1 CONFIDENTIAL – Please do not disseminate ...

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1 CONFIDENTIAL – Please do not disseminate ... - Cloudinary

January 2021. Mission: To manage the allocation of scarce resources to maximize survival for the overall patient population and to minimize ...

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stanford-iccp-20210106

Interim Crisis Care Plan January 2021
Mission: To manage the allocation of scarce resources to maximize survival for the overall patient population and to minimize the adverse outcomes that might occur as a result of changes in usual practice with the ethical tenets of fairness, equity, transparency, proportionality, and accountability.
OBJECTIVES Identify indicators and triggers for the progression to Crisis Care and recovery Create an ethically sound process for the allocation of critically limited resources Outline staffing models during Crisis Care and provisions for emergency privileging of
independently licensed practitioners Assess and re-assess the impact of the incident and resources required to respond to the
incident CRISIS CARE PLAN AUTHORITY 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. When the Crisis Care Plan 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 1). The local authority to activate the Crisis Care Plan will rest with the Hospital Command Center's Incident Commander in consultation with the Chief Medical Officer and input from Hospital Leaders. CRISIS CARE PLAN PRE-REQUISITES AND TRIGGERS The following is a partial list of potential triggers that may require activation of the Crisis Care Plan:
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
Lack of critical infrastructure Lack of security to maintain the safety of healthcare providers and patients Lack of personal protective equipment Loss of power Lack of trained staff Inadequate staff support (food, housing, water, etc.) Lack of specialty care such as burn care resources Indicators and triggers for Crisis Care will be continually monitored to determine the need for continued altered care and rationing of critically limited resources. The Crisis Care Pre-Implementation Checklist released by the California Hospital Association can be referenced in Appendix 2.
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Prior to implementing the Crisis Care Plan, 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 including but not limited to health system resources (see Surge Plan Incident Response Guide > Transfer Center Mutual Aid Process), healthcare coalition partners, the County partners including the Public Health Department, Emergency Medical Services, and the Medical Health Operational Area Coordinator (MHOAC); regional partners, and state resources. When demands exceed state capacity and resources, the state will coordinate with the federal government for resources and assistance.
Implementation of crisis care, including triage of critical care resources, requires immediate notification to: The local public health department (including local health officer and Medical Health Operational Area Coordinator), AND The local CDPH district office via email and phone call to ensure the State is aware of conditions at the facility.
STRATEGIES TO PREVENT CRISIS CARE The Crisis Care Plan is an extension of the Hospital Surge Incident Response Guide.
Core strategies to mitigate Crisis Care as delineated by CDPH Guidelines are listed below: Prepare: pre-event actions taken to minimize resource scarcity (e.g. stockpiling of personal protective equipment (PPE), medications or supplies, planning, training). Substitute: use an equivalent device, drug, or personnel for one that would usually be available (e.g. exchanging morphine for fentanyl). Adapt: use a device, drug, or personnel that are not equivalent but that will provide sufficient care (e.g. anesthesia machine for mechanical ventilation; licensed practical nurse (LPN) with registered nurse (RN) supervision instead of multiple RNs); explore alternatives to single-use invasive ventilation by gathering data on the utility and safety of non-invasive ventilation and to investigate the efficacy and safety of splitting ventilators) Conserve: use less of a resource by lowering dosage or changing utilization practices (e.g. minimizing use of oxygen driven nebulizers to conserve oxygen). Re-use: re-use (after appropriate disinfection/sterilization) items that would normally be single-use items. Re-allocate: restrict or prioritize use of resources to those patients who are likely to benefit and survive in the immediate short-term or to those with greater need only in times of actual shortage.
CRISIS CARE CROSS-CUTTING STRATEGIES 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.
Determining who receives the use of a limited supply of ventilators or other critical care modalities.
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Creating alternate care sites from areas never designed to provide medical care, such as the hospital cafeterias, radiology suites, hospital corridors, in 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 care can still 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 (See Appendix 3). Credentialing of providers may be granted on an emergency or temporary basis (See Appendix 4). Additional strategies can be found in Appendix 14.
ETHICAL CONSIDERATIONS DURING CRISIS CARE Ethical considerations of Crisis Care are highlighted here for full transparency of the Key Points taken from the SARS-CoV-2 Crisis Care Guidelines by the California Public Department of Health (CDPH). While these guidelines were created specifically in the setting of a pandemic, the tenets of these guidelines are applicable to other crises. These Key Points guide the difficult decisions required with scarce resource allocation:
Crisis care is not a separate triage plan. These strategies are extensions of surge-capacity plans.
Crisis care may occur during long-term events such as pandemics when resource constraints are likely to persist for long periods of time, or during short- term, no-notice events where help will arrive, but too late to solve an acute resource shortfall.
Healthcare facilities will not have an option to defer caring for patients in a crisis. Demand, guided by ethics, will drive the choices that have to be made.
Healthcare decisions, including allocation of scarce resources, cannot be based on age, race, disability (including weight-related disabilities and chronic medical conditions), gender, sexual orientation, gender identity, ethnicity (including national origin and language spoken), ability to pay, weight/size, socioeconomic status, insurance status, perceived self-worth, perceived quality of life, immigration status, incarceration status, homelessness, or past or future use of resources.
If strategies are not planned for ahead of time, they might not be considered and/or will be difficult to implement.
Strategies should be proportional to the resources available. As more resources arrive, response will return to strategies that are less demand driven (and therefore, back toward contingency and eventually conventional status)
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The Crisis Care Plan is designed to produce the best possible 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. A public health emergency compels transition from individual patient-focused clinical care to a population-oriented public health approach with the goal of providing the best possible outcome for the largest number of impacted people.
