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Stanford Hospital and Clinics Lucile Packard Children’s Hospital

Template For

Crisis Standards of Care Plan

Prepared for the CHA Disaster Planning for California

Hospitals Conference by

Draft October 15, 2012

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I. Introduction and Overview 4

II. Standard of Care 5

III. Crisis Standards of Care 5

IV. Legal and Regulatory Issues 6

V. Granting Disaster Privileges to Volunteer Licensed Independent Practitioners 7

VI. Crisis Care Plan Prerequisites and Triggers 9

VII. CSCP Critical Care Staffing Model 10

VIII. Critical Care Triage Officer (CCTO) and Critical Care Triage Team 10

IX. Critical Care Triage Protocol and Procedure 11

X. SHC and LPCH Palliative Care Plan During a Mass Casualty Event (MCE) 14

Appendix A: Adult Palliative Care Medical Pack 21

Appendix B: Pediatric Palliative Care Medical Pack 22

Appendix C: Adult Comfort Care Order Set 23

Appendix 1. Triage Protocol Inclusion Criteria 27

Appendix 2. Triage Protocol Exclusion Criteria 28

Appendix 3. Sequential Organ Failure Assessment (SOFA) score 29

Appendix 4. Critical Care Triage Tools 30

Appendix 5. Laws And Regulations 33

Appendix 6. Glasgow Coma Scale - Adults 34

Appendix 7. Triage Algorithy Process 35

Appendix 8. Pediatric CSC Palliative Care Order Set (Less than 10 kg) 36

Appendix 9. Pediatric CSC Palliative Care Order Set (10 - 25 kg) 39

Appendix 10. Pediatric CSC Palliative Care Order Set (greater than 25 kg) 42

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I. Introduction and Overview During a pandemic or in the aftermath of a mass casualty event such as an earthquake, hospital resources and personnel may become severely constrained or unavailable. Though there is no one agreed-upon set of guidelines or protocols to manage such a situation, it is generally agreed that crisis standards of care will eventually need to be adopted. The Institute of Medicine of The National Academies defined crisis standards of care (CSC) as a state of being that indicates a substantial change in health care operations and the level of care that can be delivered in a public health emergency, justified by specific circumstances. Medical care delivered during disasters shifts beyond focusing on individuals to promoting the thoughtful stewardship of limited resources intended to result in the best possible heath outcomes for the population as a whole. During such a crisis, the Medical Center may be without power; trained staff may be unavailable; medicines, supplies, and hospital beds could be short supply; and medical care may need to be delivered in alternate care facilities. The Crisis Standards of Care Plan (CSCP) is a set of changes from everyday patient care staffing, medical equipment, and treatment decisions that are intended to maximize survival for the overall patient population and, at the same time, to minimize the adverse outcomes that might occur as a result of changes in usual practice. The CSCP should only be implemented for disasters or pandemics when numbers of critically ill patients surpass the capability of available critical care capacity and normal standards of care can no longer be maintained. The CSCP is designed to produce the best care that is possible in a rare, catastrophic event. The Plan is driven by several values that have been recognized as central to a just process. Fairness – the standards developed attempt to be fair to all those who are affected by the Plan. Every effort will be made to provide compassionate and evidence based care that is responsive to the needs of our patients, while recognizing that this will need to be balanced by our obligation to act as good stewards of scarce resources. Consistency – these standards will be applied equitably across populations without regard to patients’ race, age, disability, ethnicity, religion, or socio-economic status. Proportionality – any alteration in the Standard of Care will be commensurate with the degree of emergency and the degree of scarcity of any limited resources.

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Transparency – the Plan developed here was developed with input from the community and efforts will be made to engage and educate our community about the Plan.

II. Standard of Care Standard of care during a hospital surge has been defined as “the degree of skill, diligence, and reasonable exercise of judgment in furtherance of optimizing population outcome during a healthcare surge event that a reasonably prudent person or entity with comparable training experience or capacity would have used under the circumstances” (California Department of Public Health Standards and Guidelines for Healthcare Surge During Emergencies, Volume 1, page 10, 2008) Under normal conditions, current standards of care might be interpreted as calling for the allocation of all appropriate health and medical resources to improve the health status and/or save the life of each individual patient. However, should a mass casualty event occur, the demand for care provided in accordance with current standards may exceed the Medical Center’s resources. Our goal then would be to keep health care systems functioning and to deliver acceptable quality of care to preserve as many lives as possible.

III. Crisis Standards of Care The term “Crisis Standards of Care” is assumed to mean a shift to providing care and allocating scarce equipment, supplies, and personnel in a way that saves the largest number of lives in contrast to the traditional focus on saving individuals. The Agency for Healthcare Research and Quality developed the following characteristics of altered standards of care that might be manifest during a surge situation:

Usual scope of practice will not apply.

Equipment and supplies will be rationed to save the most lives.

There will be an insufficient number of trained staff.

Severe delays and backlogs in emergency and hospital care will likely exist.

Treatment decisions may need to be based entirely on clinical judgment as other diagnostic tools become inaccessible.

Examples of other fundamental changes that may be considered in conjunction with implementing a Crisis Care Plan include, but are not limited to:

Applying principles of field triage and a graded scoring system to

determine who gets what kind of care.

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Determining who receives the use of a limited supply of ventilators or other critical care modalities.

Creating alternate care sites from areas never designed to provide medical care, such as the hospital(s) cafeteria, radiology suites, hospital corridors, in-patient hallways and corridors, hospital atrium, athletic centers or research buildings.

Changing infection control standards to permit group isolation rather than single person isolation units.

Changing who provides various kinds of care.

Changing privacy and confidentiality protection procedures temporarily.

Emergency Department access may be reserved for immediate-need patients; ambulatory patients may be diverted to alternate care sites where "lower level" care can be provided.

Elective procedures and surgeries may have to be cancelled. Under some circumstances only lifesaving surgeries will be performed, and initial surgical care will aim to stabilize the patient. When more resources become available, additional surgery to fully treat injuries can occur.

Usual scope of practice standards may not apply. Nurses may take on expanded roles, and physicians may function outside their specialties.

Credentialing of providers may be granted on an emergency or temporary basis.

IV. Legal and Regulatory Issues The legal, regulatory, and accreditation implications of initiating a triage algorithm that allocates scarce resources to select patients (CSC) is daunting and should occur in conjunction with other nearby hospitals if possible. The plan should be communicated to, and coordinated with your County Public Health Departments and the California Department of Public Health. The Governor of California has the authority to allow hospitals to suspend standards of medical practice during an emergency without practitioners and hospitals incurring legal liability. In a mass casualty event, when the CSCP is triggered, it is likely that some temporary modifications of regulatory and legal requirements for health care providers and the hospitals at all levels will be necessary (See Appendix 5). The legal departments of the Hospital Boards will research the legality of and, if found to be legal, assist with drafting policies for the following proposals:

1) Liability of providers at medical centers for care provided under stress with less than a full complement of resources. This plan, when activated, may provide some immunity to health care providers from civil or criminal liability pursuant to the Good Samaritan statutes as noted by California law.

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2) Scope of practice. It may be necessary to grant permission to certain professionals on a temporary and emergency basis to function outside their legal scope of practice or above their level of training.

3) Facility standards. Standards of care that pertain to space, equipment, and physical facilities may have to be altered such as nursing to patient care ratios and bed allotment.

4) Patient privacy and confidentiality. Provisions of HIPAA and other laws and regulations that require signed releases and other measures to ensure privacy and confidentiality of a patient’s medical information may have to be altered or suspended.

