Chapter 7. Critical care triage. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster.

PURPOSE:To provide recommendations and standard operating proceduresfor intensive care unit (ICU) and hospital preparations for an influenza pandemicor mass disaster with a specific focus on critical care triage. METHODS:Based on a literature review and expert opinion, a Delphi process was used to define the essential topics including critical care triage. RESULTS:Key recommendations include: (1) establish an Incident Management System with Emergency Executive Control Groups at facility, local, regional/state or national levels to exercise authority and direction over resources; (2) developing fair and equitable policies may require restricting ICU services to patients most likely to benefit; (3) usual treatments and standards of practice may be impossible to deliver; (4) ICU care and treatments may have to be withheld from patients likely to die even with ICU care and withdrawn after a trial in patients who do not improve or deteriorate; (5) triagecriteria should be objective, ethical, transparent, applied equitably and be publically disclosed; (6) trigger triageprotocols for pandemicinfluenza only when critical care resources across a broad geographic area are or will be overwhelmed despite all reasonable efforts to extend resources or obtain additional resources; (7) triageof patients for ICU should be based on those who are likely to benefit most or a ' first come, first served' basis; (8) a triageofficer should apply inclusionand exclusion criteriato determine patient qualification for ICU admission. CONCLUSIONS:Judicious planning and adoption of protocols for critical care triageare necessary to optimize outcomes during a pandemic.