Any crisis planning framework should be designed to achieve the following: 1. To create meaningful access for all patients. For example, all patients who are eligible for ICU services during ordinary circumstances remain eligible, and there are no exclusion criteria based on age, disabilities, or other factors, including those listed in Key Points. 2. To ensure that all patients receive individualized assessments by clinicians, based on the best available objective medical evidence. 3. To ensure that no one is denied care based on stereotypes, assessments of quality of life, or judgments about a person's "worth" based on the presence or absence of disabilities or other factors, including those listed in Key Points. 4. To diminish the impact of social inequalities that negatively impact patients' long- term life expectancy by keeping in mind historic disparities and inequalities.
In general, triage decisions must meet the five basic requirements outlined in the IOM/NAM 2012 publication:
Fairness and Equity: process recognized as fair, equitable, evidence based, and responsive to specific needs of individuals and the population focused on a duty of compassion and care, a duty to steward resources, a duty to abide by nondiscrimination laws, and a goal of maintaining the trust of patients and the community.
Transparency: in design and decision-making. Consistency: in application across populations and among individuals with reasonable
modifications for disability. Proportionality: public and individual requirements must be commensurate with the
scale of the emergency and degree of scarce resources (i.e. the restrictions on care should not be more restrictive than the situation requires and this may require reevaluation as more resources become available). Accountability: individuals making the decisions and the facilities and governments to support the processes and the providers.
Additional ethical principles regarding triage of patients and allocation of resources include the following tenets:
1. Duty to implement distributive justice (socially just allocation of goods) 2. Duty to care: treat people with dignity and respect, and make decisions based on an
individualized assessment based on objective medical evidence 3. Duty to plan: steward resources and promote instrumental value 4. Duty to transparency (in planning and implementation) 5. Duty to implement distributive justice (socially just allocation of goods)
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Ethical principles as applied to triage raise considerations of moral equality. Triage must respect equality and human dignity in the following ways, among others:
Protection and Provision for Vulnerable Populations: Health systems should take deliberate, active steps to ensure that vulnerable or marginalized populations receive equal access to scarce resources. These should include, among other things; (1) reaching out to organizations and services designed to serve groups with special needs or groups that are particularly vulnerable or disadvantaged; (2) ensuring access for those with disabilities, limited English proficiency (LEP), and other groups with functional needs; (3) mitigating or eliminating, as far as possible, the sense of distrust that some historically or currently disadvantaged people might feel towards the medical system in general or a triage system in particular; and (4) being prepared to participate in regional or statewide plans designed to ensure that the same resources are available and in use at similarly situated facilities a step that helps mitigate or eliminate disparities of access and distribution among facilities.
Disability and Return to Previous State of Health: Some triage protocols make allocation decisions based not only on overall predicted acute-episode survival but also on quality of life after treatment. Such protocols are sometimes viewed with suspicion by individuals with disabilities who fear that they are seen as having lower quality of life than non-disabled individual and, therefore, that they may be assigned lower triage priority in virtue of their disabilities. To ensure non-discrimination against individuals with disabilities, triage protocols must either not score individuals based on their quality of life after treatment or assess at most how far treatment will return the patient to their own baseline quality of life. Decisions cannot be based on generalized assumptions about a person's disability. The mere fact that a person has diabetes, depression, an intellectual disability, or a mobility impairment, for example, cannot be a basis for denying care or making that person a lower priority to receive treatment. Treatment allocation decisions cannot be made based on misguided assumptions that people with disabilities experience a lower quality of life or that their lives are not worth living.
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CRISIS CARE CONTINUUM The Crisis Care Continuum is a framework to describe changes to patient care during a disaster or crisis. As demand for resources increases, increased resource utilization will result in scarcity. This imbalance necessitates a change in daily practice and normal standards which increases patient risk of morbidity and mortality. Care along this continuum shows a progression from conventional care to contingency care to crisis care and back again (see Fig 1 below).
https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-91.aspx
Conventional 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." The usual resources and level of care are provided to all patients. During a surge in patients where resources are not strained, maximizing bed occupancy and calling in additional staff to assist makes it possible to allocate of all appropriate health and medical resources to improve the health status and/or save the life of each individual patient. However, should a crisis 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. Contingency Care
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Contingency care is defined as functionally equivalent patient care that differs from daily practice and may incur a small risk to patients. The use of spaces, staff, and supplies may be allocated differently from every day operational practices with the maintenance of care standards. For example, boarding critical care patients in post-anesthesia care areas using less traditional, but appropriate resources.
Crisis Care
The term "Crisis Standards of Care" or "Crisis Care" assumes 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. This occurs when demand forces choices that pose a significant risk to patients but is the best that can be offered under the circumstances. For example, cot-based care, severe staffing restrictions, or restrictions on use of certain medications or other resources. ALLOCATION OF CRITICALLY RESOURCED CARE Critically resourced care will be rationed only after all efforts at augmentation have been
completely exhausted. Limitations on critically resourced care will be proportional to the actual shortfall in
resources. Rationing of critically limited resources 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. Pregnant patients who are eligible for critically resourced care will be triaged to high priority as currently available triage tools do not account for normal physiology of pregnancy. Patients not eligible for critically resourced care will continue to receive supportive medical or comfort care. CDPH provides this basic triage algorithm:
