Tool 5: Triage: Prioritizing Care to Reduce Deaths

HEALTH

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TOOL

5TRIAGE: PRIORITIZING CARE TO REDUCE DEATHS

This tool will help you to:

• Understandhealthcaretriageandtherolesofmunicipalauthoritiesandhealthcareprovidersintriage

• Useyourhealthcareresourcestosavethegreatestnumberoflives

• Planfortriageinyourmunicipalitybasedonfourlevelsofcare

Who will implement this tool:

• Themayorandthemunicipal leadership team

• Hospitalsandhealthcareproviders

• Thosealreadyinchargeofdisastertriageplanningandprotocols

• Communityhealthcareorganizationsandvolunteers

WHAT IS TRIAGE AND WHY IS IT NEEDED?

Ideally,thefirstpeopletoneedmedicalcarereceiveit.Inlessthanidealconditions,somebodyhastodecidewhoreceivescarefirst.Somehealthfacilitiesfacethesedecisionsonadailybasis,evenwithoutanydisasterorhealthemergency.However,naturaldisasters(e.g.,earthquakes)orotherevents(e.g.,traincrashorbombing)canresultinalargenumberofinjuredorsickpeopleatonetime.Whenthishappens,decisionsmustbemadeabouthowtobestallocatecarewhenresourcesareinsufficientforallthosewhoneedcare.Thisprocessiscalledtriage.

Thepurposeoftriageistosaveasmanylivesaspossible.Duringaseverepandemic,youcanexpectthattheperiodoftimewhentheneedforcarewillbegreaterthantheresourcesavailablewilllastforweeksormonths.Usingscarcemedicalresourcestoprovidecareforpatientswhomaybeverysick,butwhowillprobablydieevenwithintensivecare,mayresultinotherlesssickpatientsnotreceivingcare,gettingsicker,anddying.Whendoneproperly,triageresultsinthebestoutcomeforthegreatestnumberofpeople.Without a triage plan in place, resources are likely to be wasted—and more people are likely to die. Therefore,itisimportantthatyourmunicipalitydevelopapandemictriageplan.

Itisveryimportantforyoutodetermineinadvancewhowillhavetheauthoritytoimplementthetriageplan.Theneedfortriageislikelytochangerapidlyandfrequentlyduringthepandemicwave,astheepidemicescalatestoitspeakandthenbeginstosubside.Thepersonorgroupresponsibleforthetriageplanningwillneedtoconsidertheneedforhealthcareresourcesandtheavailabilityofthoseresourcesonadailybasis,thencommunicatetothehealthcareproviderstheappropriatetriageplan.Insituationswheresickpatientscannotbecaredforandthepublicpanicsorviolentlyproteststhedecisionmaking,youmayneedsecurityforcestoprotecthealthcarefacilitiesandproviders.

Figure1isagraphfromTool2,Presentation on the Threat of a Severe Influenza Pandemicthatshowsthenumberofcasesthatwouldbeexpectedinapopulationof100,000peopleduringaseverepandemic.Duringtheearlyandlatephasesofthepandemicwave,therewillbefewercasesatanyonetime.However,duringthemiddlepartofthewave,thelargestnumberwillneedcareatthesametime.Thisisreferredtoasthepeak period ofthepandemic.Theremaybesomeplaceswherehealthfacilitiesandcommunitiesareabletocopewithprovidingcareduringtheearlyandlatephases,butareoverwhelmedatthepeakofthewaveandneedtoimplementtriagestrategies.Otherplacesmaybequicklyoverwhelmedandneedtriagethroughoutthewave.

RECOVERYPREPAREDNESS RESPONSE

TOOL 5: TRIAGE: PRIORITIZING CARE TO REDUCE DEATHS

2 LEADERSHIP DURING A PANDEMIC: WHAT YOUR MUNICIPALITY CAN DO 3TOOL 5: TRIAGE: PRIORITIZING CARE TO REDUCE DEATHSLEADERSHIP DURING A PANDEMIC: WHAT YOUR MUNICIPALITY CAN DO

FIGURE 1: THE NUMBER OF CASES EXPECTED PER WEEK FOR A POPULATION OF 100,000 IN A SEVERE PANDEMIC

NOTE: As with all projections generated by the Pandemic Health Impact Projection Tool, these are estimates based on a number of assumptions. These projections are for planning, not to predict actual numbers.

