Hostname: page-component-76fb5796d-45l2p Total loading time: 0 Render date: 2024-04-29T10:37:00.574Z Has data issue: false hasContentIssue false
  • English
  • Français

Pediatric Disposition Classification (Reverse Triage) System to Create Surge Capacity

Published online by Cambridge University Press:  27 March 2015

Gabor D. Kelen ,
Lauren Sauer ,
Eben Clattenburg ,
Mithya Lewis-Newby  and
James Fackler
Gabor D. Kelen*
Affiliation:
The Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland the Johns Hopkins Office of Critical Event Preparedness and Response, Johns Hopkins Institutions, Baltimore, Maryland the National Center for the Study of Preparedness and Catastrophic Event Response, The Johns Hopkins University, Baltimore, Maryland
Lauren Sauer
Affiliation:
The Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland the Johns Hopkins Office of Critical Event Preparedness and Response, Johns Hopkins Institutions, Baltimore, Maryland the National Center for the Study of Preparedness and Catastrophic Event Response, The Johns Hopkins University, Baltimore, Maryland
Eben Clattenburg
Affiliation:
The Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland the National Center for the Study of Preparedness and Catastrophic Event Response, The Johns Hopkins University, Baltimore, Maryland
Mithya Lewis-Newby
Affiliation:
the Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
James Fackler
Affiliation:
the Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
*
Correspondence and reprint requests to G.D. Kelen, MD, FRCP(C), FACEP, Director, National Center for the Study of Preparedness and Catastrophic Event Response, 5801 Smith Ave, Suite 3220, Davis Bldg, Baltimore, MD 21209 (e-mail: gkelen@jhmi.edu).
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Critically insufficient pediatric hospital capacity may develop during a disaster or surge event. Research is lacking on the creation of pediatric surge capacity. A system of “reverse triage,” with early discharge of hospitalized patients, has been developed for adults and shows great potential but is unexplored in pediatrics.

Methods

We conducted an evidence-based modified-Delphi consensus process with 25 expert panelists to derive a disposition classification system for pediatric inpatients on the basis of risk tolerance for a consequential medical event (CME). For potential validation, critical interventions (CIs) were derived and ranked by using a Likert scale to indicate CME risk should the CI be withdrawn or withheld for early disposition.

Results

Panelists unanimously agreed on a 5-category risk-based disposition classification system. The panelists established upper limit (mean) CME risk for each category as <2% (interquartile range [IQR]: 1–2%); 7% (5–10%), 18% (10–20%), 46% (20–65%), and 72% (50–90%), respectively. Panelists identified 25 CIs with varying degrees of CME likelihood if withdrawn or withheld. Of these, 40% were ranked high risk (Likert scale mean ≥7) and 32% were ranked modest risk (≤3).

Conclusions

The classification system has potential for an ethically acceptable risk-based taxonomy for pediatric inpatient reverse triage, including identification of those deemed safe for early discharge during surge events. (Disaster Med Public Health Preparedness. 2015;9:283-290)