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CRISIS CARE TRIAGE OFFICERS AND TEAM Creation of Crisis Care Triage Teams (CCTT) In anticipation of the Crisis Care Plan activation, the Chief Medical Officer or designee with input from Hospital Leaders will appoint a group of Crisis Care Triage Officers (CCTOs) and Crisis Care Triage Team (CCTT) Members. This appointment should precede the activation of the Crisis Care Plan to ensure adequate training for the consistent application of the Crisis Care Framework to triage decisions. The CCTO and Crisis Care Triage Team is charged with using the allocation framework detailed in this Plan: 1. Determining priority scores of all patients eligible to receive the critically limited resource. 2. Deciding on the allocation of the scarce resource. For patients already being supported by
the scarce resource, the evaluation should include reassessment to evaluate for clinical improvement or worsening at pre- specified intervals, as detailed in this Plan. 3. Documenting all scoring and decisions.
At the discretion of the Chief Medical Officer, an oversight subcommittee to retrospectively review the decisions of the Critical Care Triage Officers may be convened for the purposes of quality improvement.
Crisis Care Triage Team Training and Preparation CCTO and members of the CCTT will receive advanced training to prepare them for the role, including the following:
1. Application of the allocation framework 2. Communication with clinicians and families about triage and triage decisions 3. Avoidance of implicit and explicit bias, including with regard to age, disability, sex,
gender identity, sexual orientation, immigration status, or other factors, including those listed in Key Points. 4. Respect for the rights of all individuals, including those with disabilities 5. Diminishing the impact of social inequalities on health outcomes
Outside of crisis, the CCTT will regularly review training as above and exercise the tenets of this document to ensure consistent application of this framework and quality improvement.
Crisis Care Triage Officer (CCTO) When the Crisis Care Plan is activated, the CCTO will report directly to the Hospital Command Center's Incident Commander as a Medical Technical Specialist. The CCTO oversees the triage process, assesses all patients, assigns a level of priority for each, communicates with treating physicians, and directs attention to the highest-priority patients. They are expected to make decisions according to the allocation framework described in this Plan, which is designed to benefit populations of patients, even though these decisions may not necessarily be best for some individual patients.
The CCTO has the authority and responsibility to apply the principles and processes of this document to make decisions about which patients should receive the highest priority for receiving critically resourced care. The CCTO is also empowered to make decisions regarding
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reallocation of critically limited resources that have previously been allocated to patients, again using the principles and processes in this document. In making these decisions, underlying health conditions should not form the basis of the determination regarding the immediate or long-term survivability of the patient.
The CCTO will not participate in direct patient care to enhance objectivity, avoid conflicts of commitments, and minimize psychological moral distress. 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 duties are delineated below:
Review available resources at the beginning of each shift with the Operations Section Chief and when there are any significant changes in resource availability.
Evaluate all patients requiring critically resourced care daily. Calculate triage score for all eligible patients (see Appendix 5 for Adult Triage Tool and
Appendix 6 for Pediatric Triage Tool). These triage tools are not applicable to pregnant patients, who will receive high priority for scarce resources. Apply the framework in this document to prioritize patients for the allocation of critically resourced care, including patients who were not allocated that care previously based on their score. Communicate decisions made to the patient's attending physician. Coordinate with the patient's attending physician and team regarding disclosure of the triage decision to the patient/surrogate. Coordinate with the Palliative Care Unit Leader about the identification and provision of comfort care for patients who will not receive critically resourced care. Ensure the documentation of all patient evaluations and decisions. Consult Ethics for any triage decision appeals (see below). Hand off to oncoming CCTO at the end of your shift.
Crisis Care Triage Team The CCTO will work closely with a Crisis Care Triage Team (CCTT). The Crisis Care Triage Team includes a nurse with experience in acute care services, even if not currently clinically active, and administrative staff. The CCTT may require additional administrative or informatics support needed to facilitate the responsibility of the CCTO and the Crisis Care Team to gather, document, and communicate decisions.
Staffing and Shift Duration A group of CCTOs and team members will be appointed. The triage officers and team members will function in shifts lasting no longer than 13 hours (to enable 30 minutes of overlap and handoffs on each end). Therefore, there should be at least two shifts per day to fully staff the triage function. Team decisions and supporting documentation will be reported daily to appropriate hospital leadership and the Incident Commander in the Hospital Command Center.
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CRISIS CARE TRIAGE APPEALS Triage Review Committee The independent Triage Review Committee will adjudicate appeals to individual triage decisions in a timely fashion. This committee will be made up of at least three individuals who are not members of the care team, recruited from the following groups or offices:
- Chief Medical Officer or designee - Chief Nursing Officer or designee - Legal Counsel - Hospital Ethics Committee or Consult Service - Off-duty triage officer - Lay community member (representation consistent with the patient population being served)
Three committee members, including one physician and one non-physician, are needed for a quorum to render a decision, using a simple majority vote. The process can happen by telephone/virtually or in person, and the outcome will be promptly communicated to whoever brought the appeal.
Crisis Care Triage Appeals Process - Once the triage decision has been communicated with the patient/surrogate, the patient/surrogate has the right to appeal the decision. - If the patient/surrogate appeals the decision, an Ethics Consultation is placed by the CCTO: o Stanford Health Care: pager #16230 o Stanford Health Care ValleyCare: 816-214-2529 (Maureen Dudgeon) o Stanford Children's Health: pager #18537 - The Ethics Consultant will convene the Triage Review Committee - The Triage Review Committee will recalculate the triage score to ensure that the framework has been appropriately applied and assessed for discrimination. - The Triage Review Committee will communicate the decision back to the CCTO. - All reviews will be documented and maintained by the CCTT. - Triage Review Committee decisions are final.