THE ROLE OF MUNICIPAL AUTHORITIES

Mayorsandtheirmunicipalleadershipteamsareresponsibleforthewell-beingoftheirpopulations.Therefore,youwillbeexpectedtotakeactionstoreducedeathsduringaseverepandemic.Partofthisresponsibilitywillinvolvedecreasingdeathsthroughaneffectivetriageplan.

Themayorshouldrelyonthehealthsectortodeveloptriageprotocolsandstandardsandultimatelytocreateatriageplanthatisbasedontheanticipatedneedsofthepopulationandthemunicipality’savailableresources.However,themunicipalgovernmentwillneedtosupportthehealthsectorplan,providethenecessaryresources,ensurealegalbasistoimplementit,andaddresspublicinformationandconcerns.(SeeTool15,Disaster Management in a Pandemic.)

Municipalauthoritiesshouldalsobeawarethatalternativecommunitycarecentersmaybeneededtoprovideadditionalaccesstomedicalcarewhenhospitalsandotherhealthfacilitiesarefull.Thesemaybesetupinclosedschools,churches,orotherbuildingsthatareconvertedtoserveasmakeshifthospitals,withcommunityhealthworkersandothervolunteersprovidingmostofthecarefollowingbrieftraining.(Formoreinformation,seeTool6,Training for Community Health Responders andTool17, Volunteer Coordination.)

Alegalbasisfortheuseoftriagemayalreadyexistatacentral,regional,orlocallevel.Ifnot,youshouldrefertoyournationalpandemicplanforguidance,thenworkwithhealthsectorleaderstodevelopone.Itshouldnotbecommunicatedtothepublicbeforeitisneededtoavoidundueconcern,butitisimportanttohavejustificationreadyastherewillnotbethetimetoresearchwhentriageisneeded.

Aswithotheraspectsofdisasterresponse,effectivetriagewillrequirethepublictobecalmandcooperative,whichinturnisdependentonstrongmunicipalleadershipandeffectivepubliccommunication.Municipalauthoritiesmustbeabletoexplaintriageandwhyitisnecessarytothecommunity.Youwillalsoneedtoknowwhetherandwhyalternativecommunitycarecentersareneeded,wheretheyarelocated,andhowtoaccessthemsothatthisinformationcanbeprovidedtothepublicandotherauthorities.Thiswillbe

criticalbothinhelpingtopreventhealthservicesfrombeingoverloadedandinreassuringthepublictoavoidthepossiblepanicapandemicnaturallygenerates.(Formoreinformation,seeTools12–14inthesectionCrisis and Emergency Risk Communications.)

THE ROLE OF HOSPITALS AND HEALTHCARE PROVIDERS

Hospitalsandotherhealthcarefacilitieswillfaceanumberofchallengesduringaseverepandemic.Theywillneedtoprovidecaretoamuchgreaternumberofpatientsthannormalduringatimewhentheywillexperiencehighratesofworkerabsenteeism.Hospitalemployeesmaybeill,ormayneedtocareforsickfamilymembersorchildrenwhoseschoolshaveclosed.Therefore,attheverysametimethatthenumberofpeopleneedingcareincreases,thenumberofpeopleavailabletoprovidethatcarewilldecrease.

Hospitalswillneedtoprotectbothstaffandtheotherpatientsfromthepandemic,soprovidingseparatetreatmentareaswithseparatecareprovidersforinfluenzapatientsmaybenecessary.Itisveryimportanttoremember that the non-pandemic needs for hospital-level care will continue during the pandemic,andmayincludebirths,heartattacks,caraccidents,andotherinfectiousdiseases(e.g.,pneumonias,diarrhealdiseases,malaria,andtuberculosis).Hospitalsmustthereforepreparetoincreasetheirresourcestosurgecapacityinordertocontinuetocareforthosewhoneeditmost.Atalltimes,municipalitiesshouldplantoprovidethehighestlevelofcareavailabletoallpandemicandnon-pandemicpatients.However,asthenumberofsickpeopleoverwhelmsavailableresources,healthcareproviderswillneedtoallocatecareefficiently.Forallofthesereasons,duringaseverepandemiconly the very sickest patients who are likely to survive with hospital-level care should be admitted to health facilities.Allothercaseswillneedtobecaredforoutsideoftheusualhealthcaresystem,athome,orinalternativecommunitycarecenters.