5) Documentation of care. Minimally accepted levels of documentation of care provided to an individual may have to be established, both for purposes of patient care quality and as the basis for reimbursement from third-party payers.

V. Granting Disaster Privileges to Volunteer Licensed Independent Practitioners During disasters, hospitals may grant disaster privileges to volunteer licensed independent practitioners. For this purpose, a disaster is defined as an emergency that, due to its complexity, scope, or duration, threatens the organization's capabilities and requires outside assistance to sustain patient care, safety, or security functions. The hospitals may grant disaster privileges to volunteer licensed independent practitioners only when the Emergency Operations Plan has been activated in response to a disaster and the hospitals are unable to meet immediate patient needs. The Chief of Staff or Chief Medical Officer or their designee(s), may grant disaster privileges on a case-by-case basis when the hospital’s emergency management plan is activated and the hospital is unable to handle immediate patient care needs. Oversight of the performance of volunteer licensed independent practitioners who are granted disaster privileges will be by direct observation, mentoring, and medical record review.

Before a volunteer practitioner is considered eligible to function as a volunteer licensed independent practitioner, the hospitals will obtain his or her valid government-issued photo identification (for example, a driver’s license or passport) and at least one of the following:

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A current picture identification card from a health care organization that clearly identifies professional designation.

A current license to practice.

Primary source verification of licensure.

Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), the Medical Reserve Corps (MRC), the Emergency System for Advance Registration of Volunteer Health Professionals (ESARVHP), or other recognized state or federal response hospital or group.

Identification indicating that the individual has been granted authority by a government entity to provide patient care, treatment, or services in disaster circumstances.

Confirmation by a licensed independent practitioner currently privileged by the hospital or a staff member with personal knowledge of the volunteer practitioner’s ability to act as a licensed independent practitioner during a disaster.

Once a practitioner obtains approval for disaster privileges, the receiving hospital will issue appropriate identification. The practitioner will then report to and practice under the auspices of the chairman/designee of the department to which he/she is assigned. Based on its oversight of each volunteer licensed independent practitioner, the hospitals will determine within 72 hours of the practitioner’s arrival if granted disaster privileges should continue. Primary source verification of licensure occurs as soon as the immediate emergency situation is under control or within 72 hours from the time the volunteer licensed independent practitioner presents him- or herself to the hospitals, whichever comes first. If primary source verification of a volunteer licensed independent practitioner’s licensure cannot be completed within 72 hours of the practitioner’s arrival due to extraordinary circumstances, the hospitals document all of the following:

1) Reason(s) why it could not be performed within 72 hours of the

practitioner’s arrival.

2) Evidence of the licensed independent practitioner’s demonstrated ability to continue to provide adequate care, treatment, and services.

3) Evidence of the hospital’s attempt to perform primary source verification as soon as possible.

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If, due to extraordinary circumstances, primary source verification of licensure of the volunteer licensed independent practitioner cannot be completed within 72 hours of the practitioner’s arrival, it is performed as soon as possible. All disaster privileges will immediately terminate once the emergency management plan is no longer activated. However, the hospital may choose to terminate disaster privileges prior to that time. The practitioner must return the temporary ID card to the Medical Staff Office. The medical staff will maintain a list of all volunteer practitioners who received disaster privileges during the emergency management/disaster event.

VI. Crisis Standards of Care Plan Prerequisites and Triggers It is important to establish clear authority regarding who can trigger and activate the CSCP and then who is responsible for its governance. The authority to trigger and activate the CSCP will rest with the Incident Commander in consultation with the Senior Physician Disaster Managers (SPDM) of the hospital. The SPDM must be a member in good standing of the Senior Physician Disaster Medical Committee. The SPDM is assigned to the role of a Medical/Technical Specialist in the Hospital Command Center by the Incident Commander. Once the call is made, the SPDM assumes responsibility for overseeing and directing the CSCP at each hospital. The following is a partial list of potential triggers that may require activation of the CSCP:

1) Lack of critical equipment or medications

a. Mechanical ventilators

b. Oxygen

c. Antibiotics, antiviral medication or specific antidotes

d. Vasopressors or other critical care medications

e. Intravenous fluids or blood products

f. Operating room equipment and space

g. Lack of adequate beds

2) Lack of critical infrastructure

3) Lack of security to maintain the safety of healthcare providers and patients

4) Lack of personal protective equipment

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5) Loss of power

6) Lack of trained staff

7) Inadequate staff support (food, housing, water, etc.)

8) Lack of specialty care such as burn care resources

Before implementing the CSCP, all attempts should be made to acquire scarce critical resources or infrastructure, or to transfer patients to other healthcare facilities that have the appropriate ability to provide care (state, national, and even international). Critical care will thus be rationed only after all efforts at augmentation have been completely exhausted. Limitations on critical care will be proportional to the actual shortfall in resources, and rationing of critical care will occur uniformly, be transparent, and abide by objective medical criteria. Rationing should apply equally to withholding and withdrawing life-sustaining treatments based on the principle that withholding and withdrawing care are ethically equivalent.

Patients not eligible for critical care will continue to receive supportive medical or palliative care.

VII. CSCP Critical Care Staffing Model When the hospital can no longer meet the increased demand for critical care services using its existing critical care practitioners, a two-tiered staffing model comprising noncritical care physicians and nurses may be substituted. Based on recommendations of The Society of Critical Care Medicine, a critical care physician may supervise up to four noncritical care physicians who may each manage up to six critically ill patients. A critical care nurse may supervise up to three noncritical care nurses with each caring for up to two patients. In this model, one critical care physician could oversee the care of up to 24 critically-ill patients, and one critical care nurse could oversee the care of up to six critically-ill patients (Rubinson L, et al. Augmentation of Hospital Critical Care Capacity after Attacks or Epidemics: Recommendations of the Working Group on Emergency Mass Critical Care. Critical Care Medicine 2005; (33)10 (Suppl).

An expanded role for students and trainees should be considered in this model and will need to be further elucidated.

VIII. Critical Care Triage Officer (CCTO) and Critical Care Triage Team A Critical Care Physician will assume the role of the Critical Care Triage Officer (CCTO). The CCTO will review all patients for inclusion and exclusion criteria,

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and will calculate SOFA scores for eligible patients (see Section VIII). The CCTO will evaluate daily all patients receiving critical care, and evaluate those requested to be considered for critical care as they arise. The CCTO will work closely with a Critical Care Triage Team ideally comprised of a critical care attending and nurse, respiratory therapist, and social worker to facilitate decisions regarding allocation of critical care resources. The CCTO is not expected to examine patients, except under special circumstances where this information may be vital in reaching a triage decision. The CCTO has the ultimate responsibility and authority for making decisions as to which patients will receive the highest priority for receiving critical care, and is empowered to make decisions regarding reallocation of critical care assets. The CCTO will share decisions with the attending physician and house staff, who will then inform patients and family members. The Critical Care Triage Officer’s decisions are final and there will be no appeals process. At the discretion of the Incident Commander (IC), an oversight subcommittee to retrospectively review the decisions of the Critical Care Triage Officer may be convened.

Shift Duration The CCTO and Critical Care Triage Team will function in shifts lasting no longer than 12 hours and will be assigned a scribe along with secretarial and administrative support as they deem necessary.

IX. Critical Care Triage Protocol and Procedure This protocol is intended to provide guidance for making triage decisions pursuant to activation of the CSCP, when the critical care system is overwhelmed. Other surge response strategies such as scaling back elective procedures and opening additional critical care areas will have already been exhausted. The Critical Care Triage Protocol has 4 components: A) inclusion criteria, B) exclusion criteria, C) minimum qualifications for survival, and D) a prioritization tool (see Table 1).