Keywords

surge capacitydisaster planninghealth care rationinghospital bed capacityrisk assessment
Type
Original Research
Information
Disaster Medicine and Public Health Preparedness , Volume 9 , Issue 3 , June 2015 , pp. 283 - 290
Copyright
Copyright © Society for Disaster Medicine and Public Health, Inc. 2015 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1. Committee on the Future of Emergency Care in the United States. Hospital Based Emergency Care at the Breaking Point. Future of Emergency Care Series. Washington, DC: National Academies Press; 2006.Google Scholar
2. Surge Hospitals: Providing safe care in emergencies. 2006. The Joint Commission on Accreditation of Healthcare Organizations. http://www.jointcommission.org/assets/1/18/surge_hospital.pdf. Accessed March 3, 2014.Google Scholar
3. Homeland Security Presidential Directive/HSPD-21. Public Health and Medical Preparedness. October 2007. http://www.dhs.gov/xabout/laws/gc_1219263961449.shtm#1. Accessed March 3, 2014.Google Scholar
4. FEMA 577, Design guide for improving hospital safety in earthquakes, floods, and high winds: providing protection to people and buildings. 2007. http://www.fema.gov/media-library/assets/documents/10672?id=2739 and www.fema.gov/.../20130726-1610-20490-3588/577_ch1.pdf Accessed January 18, 2014.Google Scholar
5. DeLia, D. Dwindling supply of empty beds: implications for hospital surge capacity. Health Affairs. 2008;27:1688-1694.CrossRefGoogle ScholarPubMed
6. Kelen, GD, McCarthy, ML. The science of surge. Acad Emerg Med. 2006;3:1089-1094.CrossRefGoogle Scholar
7. Kaji, AH, Koenig, KL, Lewis, RJ. Current hospital disaster preparedness. JAMA. 2007;298:2188-2190.CrossRefGoogle ScholarPubMed
8. Peleg, K, Kellermann, AL. Enhancing hospital surge capacity for mass casualty events. JAMA. 2009;302:565-567.CrossRefGoogle ScholarPubMed
9. Hick, JL, Hanfling, D, Burstein, JL, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med. 2004;44:253-261.Google ScholarPubMed
10. Hick, JL, Barbera, JA, Kelen, GD. Refining surge capacity: conventional, contingency, and crisis capacity. Disaster Med Public Health Prep. 2009;3:S59-S67.Google ScholarPubMed
11. Barbisch, DF, Koenig, KL. Understanding surge capacity: essential elements. Acad Emerg Med. 2006;13(11):1098-1102.CrossRefGoogle ScholarPubMed
12. Kaji, A, Koenig, KL, Bey, T. Surge capacity for health care systems: a conceptual freamework. Acad Emerg Med. 2006;13:1157-1159.CrossRefGoogle Scholar
13. Kelen, GD, Kraus, CK, McCarthy, ML, et al. Inpatient disposition classification for the creation of hospital surge capacity: a multiphase study. Lancet. 2006;368:1984-1990.Google ScholarPubMed
14. National Academies Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Emergency Care for Children: Growing Pains. National Academies Press, 2007. http://books.nap.edu/openbook.php?record_id=11655. Accessed March 3, 2014.Google Scholar
15. Allen, GM, Parrillo, SJ, Will, J, Mohr, JA. Principles of disaster planning for the pediatric population. Prehosp Disaster Med. 2007;22(6):537-540.CrossRefGoogle ScholarPubMed
16. National Commission on Children and Disasters. 2010 Report to the President and Congress. AHRQ Publication no. 10-M037. Rockville, MD: Agency for Healthcare Research and Quality; October 2010.Google Scholar
17. Antommaria, AHM, Powll, T, Miller, JE, Christian, MD; for the Task Force for Pediatric Emergency Mass Critical Care. Ethical issues in pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(Suppl):S163-S168.CrossRefGoogle ScholarPubMed
18. Kanter, RK, Moran, JR. Pediatric hospital and intensive care unit capacity in regional disasters: expanding capacity by altering standards of care. Pediatrics. 2007;119:94-100.CrossRefGoogle ScholarPubMed
19. Kanter, RK. Strategies to improve pediatric disaster surge response: potential mortality reduction and tradeoffs. Crit Care Med. 2007;35(12):2837-2842. PMID 17901842.CrossRefGoogle ScholarPubMed
20. Vetter, S, Dulaev, I, Mueller, M, et al. Impact of resilience enhancing programs on youth surviving the Beslan school siege. Child Adolesc Psychiatry Ment Health. 2010;22:4-11.Google Scholar
21. Dyb, G, Jensen, TK, Nygaard, E, et al. Post-traumatic stress reactions in survivors of the 2011 massacre of Utoya Island, Norway. Br J Psychiatry. 2014;204:361-367. 10.1192/bjp.bp.113.133157.CrossRefGoogle ScholarPubMed
22. Kelen, GD, McCarthy, ML, Kraus, CK, et al. Creation of surge capacity by early discharge of hospitalized patients at low risk for untoward events. Disaster Med Public Health Prep. 2009;3:S1-S7.CrossRefGoogle ScholarPubMed
23. The Joint Commission. Emergency Management. The Joint Commission edition. July 2012. http://www.uhnj.org/mdstfweb/The_Joint_Commission/Emergency%20Management.pdf. Last accessed March 3, 2014.Google Scholar
24. Kanter, RK, Andrake, JS, Boeing, NM, et al. Developing consensus on appropriate standards of disaster care for children. Disaster Med Public Health Prep. 2009;3(1):27-32. PMID 19293741.Google ScholarPubMed
25. Kraus, CK, Levy, FL, Kelen, GD. Lifeboat ethics: considerations in the discharge of inpatients for the creation of hospital surge capacity. Disaster Med Public Health Prep. 2007;1(1):51-56.CrossRefGoogle ScholarPubMed
26. Antommaria, AHM, Sweney, J, Poss, B. Critical appraisal of: triaging pediatric critical care resources during a pandemic: ethical and medical considerations. Pediatr Crit Care Med. 2010;11:396-400.CrossRefGoogle ScholarPubMed