STEPS TO AN EFFECTIVE TRIAGE PLAN

STEP 1: UNDERSTAND THE HEALTH IMPACT OF A PANDEMIC ON THE POPULATION

Understandingwhattheimpactofapandemicwillbeonthepopulationisthefirststepinplanninghowtouseresourcestodecreasedeaths.Therealityofwhatmaybeneededinamunicipalityduringaseverepandemicmustbeseenclearlybeforedevelopingtheneededplan.ItishighlyrecommendedthatyoubeginthisprocessbyusingTool3,Pandemic Health Impact Projection Tool andits User Guide.Thetoolwillgenerateanestimateofthenumberofcasesanddeathsprojectedinamunicipality.Pleaserefertothistooltofillintheboxesbelow:

Name of Population (e.g., city, neighborhood, employees):

Population Size

Severity Level

Total # Cases

Peak Week Cases (total)

Peak Week Cases by Level of Care

Peak Week Level 1 Care




STEPS YOUR MUNICIPAL LEADERSHIP TEAM CAN TAKE BEFORE THE PANDEMIC TO ENSURE TIMELY TRIAGE PLANNING INCLUDE:

• Identify any existing triage plans and protocols.

• Delegate authority for triage policy to an individual or a sector.

• Conduct a baseline assessment of all healthcare resources: beds, supplies and medications, healthcare providers, and volunteers.

• Coordinate preparedness planning to increase stocks of medications (for both pandemic and non-pandemic illness) and general medical supplies.

• Create data collection forms you can use to compile daily counts of patients needing care, and to assess the current level of available resources.

• Develop a communication plan you can use to inform healthcare providers and volunteers about the current triage plan.

• Develop a security plan for healthcare facilities.


STEP 2: PLAN FOR THE PEAK

Itisbesttoplanyourtriageforthetimewhenthepandemicwillcausethegreatestnumberofcases,orthepeak week.Asthegraphpresentedearliershowed,thepandemicisexpectedtofollowatypicalbell-shapedcurve,startingatabaselineandincreasingtoapeaknumberofcasesmid-wavebeforedecreasingbackdowntobaselineoveraperiodof6–12weeks.Duringthepeakweek,thegreatestnumberofpeoplewillbesickatonetime,and,simultaneously,thenumberofhealthcareprovidersthatareunabletoworkwillbeatitshighestlevel.Inaddition,supplychainshortagesofgoodsandmedicationswillbethemostlikelyatthistime.Therefore,thepeakperiodofthepandemicwaveisthetimewhentriageplanningwillbemostneeded.

(Formoreinformation,seeTool3,Pandemic Health Impact Projection Tool.)

STEP 3: IDENTIFY AND DESCRIBE ALL HEALTHCARE RESOURCES

Beforeplanningthetriagesystemforyourmunicipality,makeacompleteinventoryofallavailableresources.Triage should only be used as last resortwhenhealthcareresourcesareoverwhelmedandunabletorespondtoallthatneedimmediatecare.Triageisneededwhenthebalanceofneedoutweighsavailability.Thisbalancewillchangeonadailybasisinapandemic.Atthestartofthewave,theremaynotbeaneedfortriage.Asmorepeoplegetsickandsuppliesandhumanresourcesdecrease,thetimewillcometoimplementtriage.Ascasesbegintodeclinepost-peak,therewillbeatimewhentriagecanbesuspended.Therefore,itisimportantthatyoudevelopaplantoassessandtracktheavailabilityofresourcespriorto,during,andafterthepeakofthepandemicwave.Resourcetrackingshouldinclude:

• Humanresources:Thisshouldincludethepeopleinvolvedinpatientcare,communityeducationanddiseaseprevention,transportofpatients,andlogisticsandsupportpersonnelneededforhealthfacility,community,andhouseholdlevelcare.Considerallskilledandunskilledhealthcareproviders(doctors,nurses,technicians,andpharmacists,aswellastrainedanduntrainedvolunteers).

• Logistics:Medicalsupplies,suchasmasks,gloves,oralandintravenousfluids,andmedications(antibiotics,antipyretics,antivirals,handwashinggels,andsoap);non-medicalsuppliessuchasgasoline,electricity,communicationdevices,clericalsupport,etc.

• Financialresources

• Communityresourcesforalternatecaresitesandstaffing

• Inaddition,theplanshouldincludethenamesandcontactinformationforthosewhowillberesponsibleforimplementingtheplan(bothfromthehealthsectorandthemunicipalgovernment).