A. Inclusion criteria: These criteria attempt to identify patients who may more likely than not benefit from admission to critical care and primarily focuses on respiratory failure (See Appendix 1). B. Exclusion criteria: Patients will meet exclusion criteria when they have a very high risk of death or little likelihood of long-term survival, and a correspondingly low likelihood of benefit from critical care resources. This

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category includes life-limiting illnesses, such as end-stage congestive heart failure, end-stage COPD, and terminal liver disease or cancer (See Appendix 2). Another category of exclusion criteria includes patients who may benefit from critical care but would require intense use of resources and prolonged care that cannot be justified during a multi-casualty event or pandemic. Sequential Organ Failure Assessment (SOFA) The Sequential Organ Failure Assessment (SOFA) score may be used to triage critical care patients and to guide exclusion decisions. Its advantages include a fundamental reliance on physiologic parameters, ease of calculation; requirement for simple laboratory tests and its validation for use in patients with a wide variety of conditions requiring critical care (See Appendix 3).

The SOFA score is used to assess acute inpatient severity of illness and is to be calculated daily. To meet the exclusion criteria using the SOFA score, a patient has to have at minimum an 80% risk of mortality. Based on published data, the following SOFA criteria are highly likely to represent a mortality of at least 80%:

Highest SOFA score ≥ 15 at any time during the hospital admission.

Mean SOFA score ≥ 5 for at least 5 days and with a SOFA trend that is either rising or flat.

Any patient that has six or more organ failures at any time.

C. Minimum qualifications for survival: These qualifications represent a potential ceiling on the amount of critical care resources that can be expended on any one person. The minimum qualifications for survival dictate reassessment at 48 and 120 hours, as well as an ongoing cut-off ceiling if a patient ever has a SOFA score of 15 or higher or any other exclusion criteria. The key component of the minimum qualifications for survival is the attempt to identify, at an early stage, patients who are not improving and who are likely to have a poor outcome.

D. Prioritization of patients: Following application of the inclusion and exclusion criteria, patients will be prioritized in a ranked grading that utilizes the latest SOFA score and daily SOFA trend. Prioritization of these patients will also require the expertise and judgment of the Critical Care Triage Officer and Team using the severity of acute and/or chronic illness, prognosis, and projected duration of resources needed. Allocation of critical care resources, or reasons for reallocating critical care resources away from any given patient(s), will include the following circumstances:

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1) Patients who have the highest SOFA scores and/or a SOFA trend that is flat or rising over several days but do not yet meet formal SOFA exclusion criteria.

2) A high degree of inpatient acuity with a poor chance for survival and a likely long duration of need for critical care resources

3) A moderate degree of acuity but a prolonged duration of critical care resource need is expected.

4) A severe underlying chronic illness that in conjunction with any of the above factors leads a decision maker to feel the prognosis is poor, and/or the patient’s likely duration of critical care resource need will be prolonged.

Critical Care Triage Tool

The Disaster Management Systems color scheme (black, red, yellow, green) commonly used in civilian and military disasters will be used to highlight triage categories. Patients in the black category are those who fall into the expectant category and should be lowest priority for receiving critical care. They will receive palliative care on a non-critical care ward.

Patients in the red category have the highest priority for ICU admission and mechanical ventilation, if required. In selecting the patients for this category, the aim is to find those who are sick enough to require the resource, and whose outcome will be poor if they do not receive it, but are not so sick that they will not recover even if they do receive ICU care. Patients with single organ failure, particularly those with respiratory failure due to influenza or other illness or injury, are included in the red category assuming they have no exclusion criteria. Patients in the yellow category are those who, at baseline, are very sick and may or may not benefit from critical care. They should receive care if the resources are available but not at the expense of denying care to someone in the red category. At the reassessment points, patients who are improving are given high priority (red) for continued care while those who are not showing signs of improvement are classified as yellow. Patients in the green category are those who should be considered for transfer out of the ICU because they are well enough to be cared for without mechanical ventilation or other ICU-specific interventions (See Appendix 4). Prioritization that arises within categories and responsibility for assignment of patients to categories on an ongoing basis is the responsibility of the CCTO. See Triage Algorithm Process in Appendix 7.

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X. Palliative Care Plan During a Mass Casualty Event (MCE) “The goal of an organized and coordinated response to a catastrophic MCE should be to maximize the number of lives saved. At the same time, the goal also should be to provide the greatest comfort and minimize the physical and psychological suffering of those whose lives may be shortened as a result of either an immediate surge of patients or long-term exposure following a catastrophic event.” Agency for Healthcare Research and Quality What Is Palliative Care?

Palliative Care is the aggressive management of symptoms and relief of suffering. The World Health Organization defines palliative care as "an approach, which improves the quality of life of patients and their families facing life-threatening illness, through the prevention, assessment, and treatment of pain and other physical, psychosocial, and spiritual problems."

While it is important to understand what palliative care is, it is also important to specify what palliative care is not. Palliative care is not abandonment of the patient or reduction or elimination of treatment. Rather, it involves active treatment for symptom management and support to address the comfort of the patients and their families. The aggressive and appropriate treatment of pain and other symptoms is not euthanasia. This treatment does not "hasten death" and it recognizes that initial prognostication may change if additional resources become available or if the situation deteriorates. Palliative Care During a Mass Casualty Event (MCE) In a MCE, standards of care will require adaptation, as unfamiliar personnel will be providing services, supplies will be strained, and command and control lines of authority will need to be established. Prioritizing access to limited resources and altering the usual standard of care can only formally be justified and sanctioned legally by the Governor of California. In the interest of maximizing good outcomes for as many patients as possible, and at the very least, providing palliative care to all, treatment decisions will have to balance utilitarian notions against other ethical values, with medical effectiveness as a key determinant. Priority access to scarce resources, including skilled personnel resources, may be applied or moved to those with the greatest potential for survival. As such, services to those expected to die soon will fall more heavily on people who do not have the highest level of medical training.

A MCE may create sudden large numbers of fatally injured or critically ill short-term survivors. Depending on the event, some victims will last only a few weeks (e.g., pulmonary injury from airborne chemicals) and some may last for months

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(e.g., pandemic influenza). In many cases, those who survive the onset usually will live for some time – days to months – but will not be expected to survive due to the event itself or to the ensuing resource scarcities it creates. Initial identification of those who might fit into the "not expected to survive" category following a catastrophic MCE may include:

1) Those exposed to the event who are expected to die over the course of weeks (e.g., those with radiation exposure)

2) The "already existing" palliative care population (e.g., those already enrolled in hospice or receiving palliative care in acute care settings)

3) Vulnerable patients (e.g., advanced illness patients in long-term care facilities) whose situation will be worsened due to scarcities associated with the event

4) Patients who are triaged to the Black Category as a result of their illness/injury or as a result of scarce resources.

Those who are not expected to survive cannot be simply abandoned or ignored, nor should they overwhelm the hospitals. By including these populations in the Palliative Care Plan of the Crisis Care Plan, hospitals can ensure humane palliative care for all affected by such disasters.