PALLIATIVE CARE DURING CRISIS CARE 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; nor does it "hasten death," recognizing that initial prognostication may change if additional resources become available or if the situation deteriorates.
Palliative Care During Disaster Priority access to scarce resources, including skilled personnel resources, may be applied or moved based on triage. Thus, services to those expected to die soon will fall more heavily on people who do
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not have medical training for high clinical acuity.
A disaster 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 (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 event 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" comfort care population (e.g., those already enrolled in hospice or receiving comfort 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 supportive or palliative care as a result of their illness/injury or as a result of scarce resources.
Those who are not expected to survive cannot be 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 care for all affected by such disasters.
As conventional care progresses to crisis care, the demand for palliative care will increase dramatically. Palliative or comfort care plays an important role by addressing symptom management as well as emotional and spiritual support for patients and families.
Identification and Management of Comfort Care Patients Patients will be deemed likely to die during disaster and therefore will be triaged not to receive (or not to continue to receive) life-supporting treatment. For these patients, death will be expected within a short period:
1) Patients exposed to the event that are not expected to survive a. Via triage at initial admission. b. Via triage during their hospital course.
2) Patients who are already receiving comfort care or hospice care. Prognostication/triage may change if resources become more available or if the situation worsens and resources become even scarcer.
Comfort 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 AHRQ community planning guide, 50 comfort care patients would be cared for by one physician, one advanced practice provider, 6 nurses (RN/LVNs), one social worker, one chaplain, and 4 volunteers. In the event of a pandemic, team members may be limited to backup staffing from the palliative care departments.
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If travel is possible in the disaster, then the recruitment of community-based providers (if available) would free up other clinicians for higher acuity patients. A possible pool for comfort care staffing (a palliative care response team) would include:
1) Community Hospice Agency Staff-nurses, nurse's aides, hospice medical directors, chaplains, volunteers
2) Skilled Nursing Facility (SNF) and Home Care Agency Staff-nurses, medical assistants, geriatricians
3) Volunteers from faith-based organizations, such as churches and synagogues 4) Mental health providers 5) Medical Reserve Corp and Community Emergency Response Teams (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
Integration of Community-Based Health Care Organizations and Other 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. Healthcare 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 an MCE could 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.
We may request support from the Medical Reserve Corp of their County and the Community Emergency Response Teams (CERT) for deployment depending on the nature and scope of an incident. We will also consider extending the credentialing of palliative care disaster volunteers into the existing disaster response Federal/State and local legal/insurance systems in order to expand community capacity through such mechanisms as the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) and Disaster Medical Assistance Teams (DMAT). These rapid response teams would supplement, not replace, palliative care services.
Training Education and training will be competency based, with programming specific to the individual's role in emergency response. Just-in-time training will be provided to educate the caregivers with regard to the care for the dying patient and allow access to specific palliative medical supplies. There is high
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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.
PALLIATIVE CARE DISASTER TEAM Palliative Care Unit Leader A Palliative Care Unit Leader will be appointed by the Operations Section Chief with the primary responsibility of overseeing the provision of palliative care during a crisis such as mass casualty incident or pandemic. This includes but is not limited to the direction of treatment for patients designated to receive supportive or comfort care by the CCTO, creation of Palliative Care Disaster Team or "rapid response" teams, deployment of just-in-time training for the provision of comfort care, and consideration of the creation of a Palliative Care primary service.
Ensure provision of palliative care and bereavement services for patients and families. Coordinate with CCTO and Crisis Care Triage Team to identify and treat patients designated to
receive comfort care. Ensure provision of just-in-time training for the provision of palliative care as described above
(see Appendix 7 and Appendix 8). Facilitate discharge to hospice, whether home or another facility, as indicated. Deploy Palliative Care Surge Plan (see Appendix 9 for Palliative Care Surge Plan) as needed Consider the creation of a Palliative Care Primary Service to deliver care to patients receiving
comfort care and support for their families. o Consider Comfort Care Staffing Model as discussed above o Consider co-location vs scatter-bed of comfort care patients
Collaborate with County Public Health Department and local community leaders to provide staff for "rapid response" teams (CERT, MRC, ESAR-VHP, etc) for palliative care delivery in the hospital, if able.
Identify and request Alternative Care Sites (see Emerging Infectious Disease and Surge Incident Response Guides) for use by comfort care patients for the delivery of care, as needed
Coordinate with Pharmacy for the provision of Palliative Care Medication Packs (see Appendix 10 and Appendix 11) for delivery of care in an Alternative Care Site
Serve as a subject matter expert regarding palliative care guidelines and protocols with local and regional first responder and disaster response personnel (e.g. EMS, Fire, Police, public health, community health clinics, local and regional governmental entities).
Implement Comfort Care Order Sets (Appendix 12-15). Provide triage training for leaders of Skilled Nursing Facilities to identify patients who should
and should not be transferred to the hospital. Coordinate with the Clinical Ethics Service and hospital support systems to establish ethical
and psychological support for frontline responders, patients, and their families. If activated, coordinate with the following Hospital Incident Management Team (HIMT) positions:
o Patient Family Assistance Branch Director under Operations Section Chief Social Services Unit Leader
o Support Branch Director Under Logistics Section Chief Employee Health and Well-being Unit Leader
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HOSPITAL COMMAND CENTER ACTIVITIES
INCIDENT COMMANDER: Review and revise incident objectives as necessary and conduct briefings with Hospital Incident
Management Team. Ensure all staff have been notified of the situation, response objectives, and critical information.