STEP 4: GENERATE SEVERITY-BASED PYRAMIDS OF CARE

Figure2onpage6isapyramid of caregraphfromTool3,Pandemic Health Impact Projection Tool.Itisusefulindevelopingatriageplan.All municipalities should generate and plan for a pyramid of care during a severe pandemic,anditmaybeusefultoreviewthepyramidsofcareformildandmoderatepandemicsaswell.YoucanusetheTool’sseveritydrop-downmenutoselectaseveritycategory,andthenclickongraphic#5(“PeakWeekCasesbyLevelofCare”).Thepyramidsofcarecanbecopiedandpastedintoadocumentand/orprintedoutonpaper.

LEVELS OF HEALTHCARE

Thepyramidofcaregivesanapproximationofthenumberofcasesthatwillfallintoeachoffourlevelsofcare.Justasallpandemicsarenotthesame,allcasesofinfluenzainapandemicarenotthesame.Therearefourlevelsofhealthcarepatientsmayneed,rangingfrommildtosevere,dependingontheseverityofthedisease.Manypandemicinfluenzacaseswillbeverymild,similartoaseasonalinfluenzacase(level1).Thesepeoplewillbeabletocareforthemselvesathomeandreturntoworkorotheractivitieswithinonetotwoweeks.Otherswillhaveaverysevereformoftheillnessandmaydiedespiteintensivecare(level4).Followingaredetaileddefinitionsofthefourlevelsofcare:

Level 1: Unassisted Home Care Thelevel1casesarethemildestcases,andmostareexpectedtorecoverathomewithoutcomplications.Level1includesbothselfcareandcarebyafamilymemberorotheravailablecaregiver.Thesecasesdonotrequireoutsideassistance.

Level 2: Assisted Home Care Level2casesareuncomplicatedcasesthatneedtheassistanceofcommunityresources(suchasatrainedcommunityhealthworker)fortheirinfluenzaorforotherillnesses(suchasTBormalaria).Themosturgentneedsofpeoplefallingintolevel2ofcareprobablywillbeoralhydration(takingliquidsbymouth),andthecontinuationofmedicationsorothertreatmentsforcoexistingillnesses.Peoplewhorequiresignificantassistancewiththeactivitiesofdailyliving(suchasbathing,doingerrands,cleaning,cooking,andsecuringfood)alsofitintothislevelofcare.

Level 3: Skilled Clinical Care Needed Level3casesrequirecareofmoderateintensitybyaclinically-trainedprovider.Peoplewhofallintothislevelmaybecaredforathomeoratanalternatehealthcaresiteinthecommunity.Examplesofskilledcareincludeexaminationtoseeifpneumoniaisdeveloping,intravenoushydration,intravenousantibiotics,andrespiratorytreatments.

Level 4: Highest Available Level of Care Needed Thesearethemostseverecases,andtheyshouldbetreatedinahospitalifoneisavailable.However,inareaswithlimitedresources,thesecasesarenotlikelytosurviveevenwiththehighestavailablelevelofcare,andmaybeassignedtocomfort careratherthanprovidedwithskilledhealthcareresources.Policiesforlevel4careshouldbeincludedinthemunicipalplanfortriage.


Examples: Thefollowingfiguresillustratethepyramidofcare.Figure2showsthepercentofcasesthatareexpectedtobeineachlevelofcareinaseverepandemic.Figure3showsthepyramidofcareforthesamepopulationof100,000thatweusedinFigure2.Thisisbasedonanestimatethattherewouldbe6,000casesaweekduringthepeakofthepandemicwave.Thispyramidtakesthose6,000casesandestimateshowmanywillbemild,howmanywillbeveryill,andhowmanywillfallbetweenthoseextremes.

FIGURE 2: PERCENT ALLOCATION OF CASES PER LEVEL OF CARE IN A SEVERE PANDEMIC

FIGURE 3: PYRAMID OF CARE SHOWING NUMBER OF CASES PER LEVEL OF CARE FOR A POPULATION OF 100,000 IN A SEVERE PANDEMIC

STEP 5: ALLOCATE RESOURCES ACCORDING TO THE LEVELS OF CARE

Usingthesetoolswillprovideaprojectionastohowmanysickpeoplewillneedcareduringthepeakweekofthepandemic.Withthisinformation,youcancomparetheneedforcarewiththeresourcesavailable,anddevelopaplantoreducethenumberofdeathsbasedonthelevelsofcareoutlinedabove.