Integration of Community-Based Health Care Organizations and Other Community Groups into Palliative planning To mobilize a more concerted and comprehensive effort in the care of patients, hospitals should look to establish collaborative outreaches with a network of community-based organizations in the immediate area around the hospital, including but not limited to home care agencies, hospice agencies, long-term care facilities, County Public Health Department. Health care providers and other interested individuals in some of these community-based organizations have particular skills in the care of vulnerable patients with advanced illness which can be applied when altered standards of care must be implemented. A reserve capacity for providing palliative care during a MCE will come from local palliative assistance teams that will be recruited from a variety of practice settings (e.g., hospices, hospitals, long-term care) and disciplines (e.g., physicians, nurses, social workers, chaplains). These teams are developed in collaboration with groups such as senior centers, churches and synagogues, hospices, long-term care providers, nurses' organizations, senior citizens' organizations (e.g., AARP, the National Hospice and Palliative Care Organization, the American Academy of Hospice and Palliative Medicine), and other regional hospitals and palliative care programs. Hospitals should also tap into the Medical Reserve Corp of their County and the Community Emergency Response Teams (CERT) for deployment depending on

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the nature and scope of an incident. Hospitals should consider extending the credentialing of palliative care disaster volunteers into the existing disaster response by Federal/State and local legal/insurance systems in order to expand community capacity through such mechanisms as the ESAR-VHP and DMAT. These rapid response teams would supplement, not replace, palliative care services. Palliative Care During a MCE Action Guide

1) A Palliative Care Unit Leader will be appointed by the Medical Care Branch Directors to oversee the Palliative Care Plan and Operations.

2) The Adult Palliative Care Unit Leader and/or Pediatric Palliative Care Unit Leader will work closely with the Critical Care Triage Officer (CCTO) and Critical Care Triage Team to identify and treat patients that are designated to receive palliative care. The CCTO has the ultimate responsibility and authority for making decisions regarding reallocation of critical care assets.

3) The Adult Palliative Care Unit Leader will create a Palliative Care Unit and team to deliver care to adult and pediatric patients receiving palliative care and support for their families. The Pediatric Palliative Care Leader will serve as a consultant for all pediatric palliative care patients.

4) Alternative Care Sites will be identified and used for palliative care patients as well as for patients who are lower acuity and do not require acute care services (see also plan for Alternative Care Units under Pandemic Plan).

5) The Adult Palliative Care Unit Leader, Pediatric Palliative Care Leader, and team will collaborate with the County Public Health Department and local community leaders to help provide staff for Rapid Response Teams for palliative care in the hospital, if the MCE does not preclude the ability to travel locally (CERT, MRC, ESAR-VHP, etc.).

6) Pre-planning will include consideration of triage training for leaders of SNFs so that patients who should not be transferred to hospitals remain in their respective facilities or homes while those who need to be transferred are readily identified.

7) Palliative Care Medical Packs for both adult and pediatric patients will be created and stocked so that adequate supplies are available for at least 96 hours.

8) There will be a separate Palliative Care Unit Leader for pediatric patients and pediatric-specific palliative care issues. The members of the pediatric palliative care team will respond as members of their primary services except for the Core Pediatric Palliative Care Team (CPPT), which will

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consist of the Program Director, the Medical Director, and the Bereavement Coordinator. The CPPT will serve as a resource across all medical services for children, families, and hospital staff. The other members of the Palliative Care Team will serve as the bridge between their respective areas and this core group.

9) The Pediatric Palliative Care Program Director will be designated as the Pediatric Palliative Care Unit Leader.

10) The CPPT and the Critical Care Triage Officer will make triage decisions, including utilization of resources for children in palliative care, jointly.

11) Members of the Pain and Symptom Management Team will be available to consult on children in palliative care across all medical services.

12) The CPPT will facilitate transitions of appropriate children to hospice and home in conjunction with the primary service or the hospitalist team.

13) Bereavement support for children, families and staff will be organized by members of the CPPT, under the direction of the Bereavement Coordinator.

14) The Palliative Care Teams will work with first responder personnel and local and regional disaster response planners (e.g., EMS, fire, police, departments of public health, community health clinics, local and regional governmental entities) to develop clear guidelines and protocols.

15) The Palliative Care Teams will work closely with hospital support systems for establishing psychological and ethical support for front-line responders (chaplaincy, psychiatry, psychology, social services, child life specialists.) and patients and their families.

16) The Palliative Care Unit Leaders will assure that there is just-in-time training for palliative service delivery at all treatment sites.

Identification and Management of Palliative Care Patients Casualties will be triaged at the site of the incident. Some patients will be deemed likely to die during the catastrophe and therefore will be triaged not to receive (or not to continue to receive) life-supporting treatment. For these casualties, death will be expected within a short period:

1) Patients exposed to the event that are not expected to survive (triage category Black).

a. Via triage at initial admission.

b. Via triage during their hospital course.

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2) Patients who are already receiving palliative care or hospice care.

3) Patients who come from long term care facilities with progressive and advanced illness.

Prognostication/triage may change if resources become more available or if the situation worsens and resources become even scarcer. The Palliative Care Unit Leaders will act as the point person for triage coordination of palliative care patients, and collaborate closely with the Critical Care Triage Officers (Senior Physician Disaster Managers) and report to the Medical Care Branch Directors. The Palliative Care Unit Leaders will be the Medical Directors for palliative care; the alternate would be the on-call Hospitalists. All palliative care patients will be assigned to a designated unit or units, if possible. An inpatient palliative care team (combining adult and pediatric expertise) will be responsible for the care of these patients (see staffing model below). Alternative Care Sites for Palliative Care (See Pandemic Plan) As patients designated for palliative care would not require the extensive medical equipment and supplies for acute care, they would be an ideal patient population for triage at an alternative care site (ACS). This would be a population that could be triaged to a separate building from the hospital, such as an athletic center, a dormitory or other specific area designated by the County Public Health Department. If transport out of the hospital building was not feasible due to the MCE, then a converted location in the hospital could be used which did not utilize higher acuity beds or extensive technological equipment, such as one of the outpatient units, the cafeteria, or other buildings. During a MCE, Palliative Care Teams will facilitate transfer of adult and pediatric palliative care patients to hospice and home, as appropriate. Medical Supplies and Equipment (Palliative Care Medical Packs) Palliative Care Medical Packs will be created in advance by pharmacy and stored in the disaster supply area of the pharmacy. For every 10 palliative care patients there would be a designated medical pack of medications and supplies. In consideration of the symptom management, the strategies of home hospice orders could be applied for efficient utilization of scarce medications, such as intravenous opioids or benzodiazepines. For palliative care patients, first-line therapies would be oral, sublingual, or suppository forms of medications. Secondary-lines of treatment would be intravenous, subcutaneous, or intramuscular (See Appendices).

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Palliative Care Staffing Model There are no current standards for staffing models in palliative care during a disaster. Adapting the Alternative Care Site (ACS) model from the Agency for Healthcare Research and Quality (AHRQ) Community Planning Guide, 50 palliative care patients would be cared for by one physician, one physician extender, six nurses (RN/LVNs,), one social worker, one chaplain, and four volunteers. If travel is possible in the MCE, then the recruitment of community-based providers would free up other clinicians for the higher acuity patients. A possible pool for palliative care staffing (a palliative care response team) would include:

1) Community Hospice Agency Staff-nurses, nurse’s aides, hospice medical directors, chaplains, volunteers

2) SNF and Home Care Agency Staff-nurses, nurse’s aids, geriatricians

3) Volunteers from faith-based organizations, such as churches and synagogues

4) Mental health providers

5) Medical Reserve Corp and CERT

6) Palliative Care Team members

7) Chaplains

8) Volunteers, specifically the “No One Dies Alone” volunteers - these volunteers are specifically trained to be present with dying patients who have no family or friends with them.