Consider using all relevant communications methods (huddles, email, emergency alert system, Voalte, disaster hotline). Consider response of Health System to support the incident objectives. Consider designating multiple Medical Technical Specialists as the incident dictates. Make requests to University and other partners as needed to support hospital operations. Begin to plan staffing and response for 12-24 hour period.
LIAISON OFFICER: Update respective county polling system (e.g., HavBed) after patients have been rapidly
discharged and admitted. Monitor county situational awareness and/or incident management tools (Santa Clara County:
EMSystem and WebEOC; San Mateo County and Alameda County: Reddinet) for incident information. Provide regular updates. Submit resource requests to appropriate jurisdictions: o For Palo Alto this may include: City of Palo Alto Emergency Operations Center (EOC) (non-
medical), buddy hospital (El Camino Hospital), and/or the Medical Health Operational Area Coordinator (MHOAC) or Medical / Health Branch of the Santa Clara County Emergency Operations Center (medical) o For Stanford Health Care ValleyCare, this will include the Alameda County EOC or MHOAC Support the Logistics Section with Disaster Cache supplies as needed.
PUBLIC INFORMATION OFFICER: Assist in the composition of messaging to regularly communicate with staff. Monitor social media for incident information, rumors, and hospital involvement. Set up media staging area (in Palo Alto: Buckey Ball, LPCH Main, or Kaplan Lawn; for SHC-VC: area
outside the cafeteria) and direct all media to one location. Work with Incident Commander to develop media briefings. Communicate with Communications partners at University and School of Medicine to ensure
aligned messaging if either organization is also messaging their constituents about the incident. Update intranet and/or external website banners and content as incident progresses.
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SAFETY OFFICER: Evaluate safety of patients, family, staff, and facility and recommend protective and
corrective actions to minimize hazards and risks. Complete HICS 215a Incident Action Plan Safety Analysis form. Round in affected areas to ensure safety of response, especially in alternate care areas. Consider using Environmental Health & Safety team of Safety Officers. Evaluate safety of Alternate Care Sites if used.
SECURITY OFFICER: Consider limiting points of access into hospitals, both roadways and entrances. Coordinate
changes to traffic flows and/or use of parking structures with the Transportation Services team. Plan staffing and reposition officers as necessary. Display hospital security cameras in Hospital Command Center, as appropriate, for situational awareness. Maintain heightened presence in ED, Critical Care Units, and media staging area. Monitor the hospital for unauthorized media. Consider diverting Marguerite shuttles and other traffic from critical access points. Evaluate need for police response and contracted additional security.
MEDICAL TECHNICAL SPECIALIST (MTS): Advise Incident Commander on response to Crisis Care. In Crisis Care, you may need multiple
MTS subject matter experts (SMEs) to fill this role, one of which will be the CCTO. Consider the following SMEs:
o Medical Ethicist o Risk Management o Legal Affairs o Hospital/Clinic Administrator(s) o Physician Leader(s) o Other based on the nature of the underlying incident CCTO will make decisions on the allocation of scarce resources as described above. Facilitate escalations from clinical providers in patient care areas. Consult with Trauma Service and Perioperative regions on their response, if relevant. Consider sending cases to alternate OR areas such as the Ambulatory Surgery Center (875 Blake Wilbur), Redwood City Outpatient Center (450 Broadway), for SHC-VC: 1119 East Stanley Blvd Ambulatory Surgical Center, or affiliated institutions, if relevant to the incident. Ensure all clinical providers are being communicated with regularly.
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PLANNING: Establish operational periods, incident objectives and develop the Incident Action Plan, in
collaboration with the Incident Commander. Identify triggers for return to Contingency Care and then to Conventional Care Monitor indicators and triggers for changes in the Crisis Care Continuum Appoint Documentation Unit Leader and Situation Status Unit Leader as needed. Report on unit status, census projections, staffing issues, resource issues Work with Operations Section to project needs of the incident and provide to Logistics. Document all activities, ensure Incident Management Team is using HICS 214. Activity Log
forms. Assist in developing response strategy for next 12-24 hours / operational period(s). LOGISTICS: Establish a Logistics Coordination Center. Supply Chain will establish sources of medical supplies needed during the event. Sources
shall include normal suppliers, memorandum of understanding (MOUs) with other agencies, and requests for assistance from government agencies including County, State, or Federal (including the Strategic National Stockpile).
o The Liaison Officer / OEM can assist with MOUs and outside agencies and will facilitate the resource request process(es) of the pertinent county Emergency Operations Center / the Medical Health Operational Area Coordinator (MHOAC) and/or non-medical supplies from respective city entities (e.g., City of Palo Alto) and/or Stanford University.
Food Services will establish menu to meet the needs of patients and staff. Food sales to non-hospital staff shall be discontinued if food supplies become limited. Clinical Engineering will gather additional medical equipment relevant to the emergency. Planning, Design and Construction will assist in redesigning and construction of temporary
patient care facilities as needed and requested by Hospital Administration. Establish Labor Pool if directed by Incident Commander. FINANCE: Activate disaster activity code and work with the Public Information Officer /
Communications team to ensure managers receive associated information on how and when to use it to track response expenses. Ensure all managers are tracking employee time. Work with PIOs to disseminate instructions. Use templates in Finance Binder/Box file for messages.
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OPERATIONS CHIEFS: Communicate regularly with the CCTO regarding the availability of resources which require
allocation. Evaluate bed status of hospital and ensure resources are being used most efficiently and
effectively to manage the incident. Implement Crisis Care cross-cutting strategies as dictated by the incident, including adjusting
staffing ratios, in alignment with Incident Objectives Consider the present or future needs to increase bed space within units and/or need to activate
Alternate Care Areas. Request status updates from units regularly, such as through the Administrative Nursing
Supervisor (ANS). Coordinate with Logistics regarding resource availability for patient care. Communicate regularly with support services Pharmacy, Radiology, Labs, RCS, Guest Services,
etc. Delegate supply requests to Logistics Section Chief. SHC and LPCH units can call the Facilities
Services Response Center (FSRC 650-498-4400) with requests. SHC-VC units should call 925373-8004 with their requests. Establish oversight with units through the designated Unit Leaders (person in charge of unit -can be Resource Nurse, Manager, Assistant Patient Care Manager) and communicate with them regularly. Conduct huddles and/or bed meetings with Unit Leaders if needed. Instruct units to use Disaster Plans, Status Report Forms and Job Action Sheets appropriate.