Becausetheuseoftriageassumesthathealthcareresourcesareinsufficientoroverwhelmed,municipalitieswillneedtoplantoprovideasmuchcareaspossibletopatientsintheirhomes.Manypatientswillhaveamildformofthediseaseandwillbeabletocareforthemselves.Othersmayneedtheassistanceofafamilymemberorcommunityvolunteertoprovidenon-skilledcaretopreventdehydrationandtoassistwitheatingandotheractivities.Somewillneedmoreskilledcareathome—perhapsanexaminationtoseeifpneumoniaisdeveloping,orifshort-termintravenousfluidsforhydrationorothercareisnecessary.Finally,somepatientswillneedcontinuous

observationorhighlyskilledcarebutwillbeunabletoenterahospitalbecausethehospitalswillnothaveroom.Youshoulddevelopplanstocareforthesepatientsincommunitycarecenters.Thosewhoareveryillbutarenotlikelytosurviveshouldbetriagedintocomfortcareonly—inotherwords,thesepatientsshouldbekeptascomfortableaspossible,withouttheuseoflife-extendingtreatment.Belowaresuggestionsforplanningtheallocationofresourcestoeachlevel:

• Level 1 Care:Noresourcesshouldbeallocatedforthesepatients.Thesepatientswillhaveamildformofthediseaseandwillrecoverquicklywithoutanyassistance.Dedicatingresourcestolevel1patientsduringatimewhenresourcesareoverwhelmedwillreducethecareavailabletothosethatneeditforsurvival.

• Level 2 Care:Thesepatientsarewellenoughtoremainathome,buttheyneedsomecareorassistance.Theymayneeddeliveriesoffoodormedicationsfornon-pandemicillness,suchasmalariaordiabetes,assistancewithoralhydrationfortheirpandemicdiseases,clinicalassessmenttoensuretheirinfluenzaisnotadvancingtoahigherlevelofcare,orhelpwithgeneralnutrition,hygiene,orotherdailyactivities.Theobjectiveofprovidingcaretolevel2patientsistokeepthemashealthyaspossible.Thesepatientsshouldbeabletosurvivethepandemicwithminimalassistance.Itisrecommendedthattheleast-skilledpersonnel,suchascommunityvolunteers,beusedtoprovidethiscare.

• Level 3 Care:Thisisthemostdifficultlevelofcareformunicipalitiestoprovide.Thesepatientshaveaseriousformofthepandemicinfluenza,andcoulddieifcareisnotprovided.Themostfrequentandimportantcarethatwillbeneededisintravenoushydrationandantibiotics.Skilledcareprovidersshouldbeusedforthesepatients.However,youshouldplanforalternatecommunitysitesofcareforthesepatientsinordertomaximizetheuseoftheskilledpersonnel.Schoolsandothermunicipalbuildingsthatareusedassheltersinothertypesofdisasterscouldbeusedasalternatecaresites(sheltersarenotrecommendedforthegeneralpublicinapandemicastheycouldleadtoanincreaseinthespreadofthedisease).

Example: A nurse sent to a patient’s home to administer intravenous hydration would require many hours of the nurse’s time to care for just one patient. Municipalities should identify a site or sites where a number of these patients could be cared for. A single nurse could provide intravenous hydration to many patients in the same amount of time it would take to care for a single patient in their home. This is a much more efficient use of the nurse, and will result in many more lives saved.

• Level 4 Care:Whilelevel4patientsarethosethatwouldnormallybecaredforinahospitalifresourceswereavailable,manywilllikelydieofthediseaseathomewithouteverreachingahealthcarefacility.Infact,themunicipaltriageplanforlevel4shouldassumethattherewillnotberoomforthevastmajorityofthesepatientsinhealthfacilities,anddecisionsaroundreferringpatientsforthehighestavailablecareshouldbebasedonthelikelihoodthatthepatientcansurvivethedisease.Thoselevel4patientsthatarealmostsuretodieevenwiththehighestlevelofavailablecareshouldbetriagedtocomfortcareathomeoratanalternatecommunitysiteofcare(wheretheymayreceivementalhealthsupport,paincontrol,childcare,griefcounseling,etc.).Again,itisimportanttore-assesstheavailabilityofcareonafrequentbasis.Asthenumberofpandemiccasesdeclinespost-peak,morepatientswillbeabletobereferredforfacility-basedcare.