9) Child Life specialists

10) Teachers

Bereavement services for children, families and staff of palliative care patients will be organized by members of the CPPT under the direction of the Pediatric Palliative Care Bereavement Coordinator. Training Mobilization and Training in palliative care will be under the direction of the Palliative Care Disaster Team and will involve many layers of education and practice. They will incorporate experts now working with seriously chronically ill persons to be mobilized in order to serve those who might live and who are

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seriously ill. Community Emergency Response Team training should be developed to engage citizens in the hospital’s community. The Palliative Care Disaster Team will identify a variety of training methodologies to incorporate palliative care services training for all disaster response members, including house officers, staff physicians and nurses as well as non-medical members of the community. Education and training will be competency-based, with programming specific to the individual's role in emergency response. Just-in-time training would be provided to educate the caregivers with regard to care for the dying patient and allow access to specific palliative medical supplies. There is high potential that some of the non-medical staff will be “deputized” into caring for the dying, similar to the care provided to patients in home hospice setting by their own families. Management of the Dead (See also Mass Fatality Plan) In the event of a MCE, there is a great potential for large numbers of deaths in a short period of time prompting consideration for the management of the dead. Major components would include a system of identification, access to adequate supplies for care of the dead (body bags, refrigerator trucks, etc.) should the morgue be overwhelmed, and access to cremation. The Disaster Mortuary Operational Response Team (DMORT) for California (Region IX) would likely be a major contact in the event of a MCE. This is a federal agency and was involved during the management of casualties from Hurricane Katrina. See http://www.dmort.org/.

http://www.dmort.org/

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Appendix A: Adult Palliative Care Medical Pack Components of the Adult Palliative Care Medical Pack include:

Oral morphine concentrated solution – 20 mg/ml

Morphine, injection – 2 mg/ml

Hydromorphone, oral – 2 mg tablets

Hydromorphone, injection – 2 mg/ml

Lorazepam, oral – 1 mg tablets

Haloperidol, oral

Haloperidol, injectable

Oral and suppository prochlorperazine

Ondansetron ODT

Oral and suppository acetaminophen

Diphenhydramine – 12.5 mg/ml

Diphenhydramine – 50 mg/ml

Phenobarbital injection – 130 mg/ml

Atropine – 1% drops

Glycopyrrolate – 0.2 mg/ml can be used IV or sublingual

Artificial teams

Subcutaneous butterfly needles and subcutaneous pumps

Tegaderm

Dexamethasone, oral – 2 mg tablets

Dexamethasone, IV – 4 mg/ml

22

Appendix B: Pediatric Palliative Care Medical Pack Components of the Pediatric Palliative Care Medical Pack include:

Morphine, oral – 20 mg/ml solution

Morphine, injection – 2 mg/ml

Hydromorphone, oral – 2 mg tablets

Dexamethasone, oral – 2 mg tablets

Dexamethasone, IV – 4 m/ml

Ativan, oral – 1 mg tablets

Ativan, injection – 2 mg/ml

Valium, suppository – 5 mg

Valium, oral – 5 mg

Valium, injection – 5 mg/ml

Haloperidol, oral – 1 mg tablets

Haldol, IV – 5 mg/ml

Diphenhydramine – 12.5 mg/ml

Diphenhydramine – 50 mg/ml

Phenobarbital, injection – 130 mg/ml

Acetaminophen, IV – 100 mg/ml

Acetaminophen, oral liquid – 32 mg/ml and 100 mg/ml

Acetaminophen, suppository – 120/325/650

Artificial teams

Glycopyrrolate, IV or sublingual – 0.2 mg/ml

Scopolamine patches

Metoclopramide, oral – 10 mg tablets

Metoclopramide, IV injectable – 5 mg/ml

Ondansetron ODT

Sucralfate, suspension – 100 mg/ml

Ranitidine, IV – 25 mg/ml

Ranitidine, suspension – 15 mg/ml

23

Appendix C: Adult Comfort Care Order Set

IP MED COMFORT CARE

VITAL SIGNS

□ Discontinue cardiac monitor DC cardiac monitor, ONCE

□ Discontinue vital signs Routine, ONCE

□ Discontinue weight Routine, ONCE

ACTIVITY

□ Up Ad lib Routine, ONCE

□ OOB with assistance Routine, ONCE

□ Aspiration Precautions Routine

□ Fall risk precautions Routine

□ Family may stay in room Family permitted to stay in room with patient past visiting hours, ONCE.

NUTRITION

□ Feed for pleasure Feed for pleasure, CONTINUOUS

□ OK for patient to refuse PO OK for patient to refuse PO and medications, CONTINUOUS

NURSING

□ Oral care Every 2 hours and as needed

□ Reposition: For patient who are bedbound

Every 2 hours and as needed

□ Contact Guest Services Contact Guest Services for programs that would benefit this patient (Music/Art/Massage therapy), PRN

□ Nsg referral to Spiritual Care Routine, ONCE

IV Access

24

□ Saline lock and flush

MEDICATIONS Analgesics PLEASE NOTE: These are starting doses for patients who are not on scheduled opioids. If the patient has been on scheduled opioids, continue current dosing and titrate the basal opioid (basal opioid = scheduled opioid total in 24hrs) up if pain is not controlled by adding the amount of breakthrough medication used in 24hrs to the basal opioid. Manage breakthrough pain with a short-acting opioid at 5-15% of total daily dose. Use nonverbal signs to assess pain, such as grimacing or crying out, if patient cannot speak. HYDROMORPHONE IS PREFERRED IN PATIENTS WITH RENAL FAILURE

Morphine – 20 mg/ml oral solution

5-10 mg, oral, every 3 hours prn Morphine – 2 mg/ml

1-4 mg, subcutaneous or IV, every 2 hours prn Morphine – 1 mg/ml IV PCA

0.5-1.0 mg/hr, IV, at 0.5-4.0 ml/hr, continuous Hydromorphone – 2 mg/ml

0.5-1.0 mg, subcutaneous or IV, every 2 hours prn Hydromorphone – 2 mg oral tablet

2-4 mg, oral, every 3 hours prn Dexamethasone – 4 mg oral tablet

4 mg, oral, every 12 hours prn Dexamethasone – 4 mg/ml

4 mg, IV, every 12 hours prn

Antihistamines Diphenhydramine (Benadryl®) – 12.5 mg/5ml oral solution

12.5-25 mg, oral, every 6 hours prn Diphenhydramine (Benadryl®) – 50 mg/ml

12.5-25 mg, IV, every 6 hours prn

25

Antiemetics: Choose EITHER prochlorperazine OR metoclopramide Either/or statement added to avoid the use of these two counteractive antiemetics (anti-cholinergic vs. a pro-cholinergic)

Prochlorperazine tablet

5-10 mg, oral, every 6 hours prn Prochlorperazine – 5 mg/ml injection

5-10 mg, intravenous, every 6 hours prn Prochlorperazine – 25 mg suppository

25 mg, rectal, every 12 hours prn Ondansetron – 4 mg oral disintegrating tablet

4-8 mg, oral, every 6 hours prn Dexamethasone – 4 mg oral tablet

4 mg, oral, every 12 hours prn Antianxiety Lorazepam tablet

0.5-1.0 mg, oral, every 4 hours prn Lorazepam tablet

0.5-1.0 mg, sublingual, every 4 hours prn Lorazepam – 2 mg/ml syringe

0.5-1.0 mg, IV, every 4 hours prn Delirium Haloperidol tablet

0.5-1.0 mg, oral, every 6 hours prn Haloperidol injection

0.5-1.0 mg, IV, every 6 hours prn

26

Fever Management Acetaminophen tablet

650 mg, oral, every 4 hours prn Acetaminophen suppository

650 mg, rectal, every 4 hours prn Eye Care Hydroxypropyl methylcellulose – 0.5% ophthalmic solution