INPATIENT BRANCH DIRECTORS: Responsible for inpatient nursing units at the direction of the Operations Section Chief.
(Perioperative and Emergency Department have their own Branch Directors.) Ensure that every inpatient unit is following the objectives of the Hospital Command Center. Work with the ANS to communicate with Units and escalate and resolve issues. Project needs, bed status, and staffing with the Planning Section. Request equipment and supplies through the Logistics Section.
AMBULATORY BRANCH DIRECTORS: Clinics can provide any needed and available services as requested by the Incident Commander
or Nursing Administration. Anticipate issues with continuing service during incident. Consider supplies, staff,
transportation. Communicate with staff at various sites through the clinic manager and service line. In catastrophic incidents, clinics should anticipate operating as "walking wounded" treatment
areas for patients who are not seriously injured and who could be treated in an outpatient environment. Consider clinic operations and ensure that they align with incident objectives. Clinics may be requested to transfer personnel, equipment and supplies to another department in response to the emergency. All transferred personnel, equipment and supplies should be documented prior to transfer.
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ACCREDITATION, REGULATORY, AND LICENSING Per CDPH: In the event an emergency or disaster-related occurrence impacts your facility and results in an evacuation, transfer, or discharge of patients, you must contact your local Licensing & Certification District Office. Please follow these guidelines for reporting such occurrences:
Contact the local L&C district office you customarily work with for your geographic location: o The medical center in Palo Alto reports to the San Jose District Office: 408-277-1784 o The medical center in Pleasanton reports to the East Bay District Office: 510-620-3900
For after-hours contact the State Office of Emergency Services Warning Center at 916-845-8911 and ask that they notify the CDPH Duty Officer. APPENDICIES: Appendix 1. Laws and Regulations Appendix 2. Crisis Care Pre-Implementation Checklist Appendix 3. Crisis Care Staffing Model Appendix 4. Granting Disaster Privileges to Volunteer Independently Licensed Practitioners Appendix 5. Adult Triage Tool Appendix 6. Pediatric Triage Tool Appendix 7. Adult Palliative Care COVID Pocket Card Appendix 8. Palliative Care Communication Card Appendix 9. Palliative Care Surge Plan Appendix 10. Adult Palliative Care Medication Pack Appendix 11. Pediatric Palliative Care Medication Pack Appendix 12. Adult Palliative Care Order Set Appendix 13. Pediatric Crisis Comfort Care Order Set Appendix 14. Patient Care Strategies for Scarce Resource Situations Appendix 15. Author Credits, Approvals, and Additional References For comprehensive, explanatory guidance regarding Crisis Care, please refer to the CDPH SARSCoV-2 Crisis Care Guidelines.
Refer to the Institute of Medicine's Crisis Standards of Care: A Systems Framework for Castastrophic Disaster Response for additional information.
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Appendix 1. 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. CA Health and Safety Code 1799.102 (Good Samaritan Law) 5. Work hour restrictions 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 11. California Hospital Association - Emergency Preparedness summary of potentially applicable laws: "What
liability protections exist for hospitals and other healthcare providers during a disaster" 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 an additional framework to support immunity to health care providers from civil liability pursuant to various statutes as noted by CA law.
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.
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Appendix 2. Crisis Care Pre-Implementation Checklist
The purpose of this checklist is to ensure the facility has gone through all possible contingency planning before enacting crisis care guidelines.
If applicable, has the facility implemented some or all of their surge strategies to include consideration of allocation of scarce resources in the following buckets? PPE, Supplies, and Equipment:
Have you confirmed the numbers of ventilators for patient care that are available meet the needs of available ICU licensed, surge, and ED overflow space?
Exhausted all contract options? Submitted resource request through the MHOAC up to the state for resupply? Implemented re-use and extended use practices, as necessary? Staff: Have you applied for ICU staffing waivers, and exhausted all efforts to augment critical care
staffing? Have you defined a process to extend critical care staffing by using noncritical care staff (nursing
teams, non-critical care physicians assigned to ICU spaces (Cardiology, Anesthesia, Emergency)? Procure contract and registry staff? Submit staffing waiver(s)? Adoption of other staffing models? Isolation and quarantine guidelines for infected or exposed staff, including CDC and CDPH
strategies to maintain staffing during times of staffing shortages? Space (Internal and External):
Have you defined the maximal expansion of surge ICU spaces (PACU, Telemetry, other surge ICU spaces)?
Activated traditional internal and external surge space? Repurpose non-patient care spaces as necessary for decompression, both internally and
externally? Operations:
Have you identified the triage teams that will over-see and review the allocation of critical care resources (critical care space, utilization of noncritical care staffing, ventilators, therapeutics which demonstrate a survival benefit)?
Attempt to transfer as many patients as possible for decompression? Have you defined indicators and triggers for the different levels of surge response in your
emergency operations plan (EOP)? Have you defined and implemented staff engagement and training to include COVID-19
pandemic knowledge, competency and proficiency appropriate to the level of the staffing positions? Has the facility established recurring communication, and resource request processes for support from the following:
o Health system network partners o Local Healthcare Coalition partners o Local Public Health o Local MHOA
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Appendix 3. Crisis 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. Crit Care Med 2005; :10 (Suppl). An expanded role for students and trainees should be considered in this model and will need to be further elucidated.
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Appendix 4. Granting of Disaster Privileges to Volunteer Independently Licensed 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, Chief Medical Officer or their designee(s), may grant disaster privileges on a case-bycase 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:
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.
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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 himor 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. 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.
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Appendix 5. Adult Triage Tool
ADULT CRISIS TRIAGE TOOL: COVID-19 PANDEMIC