Distribution of Cases (Pyramid of Care) in a Severe Pandemic

Pyramid of Care for the Peak Week in a Population of 100,000 in a Severe Pandemic


STEP 6: REMEMBER THESE KEY CONCEPTS

Aswehaveseen,thedegreetowhichpeoplearesickwithinfluenzainyourmunicipalitywillvarywidely.Forsomepatients,thediseasewillbeverymild;forothers,itwillberapidlyfatal.Tool3,Pandemic Health Impact Projection Tool,providesagraphthatshowswhatthedistributionofcaseswillbeforthefourlevelsofcareduringmild,moderate,andseverepandemics.Aswithallpandemicprojections,thesearejustestimatesforuseinplanningandarebasedonassumptionsthatmayormaynotoccurinanactualpandemic.Triageplanninguseskeyconceptsofcare.Whiletheestimateddemandsonmunicipalhealthcareresourcesmaynotturnouttobecompletelyaccurate,therationaleandpoliciesofthetriagestrategywillremainthesame.Remembertheseconceptsintheplanforyourmunicipality.

• Triage will be necessary in a severe pandemic.

Nocountryintheworldwillhavesufficientresourcestocareforallthepatientsthatwillneedcareinaseverepandemic.Notalldeathswillbepreventable,andnotallsickpatientswillreceiveneededcare.Thegoalofpandemictriageistosaveasmanylivesaspossiblewithinthecontextofinsufficientresources.

• Triage will save lives.

Triageisnotaboutwithholdingcarefrompatients,itisaboutprovidingthebestcaretothegreatestnumberofpeople.Thismeansprovidingtheappropriatelevelofcare.Theobjectiveofmedicalcareinapandemic,whenallresourcesareoverwhelmed,istoensurethatpatientswithsurvivable illnessareprovidedwiththecareandassistancetheyneed.Someofthepatientswiththemost severe form of the diseasewillprobablydieevenwiththehighestlevelofavailableresources;therefore,inasituationwherethereareinsufficientresourcestocareforallpatients,resourcesarebestusedtocareforpersonswhocansurvive.

Patientswhoareveryillshouldbeadmittedtohospitalsandprovidedwiththehighestlevelofcareavailable,butonlywhentheresourcesdedicatedtothemdonotimpairtheabilitytocontinueprovidingcaretopatientsatlowerlevelsofcare.Intheend,thedecisionsaboutwhichoftheveryillpatientsshouldbeadmittedtohospitals,providedcareinacommunitysite,orprovidedthehighestdegreeofcomfortcarethatispossible,cannotbedeterminedinadvancesincethosedecisionswilldependontheconstantlychangingbalanceofneedsandavailableresources.

Example: Allow level 1 patients to take care of themselves at home without assistance, and provide comfort care only to a terminal level 4 patient. Both of these actions provide appropriate care to the individuals, while reserving scarce resources to take care of other patients that may not survive without them.

• The levels of care are fluid and interdependent.

Keepinmindthatthenumberofpatientsatonelevelofcarewillimpactthenumberattheotherlevels.Peoplewithmilderdisease—thoseinlevel1,atthebottomofthepyramidinFigure2—willprobablybeabletosurvivethepandemicwithminimalassistance.Evenmostofthoseinlevels2and3willprobablysurviveiftheyareabletoaccessthecaretheyneed.However,apatientmaybeginwithamildcaseoftheinfluenza(level1),butthenbecomedehydratedandmoveupthepyramidtolevel2.Theymaythendevelopasecondarybacterialpneumoniaandbecomeveryill(level3).Anotherpersonmaybegintheirillnesswitharapidlyprogressivesevereformoftheillness(level4)butrecoverandprogressdownthepyramidtofullrecovery.This ability to move up and down the

pyramid has implications for triage planning.Thepyramidsofcaregeneratedforyourmunicipalityareusefultobeginyourplanning.However,duringaseverepandemic,youmayfindthatmorepatientsthanexpectedmaybeinlevels3and4.ThiscouldbearesultofcharacteristicsofthevirusthataredifferentfromthebasicassumptionsusedinthePandemic Health Impact Projection Tool.Oritmayindicateaneedtochangeyourtriageplanning.Becausepatientscanmoveupordownthepyramidofcare,theselevelsareinterdependent.Inmanycases,theabilitytoprovidecaretolevel2andlevel3patientswilldeterminetheirfate.Municipalitiesthatcanmaximizethecareprovidedtopatientsrequiringlowerlevelsofcarewillbeabletopreventmanydeaths.However,ifaccesstocareisnotavailabletopatientsatthelowerlevelsofcare,someofthemwillprobablybecomemoreillandwilladdtothenumberofpeopleneedingahigherlevelofcare.Inotherwords,alevel2casemaybecomealevel3case.