2 drops, both eyes, every hour prn Excess Secretions Atropine (isopto atropine) – 1% ophthalmic solution (Ophthalmic drops can be used for sublingual administration)

2 drops, sublingual, every 4 hours prn Glycopyrrolate injection

0.1-0.2 mg, IV, every 4 hours prn

CODE STATUS ORDER SET DNR

No efforts are to be made to restore cardiac or pulmonary function following a cardiac or pulmonary arrest

27

Appendix 1. Triage Protocol Inclusion Criteria The patient must have 1 of the following:

A. Requirement for invasive ventilatory support:

Refractory hypoxemia (SpO2 < 90% on non-rebreather mask or FIO2 > 0.85)

Respiratory acidosis (pH < 7.2)

Clinical evidence of impending respiratory failure

Inability to protect or maintain airway

B. Hypotension (systolic blood pressure < 90 mm Hg or relative hypotension) with clinical evidence of shock (lactic acidosis, altered level of consciousness, decreased urine output or other evidence of end-organ failure) refractory to volume resuscitation requiring vasopressor or inotrope support that cannot be managed outside the ICU.

28

Appendix 2. Triage Protocol Exclusion Criteria The patient may be considered for exclusion from admission or transfer to critical care, depending on available resources, if any of the following is present and is deemed to impact short-term survival:

1) Severe burns of patient with any 2 of the following:

Age > 60 yr

> 40% of total body surface area affected

Inhalation injury 2) Cardiac arrest

Unwitnessed cardiac arrest

Witnessed cardiac arrest, not responsive to electrical therapy (defibrillation or pacing)

Recurrent cardiac arrest 3) Severe baseline cognitive impairment 4) Advanced untreatable neuromuscular disease 5) Metastatic malignant disease 6) Advanced and irreversible immunocompromised state impacting short-

term survival 7) Severe and irreversible neurologic event or condition 8) End-stage organ failure meeting the following criteria:

Heart

Class III or IV heart failure

Lungs

COPD with FEV1 < 25% predicted, baseline PaO2 < 55 mm Hg, or secondary pulmonary hypertension

Cystic fibrosis with postbronchodilator FEV1 < 30% or baseline PaO2 < 55 mm Hg

Pulmonary fibrosis with VC or TLC < 60% predicted, baseline PaO2 < 55 mm Hg, or secondary pulmonary hypertension

Primary pulmonary hypertension with Class III or IV heart failure, right atrial pressure > 10 mm Hg, or mean pulmonary arterial pressure > 50 mm Hg

Liver

MELD (Model for End-Stage Liver Disease) score > 15 9) Age > 85 yr 10) SOFA > 15 11) SOFA > 5 for > 5 days, and with flat or rising trend 12) Any patient that has six or more organ failures at any time

29

Appendix 3. Sequential Organ Failure Assessment (SOFA) score

Variable Score

0 1 2 3 4

PaO2/FiO2 mmHg

>400 < 400 < 300 < 200 < 100

Platelet count x 106

> 150

< 150

< 100

<50

< 20

Bilirubin, mg/dL

<1.2

1.2-1.9

2.0-5.9

6.0-11.9

>12

Hypotension None MABP < 70 mmHg

Dop < 5 Dop > 5, Epi < 0.1, Norepi < 0.1

Dop > 15, Epi > 0.1, Norepi >0.1

Glasgow Coma Score

15 13 - 14 10 - 12 6 - 9 <6

Creatinine, mg/dL

< 1.2 1.2-1.9 2.0-3.4

3.5–4.9

>5

Dopamine [Dop], epinephrine [Epi], norepinephrine [Norepi] doses in ug/kg/min

30

Appendix 4. Critical Care Triage Tools

Critical Care Triage Tool (Initial Assessment)

Triage Code

Criteria Priority/Action

Black

Exclusion Criteria met* or SOFA > 15*

Medical Mgmt.

Palliative care

Discharge

Red

SOFA < 7 or Single Organ Failure

Highest Priority

Yellow

SOFA 8 - 15

Intermediate

Green

No significant organ failure

Defer or D/C

Reassess as needed

* If exclusion criteria or SOFA > 15 occurs at any time from the initial assessment to 48 hours afterward, change triage code to Black and proceed as indicated D/C = discharge

31

Critical Care Triage Tool (48 Hour Assessment)

Triage Code


Black

Exclusion Criteria met or SOFA > 15 or SOFA score 8 – 15 no Δ

Palliative care

Discharge from Critical Care

Red

SOFA < 11 and decreasing

Highest Priority

Yellow

SOFA < 8 no Δ

Intermediate Priority

Green

No longer ventilator dependant

D/C from Critical Care

Δ = change D/C = discharge

32

Critical Care Triage Tool (120 Hour Assessment)

Triage Code


Black

Exclusion Criteria Met or SOFA > 15* SOFA < 8 no Δ

Palliative care

Discharge from Critical Care

Red

SOFA score < 11 and decreasing progressively

Highest Priority

Yellow

SOFA < 8 minimal Minimal decrease (< 3 point decrease in past 72h)

Intermediate Priority

Green

No longer ventilator dependant

Discharge from critical care

* If exclusion criteria or SOFA > 15 occurs at anytime from 48 – 120 hours change triage code to Black and palliate. * If SOFA score > 5 for 5 days or greater, and with flat or rising trend, move to Black. Δ = change

33

Appendix 5. Laws And Regulations Below is a list of Laws and Regulations that may impact the Crisis Care Plan 1) Emergency Medical Treatment and Active Labor Act (EMTALA)

2) Health Insurance Portability and Accountability Act (HIPAA)

3) Federal Volunteer Protection Act

4) Good Samaritan Law

5) 80-hour workweek rule for medical residents

6) Occupational Safety and Health Administration and other workplace regulations

7) Publicly funded health insurance laws (including Medicare, and Medical)

8) Children’s Health Insurance Program

9) Laws and regulations governing the use and licensure of drugs and devices

10) The Joint Commission

34

Appendix 6. Glasgow Coma Scale - Adults

35

Appendix 7. Triage Algorithm Process (from IOM report, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, p. 87).

36

Appendix 8. Pediatric CSC Palliative Care Order Set for Casualties Weighing less than 10 kg.

Weight: _______ kg Height: _______ cm Allergies: Reviewed in LINKS and accurate as documented Reviewed in LINKS: Please add _____________________________ Please cancel ___________________________ Service: ______________________________________________________________ Admit to: Inpatient _____________ Observation (Less than 24 hours) Orders to start on: _________________ Diagnosis: __________________________________________ MEDICATIONS Analgesics (non-narcotic) 1. Acetaminophen oral Susp (10-15mg/kg/dose) 10-15mg/kg = 40mg 60mg 80mg 100mg po q6hr prn pain/fever po q4hr prn pain/fever (max 4 doses/day) Dispense 120ml bottle x 1 2. Acetaminophen rectal suppository (10-15mg/kg/dose) 40mg 60mg 80mg rectally q6hr prn pain/fever rectally q4hr prn pain/fever Dispense # 12x 80mg suppositories x 1 3. Ibuprofen oral suspension (100mg/5ml)

5-10mg/kg/dose = 50mg 75mg 100mg orally q6hr prn pain/discomfort

Dispense 120ml bottle x 1 Analgesics (opiate) Note: doses may need to be escalated for refractory end of life care.