Pt initials / MRN ____/____

Date form completed ____/____/____

1) Inclusion Criteria: Patient must be age 18 years or older, not pregnant, and have one of the following:
Respiratory failure, defined as any of the following: o Requirement for invasive ventilatory support o Refractory hypoxemia (SpO2 < 90% on non-rebreather mask or FIO2 > 0.85) o Respiratory acidosis (pH < 7.2) o Clinical evidence of impending respiratory failure o Inability to protect or maintain airway OR
Hypotension (systolic blood pressure < 90 mm Hg or MAP < 65 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.
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IF ANY OF THE ABOVE ARE PRESENT, PROCEED TO STEP 2

If none of the above present, there is no absolute critical care need: continue medical management, reassess as needed.

2) Is patient intubated? If not intubated, complete to 2a. If already intubated, complete 2b.

2a) If NOT intubated, use this table to calculate modified SOFA score (no resp component):

Variable

Platelet count x 106

> 150

< 150

< 100

<50

< 20

NOT INTUBATED

Bilirubin, mg/dL

<1.2

1.2-1.9

2.0-5.9

6.0-11.9

>12

Hypotension

None

Glasgow Coma Score Creatinine, mg/dL

15 < 1.2

MABP < 70 mmHg
13 - 14 1.2-1.9

Dop < 5, or Vaso only
10 - 12 2.0-3.4

Dop > 5, Epi < 0.1, Norepi < 0.1 6 - 9 3.54.9

Dop > 15, Epi > 0.1, Norepi >0.1 <6 >5

2b) If already intubated and sedated, use this table to calculate modified SOFA (no GCS):

Variable

PaO2/FiO2 mmHg*

>400

< 400

< 300

< 200

Platelet count x 106

> 150

< 150

< 100

<50

4 < 100 < 20

INTUBATED

Bilirubin, mg/dL

<1.2

1.2-1.9

2.0-5.9

6.0-11.9

>12

Hypotension Creatinine, mg/dL

None < 1.2

MABP < 70 mmHg
1.2-1.9

Dop < 5, or Vaso only
2.0-3.4

Dop > 5, Epi < 0.1, Norepi < 0.1 3.54.9

Dop > 15, Epi > 0.1, Norepi >0.1 >5

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12 APPENDICES A1 S/F RATIO INCLUSION CRITERIA
Table 2 displays an equivalence table that determines the estimated P/F ratio from the Fi02 and Sp02. This data was generated by investigators at the University of Utah, on a cohort of critically ill
* If pnaotiePntasOwi2th apnveauimlaobnilae..,63u-69se SpO2 & FiO2 to determine equivalent PaO2/FiO2 based on table below.
Modified SOFA Score

SpO 2

For altitude adjustment, we would recommend the practice from ARDS Network studies of multiplying the qualification threshold P/F by the ratio of average ambient to sea level barometric pressure (for Utah, it is 0.86*150 = 129; for Denver it is 0.84*150 = 126).
A3dd)itionCaal lrecquuliaretmeenPtrsifoorrtihteyuSsceoorf ethe S/F ratio include:

1. SpO2 between 80-96%
2.PoSipnOt2sshould be measured at least 10 minutes afte1r any change in FiO2.
3. 4. An adequate pulse oximeter waveform tracing

Modified SOFA score

0-6

2 7-10

11-14

15+

Severe, life-limiting

Comorbidities*

...

comorbidity, exp

...

ROSE NMB Version III PETAL Network

survival <1yr

August 31, 2015

Raw scores range from 1-7. Patients with LOWEST scor4e3s| Paargeehighest priority for critical care resources.

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* Examples of Severely Life Limiting Comorbidities
Examples of Severely Life Limiting Comorbidities (commonly associated with survival < 1 year)
1. Severe dementia with FAST stage 7C plus one episode of aspiration pna, septicemia, pressure ulcers, recurrent fever, etc in the last year 2. Cancer, metastatic and/or aggressive disease with PPS <70%; can be not metastatic but not responding to definitive therapy 3. Heart Disease, NYHA Class IV, already optimally treated and still symptomatic 4. Pulmonary Disease: disabling dyspnea at rest, bed to chair existence, progression of disease and hypoxemia OR hypercapnia >50 5. Cirrhosis: PT >5 or INR > 1,5; albumin <1.5; and major complication (ascites, varices, refractory encephalopathy, etc) 6. Neurodegenerative disease: dyspnea at rest, VC <30% and needs O2 at rest OR rapid deterioration in functional status (Independence to bed bound status) AND critical nutritional impairment 7. Stroke: PPS<40% and poor nutritional status 8. HIV and AIDS: CD4 <25 or viral load >100,000, and at least one major complication (CNS lymphoma, PML, MAC bacteremia and PPX <50% *There may be circumstances that a patient is deemed to have less than one year of life
expectancy based on other well-established evidence..
4) IF THIS IS A REASSESSMENT, ADJUST SCORE: Score improving within past 48 hours? Subtract 1 point from score Score worsening within past 48 hours? Add 1 point to score
5) TOTAL PRIORITY SCORE: Calculate total priority score, then proceed to step 6 to assign triage category.
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5) ASSIGN TRIAGE CATEGORY AND REPORT TO TRIAGE OFFICER