Example: Level 2 patients that are slightly dehydrated may need the assistance of a volunteer to sit with them and ensure they take in fluids, and maintain their nutritional status. This does not require a skilled healthcare provider, but it does require sufficient family members or community volunteers who are able and willing to do this. If these resources do not exist, some of these patients will become more dehydrated and more ill, and will move up to level 3 and require intravenous hydration and skilled care—resources that are even more difficult to provide. The same patient with good level 2 care will likely move down to level 1 and no longer require any care at all.

Thisexamplehighlightstheimportanceofgoodtriageimplementation.Inthiscase,iflevel2patientsareprogressingtolevel3,ratherthantolevel1,areallocationofresourcesshouldfocusonlevel2.Iflevel1andlevel2arebeingwelltakencareof,thenyoushouldfocusonhowtoimprovecaretolevel3patients.

• Build the base.

Thebestsituationforamunicipalityistohaveasmanypatientsaspossiblecapableoftakingcareofthemselves.Therearemanystepsinpreparingandrespondingtoapandemicthatcanhelpbuildself-sufficiency.Thisincludesgoodgovernmentplanningandpreparednessatalllevels,household-levelpreparedness,goodpublicinformationandeducation,theeffectiveuseofsocialdistancing,andmanyotheraspectsofpandemicresponse.However,intermsoftheabilitytoprovidecaretosickpatients,thismeanshavingasmanyofthesickpatientsinlevel1,thebaseofthepyramid,aspossible.

Althoughultimatelysomeofthedeathsfromthepandemicmaynotbepreventable,thegoalofmunicipal-levelaccesstocareshouldbetominimizepreventablepandemicdeaths.Thisisbestaccomplishedbyusingavailableresourcestopushasmanycasesaspossibletothebaseofthepyramid,andtopreventcasesfrommovingupthepyramid.Inotherwords,careshouldbeallocatedtomaintainthegreatestnumberofpatientsatthelowestlevelofcare.Reducingdeathsduringapandemicwilltranslatetosavingasmanylivesasaresavable,andnotexpendingresourcesonthosethatarenotsavable.Byusingyourresourcestobuildthebaseofthepyramid,andpreventingpatientsfrommovinguptolevel3or4,youwillpreventdeaths.


Example: A physician is on her way to work at an alternate community site of care where 20 patients are waiting for intravenous hydration to begin. She is stopped by a community member who reports her 10-year-old son is very sick and having trouble breathing. The physician runs to the home and finds the son in desperate condition. He is in respiratory failure and needs oxygen and mechanical ventilation, neither of which is available. Not only is the referral hospital overwhelmed and out of life-saving resources themselves, the boy would never survive the trip. The physician must decide whether to stay with the child and do whatever she can to try to save him, or accept that the boy is going to die and request comfort care resources for the boy and the family. If the physician remains with the child for several hours before he dies, the 20 patients waiting for intravenous hydration may worsen and become level 4 patients. By providing a trained volunteer who can sit with the boy and the family to provide support and a caring and dignified death, the physician can then treat the level 3 patients. This is likely to result in some of these patients moving down the pyramid to a lower level of care, thereby building the base.

• Provide mental health support.

Healthcareproviders,patients,andtheirlovedoneswillneedagreatdealofsupport.Theuseoftriageinvolvesverydifficultdecisionsforallinvolved.Evenwhenitisclearthatlivesarebeingsaved,andthatthegreatestnumberofpatientsarereceivingthebestpossiblecare,manywillfeelgreatsadness,guilt,andstress.Thismaybeheightenedoncethecrisishaspassedandthereistimetoreflectandgrieve.Youshouldanticipatethisneed,andplantosupportthosewhoaresuffering.(SeeTool19,Recovery and Resilience.)

• Minimize preventable deaths from all causes.

Duringaseverepandemic,manypeoplewilldie.Someofthesewillbedeathsthatwouldoccurunderanycircumstances,butotherswillbedeathsthatoccurbecauseofthechangesinhealthcareaccessandresourcesduringapandemic.Thefocusofpandemictriageplanningshouldbetopreventunnecessarydeaths—thosethatwouldnotoccurifcarewereavailable.Thedeathsthatarepreventablewillvaryfromcountrytocountry,andlocalareatolocalarea.Municipalleadersneedtoworkwithintheirowncontextofhealthcareaccessandresources.Inadditiontoacceptingthatnoonecanpreventalldeaths,itisimportanttorecognizewhatyoucando.Througheffectivetriageplanning,leaderscanmakethebestuseoflimitedresourcestopreventdeathsinthelowerlevelsofcare.Withoutthiscare,manywillmoveupthepyramidofcareandbecomepreventabledeaths.