Increase doses by 10-25% for moderate refractory pain

Increase dose by 50-100% for severe refractory pain

***CII medication orders for outpatient use must be written on tamper resistant controlled substance prescription

1. Morphine oral*** 0.05-0.1mg/kg = ____mg orally q4hr prn pain 0.25mg orally q4hr prn pain 0.5mg orally q4hr prn pain

37

______mg orally q4hr prn pain Dispense: 2mg/ml oral solution x 15ml

2. Morphine IV*** 0.05-0.1mg/kg = _____mg IV q4hr prn severe pain 0.25mg IV q4hr prn pain 0.5mg IV q4hr prn pain _____mg IV q4hr prn pain

Dispense 2mg/ml syringes 10 syringes 20 syringes

3. Hydromorphone IV*** 0.015mg/kg = ____mg IV q4hr prn severe pain 0.0.05mg mg IV q4hr prn severe pain 0.1mg IV q4hr prn severe pain Dispense 2mg/ml vial x 10 vials

4. Oxycodone oral***

0.015-0.15mg/kg = _____mg po q6hr prn severe pain 0.25mg po q6hr po q6hr prn severe pain 0.5mg po q6hr po prn severe pain ____mg q6hr po prn severe pain

Dispense oral solution 1mg/ml x 20 ml

Anti-seizure

1. Phenobarbital IV Loading dose: 15-20mg /kg = _____mg IV x 1 dose Maintenance dose: 3mg/kg = _____mg IV q12h

Dispense 130mg/ml vials x 8 vials 2. Lorazepam

0.05-0.1 mg/kg = ____mg IM IV PO q6hr prn seizures agitation

0.25mg IM IV PO q6hr prn seizures agitation 0.5mg IM IV PO q6hr prn seizures agitation 1 mg IM IV PO q6hr prn seizures agitation

Dispense 15 vials (2mg/ml x 1ml vials) 3. Diazepam (0.1-0.3mg/kg/dose)

0.1-0.3 mg/kg = _____mg IM IV PR x 1 dose prn seizures; may repeat in in 5-10 minutes if seizures continued

0.5 mg IM IV PR x 1 dose prn seizures; may repeat in in 5-10 minutes if seizures continued

1 mg IM IV PR x 1 dose prn seizures; may repeat in in 5-10 minutes if seizures continued

Dispense 10mg/2ml x 10 syringes/vials

38

Anti-Inflammatory 1. Dexamethasone oral (1mg/ml oral solution or 4mg/ml injection)

Indication: Cerebral Edema: Loading Dose for 1-2mg/kg = ____mg PO IV IM x 1 dose Then 0.25-0.375mg/kg = _____mg PO IV IM q6hr Dispense Dexamethasone oral solution (1mg/ml) _______ml or Dexamethasone 4mg/ml, 1ml vials #_______

Gastrointestinal

1. Ranitidine IV(1mg/kg/dose) 1mg/kg= ____mg IV q8hr 5mg IV q8hr 10mg IV q8hr

Dispense 50mg/2ml vials #10 vials

2. Ranitidine oral 2-4 mg/kg = ____mg po twice daily 10 mg PO twice daily 20 mg PO twice daily

Dispense oral solution (75mg/5ml) x 15ml

3. Metoclopramide IV 0.1-0.2mg/kg= ____ mg IV q6hr 0.5 mg IV q6hr 1mg IV q6hr

Dispense 12 vials (10mg/2ml vials)

4. Metclopramide 0.1-0.2mg/kg= _____ mg po q6hr 0.5mg po q6hr 1 mg po q6hr 2 mg po q6hr

Dispense 1mg/ml oral solution x 30ml

5. Ondansetron– 0.1mg/kg 0.1mg/kg = _____mg po three times a day prn nausea/vomiting 0.5 mg po three times a day prn nausea/vomiting 1mg po three times a day prn nausea/vomiting

Dispense oral solution 4mg/5ml x 15ml

6. Glycopyrrolate (0.2mg/ml inj) Indication: for control of secretions (May use injectable for oral use)

39

40-100mcg/kg = ______mcg orally 3 times a day 4 times a day

4-10 mcg/kg = ______mcg IV IM every 4 hours Dispense 5 ml vials# ____ 7. Sucralfate oral suspension

10-20mg/kg = 50mg 100mg 200mg orally q6hr Dispense oral suspension 100mg/ml x #60ml

Miscellaneous

1. Artificial Tears 1 drop to each eye q6hr Dispense 15ml bottle x1

2. Haloperidol (5mg/ml vial) 0.05mg/kg = ____mg IM IV q8hr prn agitation

3. Diphenhydramine (1mg/kg)

5 mg PO IV IM q6hr prn agitation 7.5 mg PO IV IM q6hr prn agitation 10 mg PO IV IM q6hr prn agitation

Dispense: oral solution 12.5/5ml; 120ml bottle x 1 50mg/ml vials #____12__

I.V. FLUIDS 1. D5 _____ NS to run at _______ mL/hr

40

Appendix 9. Pediatric CSC Palliative Care Order Set for Casualties Weighing 10 – 25 kg.

Weight: _______ kg Height: _______ cm Allergies: Reviewed in LINKS and accurate as documented Reviewed in LINKS: Please add _____________________________ Please cancel ___________________________ Service: ______________________________________________________________ Admit to: Inpatient _____________ Observation (Less than 24 hours) Orders to start on: _________________ Diagnosis: __________________________________________ MEDICATIONS Analgesics (non-narcotic) 1. Acetaminophen oral Susp (10-15mg/kg/dose) 160mg 240mg 325mg po q6hr prn pain/fever po q4hr prn pain/fever Dispense 120ml bottle x 1 2. Acetaminophen rectal suppository (10-15mg/kg/dose) 160mg (1/2 325mg supp) 325mg rectally q6hr prn pain/fever rectally q4hr prn pain/fever Dispense # 12 suppositories 3. Ibuprofen oral suspension (100mg/5ml) – 10mg/kg/dose 100mg (5ml) po q6hr prn pain/discomfort 200mg (10ml) po q6hr prn pain/discomfort Dispense 120ml bottle x 1 Analgesics (opiate) Note: doses may need to be escalated for refractory end of life care.




5. Morphine oral solution (2mg/ml)*** 0.05-0.1mg/kg = ____mg orally q4hr prn pain 0.5mg orally q4hr prn pain 1mg orally q4hr prn pain _____mg orally q4hr prn pain

41

Dispense 2mg/ml oral solution 15ml 30ml

6. Morphine IV*** 0.05-0.1mg/kg = _____mg IV q4hr prn pain 0.5mg IV q4hr prn pain 1mg IV q4hr prn pain _____mg IV q4hr prn pain

Dispense 2mg/ml syringes: 10 syringes 20 syringes

7. Hydromorphone IV 0.015mg/kg = ____mg IV q4hr prn severe pain 0.1 mg IV q4hr prn severe pain 0.2mg IV q4hr prn severe pain ____mg IV q4hr prn severe pain Dispense 2mg/ml vials: 10 vials 20 vials

8. Oxycodone oral (0.015-0.15mg/kg)***

0.5mg po q6hr 1mg po q6hr 2 mg po q6hr ____mg q6hr po prn severe pain

Dispense oral solution 1mg/ml x 30 ml

Anti-seizure 4. Phenobarbital IV

Loading dose: 15-20mg /kg = _____mg IV x 1 dose Maintenance dose: 3mg/kg = _____mg IV q12h

Dispense 130mg/ml vials x 8 vials 5. Lorazepam (0.05-0.1mg/kg/dose);

