


Carol Potera