Partofsavinglivesandpreventingunnecessarydeathsisrelatedtonon-pandemicillness.Healthcareresourcesmustbeusedtocontinuetoprovidelife-savingnon-pandemiccareforHIV/AIDS,malaria,diarrhealillness,pneumoniaandothercommunicablediseases,cardiovasculardisease,diabetes,andothers.Ifallthehealthcareresourcesareusedbythepandemicpopulations,manydeathswilloccurfromnon-pandemiccauses.Reducingallpreventabledeaths,pandemicandnon-pandemic,shouldbethefocusofpandemictriage.Tool16,Maintenance of Essential Services,canhelptoidentifythehealthcareservicesthatneedtobemaintainedduringthepandemic.

• Consider legal and ethical implications of triage.

Thereisagreatdealofvariabilitybetweencountriesontherelevanceoflegalprotectionforhealthcareprovidersandvolunteerswhoimplementtriage.

Municipalleadersneedtoreviewthelegalframeworkinthelocalarea,andinvolvethecentralgovernmentintheplanningandimplementation.

Aswithalldisasterplanning,youshouldpayspecialattentiontoensuringthatthemostpoorandvulnerablegroups,internallydisplacedpersons,andothersthatmaybeatincreasedriskofdiseaseanddeathareprovidedfor.Publictransparencyabouttheneedforandobjectivesofpandemictriage,aswellaspublicparticipationintriageplanningandimplementationwillhelptoensureaneffectiveresponse.Finally,triageshouldonlybeusedwhenitisneeded,andonlyinproportiontothatneed.

• Get ready.

- Thetypeoftriagethatisbestsuitedtoapandemic—andothercatastrophiceventsthatoverwhelmhealthcaresystems—isverydifferentfromthetypicalconceptoftriageinamasscasualtyevent,suchasaplanecrashorearthquake.Therefore,everyeffortshouldbemadetoprovidetraininginthisconceptofcaretohealthcareprovidersandothersinvolvedinhealthcareaccessinthecommunity.

- Ensurethathealthcareprovidersareknowledgeableabouttheneedfortriageandtheobjectivesoftheplan.Thisshouldincludefamiliaritywiththeimpactprojectionsforthepeakofthepandemic,thelevelsofcare,thepyramidofcare,andtheconceptofbuildingthebase.

- Assessresourcegapsandaddressasmanyaspossibleaheadoftime.

- Trainsufficientvolunteerstoassistwithlevel2and3care.

- Identifyandplanforalternatecommunitysitesofcareforlevel3patients.

- Developaplanforlevel4,andtrainvolunteersincomfortcareandsupport.

- Developacommunicationsplanforallpersonnelneededtoimplementthetriageplan.

- Developaprocesstoassessthebalanceofcareneededversusresourceavailabilityonanon-goingbasis.

12 LEADERSHIP DURING A PANDEMIC: WHAT YOUR MUNICIPALITY CAN DO

SOURCES• AHRQ(AgencyforHealthcareResearchandQuality).2005.Altered standards

of care in mass casualty events.PreparedbyHealthSystemsResearch,Inc.undercontractno.290-04-0010.AHRQPublicationNo.05-0043.Rockville,MD:AHRQ.

• CDC(U.S.CentersforDiseaseControlandPrevention).FluSurge2.0.http://www.cdc.gov/flu/tools/flusurge/(accessedMarch18,2009).

• HHS(U.S.DepartmentofHealthandHumanServices).HHSpandemicinfluenzaplansupplement5clinicalguidelines.http://www.hhs.gov/pandemicflu/plan/sup5.html(accessedMarch18,2009).

• Phillips,S.J.,andA.Knebel,eds.2007.Mass medical care with scarce resources: A community planning guide.PreparedbyHealthSystemsResearch,Inc.,anAltarumcompany,undercontractno.290-04-0010.AHRQPublicationNo.07-0001.Rockville,MD:AHRQ.

• WHO(WorldHealthOrganization).2008.Pandemic influenza preparedness and mitigation in refugee and displaced populations.2nded.Geneva:WHO.http://www.who.int/diseasecontrol_emergencies/HSE_EPR_DCE_2008_3rweb.pdf(accessedMarch18,2009).

Documents

Tool 5: Triage: Prioritizing Care to Reduce Deaths