0.5mg IM IV PO q6hr prn seizures agitation 1mg IM IV PO q6hr prn seizures agitation 1.5mg IM IV PO q6hr prn seizures agitation 2mg IM IV PO q6hr prn seizures agitation




Dispense 10mg/2ml x 10 syringes/vials

Anti-Inflammatory 2. Dexamethasone oral (1mg/ml oral solution or 4mg/ml injection)

Indication: Cerebral Edema:

42

Loading Dose for 1-2mg/kg = ____mg PO IV IM x 1 dose Then 0.25-0.375mg/kg = _____mg PO IV IM q6hr Dispense Dexamethasone oral solution (1mg/ml) _______ml or Dexamethasone 4mg/ml, 1ml vials #_______

Gastrointestinal

8. Ranitidine (1mg/kg/dose) 10mg IV q8hr 15mg IV q8hr 20mg IV q8hr 25mg IV q8hr


9. Ranitidine (2-4 mg/kg/dose) 20 mg PO twice daily 30 mg PO twice daily 50 mg po twice daily

Dispense 15ml (15mg/ml oral solution)

10. Metoclopramide IV (0.1-0.2mg/kg) 1 mg IV q6hr 2.5 mg IV q6hr 5 mg IV q6hr


11. Metclopramide (1mg/ml oral soln); 0.1-0.2mg/kg 1 mg po q6hr 2.5 mg po q6hr 5 mg po q6hr

Dispense 30ml

12. Ondansetron (oral solution 0.8mg/ml) – 0.1mg/kg 1 mg po three times a day prn nausea/vomiting 2 mg po three times a day prn nausea/vomiting 2.5 mg po three times a day prn nausea/vomiting

Dispense oral solution 4mg/5ml x 15ml 13. Glycopyrrolate

Indication: for control of secretions (May use injectable for oral use) 40-100mcg/kg = ______mcg orally 3 times a day 4

times a day 4-10 mcg/kg = ______mcg IV IM every 4 hours

Dispense 5 ml vials# ____

43

14. Sucralfate oral suspension 10-20mg/kg = 100mg 250mg 500mg orally q6hr

Dispense oral suspension 100mg/ml x #60ml Miscellaneous

4. Artificial Tears 1 drop to each eye q6hr Dispense 15ml bottle

5. Haloperidol 0.05mg/kg/dose 0.5mg IM IV q8hr prn agitation 1mg IM IV q8hr prn agitation

Dispense #10 vials (5mg/ml vial)

6. Diphenhydramine (1mg/kg) 12.5mg po IV q6hr prn agitation 25mg IM IV q6hr prn agitation

Dispense: oral solution 12.5/5ml; 120ml bottle x 1 50mg/ml vials #______


44

Appendix 10. Pediatric CSC Palliative Care Order Set for Casualties Weighing Greater than 25 kg – 40 kg.

Weight: _______ kg Height: _______ cm Allergies: Reviewed in LINKS and accurate as documented Reviewed in LINKS: Please add _____________________________ Please cancel ___________________________ Service: ______________________________________________________________ Admit to: Inpatient _____________ Observation (Less than 24 hours) Orders to start on: _________________ Diagnosis: __________________________________________ MEDICATIONS Analgesics (non-narcotic) 1. Acetaminophen tablets (10-15mg/kg/dose) 325mg 500mg po q6hr prn pain/fever po q4hr prn pain/fever Dispense 1 bottle 325mg tablets 500mg tablets 2. Acetaminophen rectal suppository (10-15mg/kg/dose) 325mg 500mg rectally q6hr prn pain/fever rectally q4hr prn pain/fever Dispense # 12 suppositories 3. Ibuprofen tablets 10mg/kg/dose 200mg (5ml) po q6hr prn pain/discomfort 400mg (10ml) po q6hr prn pain/discomfort Dispense 1 bottle 200mg tabs Analgesics (opiate) Note: doses may need to be escalated for refractory end of life care.




9. Morphine oral *** 0.05-0.1mg/kg = ____mg orally q4hr prn pain 1 mg orally q4hr prn pain 2 mg orally q4hr prn pain _____mg orally q4hr prn pain

45

Dispense oral solution 2mg/ml 30ml

10. Morphine IV *** 0.05-0.1mg/kg = _____mg IV q4hr prn severe pain 1 mg IV q4hr prn pain 2 mg IV q4hr prn pain _____mg IV q4hr prn pain

Dispense 2mg/ml syringes 10 syringes 20 syringes

11. Hydromorphone IV)*** 0.015mg/kg = ____mg IV q4hr prn severe pain 0.25 mg IV q4hr prn severe pain 0.5mg IV q4hr prn severe pain _____mg IV q4hr prn severe pain Dispense 2mg/ml vials: 10 vials 20 vials

12. Oxycodone oral (0.015-0.15mg/kg)***

1mg po q6hr 2 mg po q6hr ____mg q6hr po prn severe pain

Dispense oral solution 1mg/ml x 25ml

Anti-seizure 7. Phenobarbital IV

Loading dose: 15-20mg /kg = _____mg IV x 1 dose Maintenance dose: 3mg/kg = _____mg IV q12h

Dispense 130mg/ml vials #8 vials 8. Lorazepam (0.05-0.1mg/kg/dose)

2mg IM IV PO q6hr prn seizures agitation 4mg IM IV PO q6hr prn seizures agitation ____mg IM IV PO q6hr prn seizures agitation





Dispense 10mg/2ml syringes/vials x 10 syringes/vials Anti-Inflammatory

3. Dexamethasone oral (1mg/ml oral solution or 4mg/ml injection) Indication: Cerebral Edema:

46

Loading Dose for 1-2mg/kg = ____mg PO IV IM x 1 dose Then 0.25-0.375mg/kg = _____mg PO IV IM q6hr Dispense Dexamethasone oral solution (1mg/ml) _______ml or Dexamethasone 4mg/ml, 1ml vials #_______

Gastrointestinal

15. Ranitidine IV (1mg/kg/dose) 25mg IV q8hr 50mg IV q8hr


16. Ranitidine oral (2-4mg/kg/dose) 37.5 mg PO twice daily 75 mg PO twice daily

Dispense 75mg tabs #12

17. Metoclopramide IV (0.1-0.2mg/kg) 2.5 mg IV q6hr 5 mg IV q6hr 10 mg IV q6hr


18. Metclopramide (0.1-0.2mg/kg) 2.5 mg po q6hr 5 mg po q6hr 10 mg po q6hr

Dispense #12 tabs (5mg tab)

19. Ondansetron (0.1mg/kg) 2 mg po three times a day prn nausea / vomiting 4 mg po three times a day prn nausea / vomiting

Dispense 10 x 4mg ODT tablets

20. Glycopyrrolate (0.2mg/ml inj) Indication: for control of secretions (May use injectable for oral use) 40-100mcg/kg = ______mcg orally 3 times a day 4

times a day 4-10 mcg/kg = ______mcg IV IM every 4 hours

Dispense 5 ml vials# ____ 21. Sucralfate oral suspension (10-20mg/kg/dose)

500mg po q6hr 1gm po q6hr

Dispense 500mg tabs x 25 tabs

47

Miscellaneous

7. Artificial Tears 1 drop to each eye q6hr Dispense 15ml bottle x1

8. Haloperidol (0.05mg/kg/dose) 1 mg IM IV q8hr prn agitation 2 mg IM IV q8hr prn agitation

Dispense # 10 vials (5mg/ml vial)

9. Diphenhydramine (1mg/kg) 25mg po IV q6hr prn agitation 50mg IM IV q6hr prn agitation

Dispense: 25mg caps x 20 50mg/ml vials #20


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