27. Kissoon, N; for the Task Force for Pediatric Emergency Mass Critical Care. Deliberations and recommendations of pediatric emergency mass critical care task force: executive summary. Pediatr Crit Care Med. 2011;12(Suppl):S103-S108.CrossRefGoogle ScholarPubMed
28. Laupacis, A, Sekar, N, Stiell, IG. Clinical prediction rules: a review and suggested modifications of methodological standards. JAMA. 1997;277(6):488-494.CrossRefGoogle ScholarPubMed
29. Fine, MJ, Auble, TE, Yealy, DM, et al. A prediction rule to identify low risk patients with community-acquired pneumonia. N Engl J Med. 1997;336:243-250.Google ScholarPubMed
30. Apgar, V. A proposal for a new method of evaluation of the newborn infant. Current Res Anesth Analg. 1953;32:260-267.CrossRefGoogle ScholarPubMed
31. Nigrovic, LE, Kuppermann, N, Maciac, CG, et al. Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis. JAMA. 2007;297:52-60.CrossRefGoogle ScholarPubMed
32. Pollac, MM, Ruttimann, UE, Getson, PR. Pediatric risk of mortality (PRISM) score. Crit Care Med. 1988;16:1110-1116.CrossRefGoogle Scholar
33. Westley, CR, Cotton, EK, Brooks, JG. Nebulized racemic epinephrine by IPPB for the treatment of croup. Am J Dis Child. 1978;132:484-487.Google ScholarPubMed
34. Maguire, JL, Kulik, DM, Laupacis, A, et al. Clinical Prediction Rules for children: a systematic review. Pediatrics. 2001;128:e666. http://pediatrics.aappublications.org/content/128/3/e666.full.pdf. Accessed January 10, 2014.CrossRefGoogle Scholar
35. Joint Commission on Accreditation of Healthcare Organizations. Health care at the crossroads: strategies for creating and sustaining community-wide emergency preparedness systems. http://www.jointcommission.org/assets/1/18/emergency_preparedness.pdf. Accessed January 10, 2014.Google Scholar
36. ACEP Policy Statement. Health care system surge capacity recognition, preparedness, and response. Ann Emerg Med. 2005;45:239.CrossRefGoogle Scholar
37. Soremukun, OA, Zane, RD, Walls, A, et al. Cancellation of scheduled procedures as a mechanism to generate hospital bed surge capacity—A pilot study. Prehosp Disaster Med. 2011;26(3):224-229.CrossRefGoogle Scholar
38. Antommaria, AH, Powel, T, Miller, JE, Christian, MD; Task Force for Pediatric Emergency Mass Critical Care. Ethical issues in pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12:S163-S168. doi: 0.1097/PCC.0b013e318234a88b.Google ScholarPubMed
39. Satterthwaite, PS, Atkinson, CJ. Using ‘reverse triage’ to create hospital surge capacity: Royal Darwin hospital’s response to the Ashmore Reef disaster. Emerg Med J. 2012;29:160-162.CrossRefGoogle Scholar
40. Moskop, JC, Sklar, DP, Geiderman, JM, et al. Emergency department crowding, Part 2—Barriers to reform and strategies to overcome them. Ann Emerg Med. 2009;612-617.CrossRefGoogle Scholar
41. Van Cleve, WC, Hagan, P, Lozano, P, Mangione-Smith, R. Investigating a pediatric hospital’s response to an inpatient census surge during the 2009 H1N1 influenza pandemic. Jt Comm J Qual Saf. 2011;37:376-382.Google Scholar
42. Christian, MD, Joynt, GM, Colvn, J, et al. Critical care triage In Sprung CL, Cohen R, Adini B, eds. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Intensive Care Med. 2010;36:S55-S64.CrossRefGoogle ScholarPubMed
43. Sprung, CL, Danis, M, Iapichino, G, et al. Triage of intensive care patients: identifying agreement and controversy. Intensive Care Med. 2013;39(11):1916-1924.CrossRefGoogle ScholarPubMed
44. Ranse, J, Zeitz, K. Disaster triage. In: Powers R, Daily E, eds. International Disaster Nursing. New York, NY: Cambridge University Press; 2010.Google Scholar
45. Griffiths, JL, Estipona, A, Waterson, JA. A framework for physician activity during disasters and surge events. Am J Disaster Med. 2011;6:39-46.CrossRefGoogle ScholarPubMed
46. Timbie, JW, Ringel, JS, Fox, DS, et al. Evidence Report/Technology Assessment, Number 207. Allocation of scarce resources during mass casualty events. AHRQ publication no. 12-E006-EF. Rockville, MD: Agency for Healthcare Research and Quality; 2012. http://www.phe.gov/coi/Documents/Allocation%20of%20Scarce%20Resources%20During%20Mass%20Casualty%20Events.pdf. Accessed January 10, 2014.Google Scholar
47. Pandemic Influenza: Surge Capacity and Prioritisation [sic] in health services. Part 12. Admission to, utilization of and discharge from services. The Scottish Government Publications October 2008. http://spoxy5.insipio.com/generator/sc/www.scotland.gov.uk/Publications/2008/10/28141252/12. Last accessed January 10, 2014.Google Scholar
48. Davis, DP, Poste, JC, Hicks, T, et al. Hospital bed surge capacity in the event of a mass-casualty incident. Prehosp Disaster Med. 2005;20:169-176.CrossRefGoogle ScholarPubMed
49. Challen, K, Walter, D. Accelerated discharge of patients in the event of a major incident: observational study of a teaching hospital. BMC Public Health. 2006;6:108.CrossRefGoogle Scholar
50. Clattenburg, E, Sauer, L, Kelen, G. Reverse triage in pediatrics. A new method to increase in-hospital surge capacity. Acad Emerg Med. 2013;20:S59-S60.Google Scholar
51. Health Systems Research, Inc. Altered Standards of Care in Mass Casualty Events. Rockville, MD: Agency for Healthcare Research and Quality; 2005. AHRQ publication 05– 0043.Google Scholar