Total Priority Score

Triage Category

LOW PRIORITY

5-6

INTERMEDIATE PRIORITY

Action
Lowest priority for critical care
Consult ethics and palliative care
Intermediate priority for critical care: escalation
of care as resources permit

HIGH PRIORITY

Highest priority for critical care

NO RESPIRATORY FAILURE OR SHOCK

Regular Care

Continue medical management,
Reassess as needed

*In case of multiple patients within the same priority category and limited resources, priority will be assigned to the patient(s) with the lowest numeric priority score. In case of an exact tie in numeric priority score between two or more patients, priority will be given to patients without severe lifelimiting comorbidities as defined above. If there is still a tie between patients after the above rules have been applied, a random lottery will be used.

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Appendix 6. Pediatric Triage Tool
PEDIATRIC CRISIS TRIAGE TOOL: COVID-19 PANDEMIC

Pt initials / MRN: __________/_______________

Date form completed ____/____/____

Statement of Intent
The Crisis Care Plan cannot be implemented without the expressed order of the Incident Commander. The decision to implement Crisis Care Plan is based on resource availability and consultation with physician leaders. This document is a tool to assist with that implementation.
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.
These standards will be applied equitably across populations without regard to patients' race, age, sex, disability, ethnicity, citizenship, religion, wealth, social status, or social connections.
The tool is not meant to apply to situations in which ventilatory support would not be medically effective. (Medically INEFFECTIVE care is excluded from triage.)
The tool applies to all patients whose goals of care align with initiation of life sustaining technologies. Any advanced care directives and POLSTs limiting these interventions will be followed.
Guide:
1. Inclusion Criteria for Critical Care Support 2. Scoring use tool according to patient age
A. Treatment Initiation and Continuation in Pediatric Patients: PELOD-2 for patients > 48 hours of age
B. Treatment Initiation in Periviable Neonates: NICHD Outcomes Estimator C. Treatment Continuation in Neonates: SNAPPE-II 3. Examples of Major Comorbidities and Severely Life Limiting Comorbidities (commonly associated with survival < 1 year) 4. Calculate Points 5. Modifying points 6. Final Triage Score 1. Inclusion Criteria for Critical Care Support:
Patient must be age 17 years or younger, not pregnant, and have one of the following:
Respiratory failure, defined as any of the following: o Requirement for invasive ventilatory support o Refractory hypoxemia (SpO2 < 90% on non-rebreather mask or FIO2 > 0.85) o Respiratory acidosis (pH < 7.2) o Clinical evidence of impending respiratory failure o Inability to protect or maintain airway OR
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Hypotension (systolic blood pressure > 2 standard deviations below normal for age 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.
IF ANY OF THE ABOVE ARE PRESENT, PROCEED TO STEP 2

If none of the above present, skip to step 7 and assign triage code "Not Indicated"

continue medical management.

2A. Pediatrics: ages >48 hrs to 17 yrs. Use this table to calculate the PELOD-2 Score:

Organ Dysfunctions & Variables

Points by Severity Levels

Neurologic

Glasgow Coma Scale

5-10

3-4

Pupillary Reaction

Both

reactive

fixed

Cardiovascular

Lactate (mmol/L)

< 5.0 5.0-10.9

11.0

Mean Arterial Pressure (mmHg)

0-<1 month

31-45 17-30

1-11 months

39-54 25-38

12-23 months

44-59 31-43

24-59 months

46-61 32-44

60-143 months

49-64 36-48

144 months

52-66 38-51

Renal

Creatinine (mg/dL)

0-<1 month

0.78

0.79

1-11 months

0.25

0.26

12-23 months

0.38

0.4

24-59 months

0.57

0.58

60-143 months

0.66

0.67

144 months

1.04

1.05

Respiratory

PaO2 (mmHg)/FiO2

PaCO2 (mmHg)

59-94

Invasive Ventilation

Yes

Hematological

WBC count (x 109/L)

> 2

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12 APPENDICES A1 S/F RATIO INCLUSION CRITERIA
Table 2 displays an equivalence table that determines the estimated P/F ratio from the Fi02 and
Sp0P2.laThtiesldeattas w(xas1g0e9n/eLra)ted by investigators at the Uni1ve4rs2ity of Uta7h7, o-1n 4a 1cohort of cr7iti6cally ill
* IfpantoienPtsaOwi2thapvnaeuilmabonleia,..u63s-6e9 SpO2 & FiO2 to determine equivalent PaO2/FiO2 based on table. *if intubated and sedated, use GCS prior to intubation if available. If not available, award 0 points for GCS score
PELOD-2 Score

SpO 2

For altitude adjustment, we would recommend the practice from ARDS Network studies of multiplying the qualification threshold P/F by the ratio of average ambient to sea level barometric pressure (for Utah, it is 0.86*150 = 129; for Denver it is 0.84*150 = 126).
2BA.dTdriteioantaml reeqnutireinmiteinatstifoornthine uPseeroivf tihaebSle/FNraetiooninactluedse::NICHD

1. SpO2 between 80-96%
Sco2.rinSgpOfo2 srhnoeulodnbaetmesea2s2ur-e2d5awt leeaeskt s10gmesintuatteisoanf,teur saenythcheanNgIeCiHnDFiOE2x.tremely Preterm Birth Outcomes Tool (NICHD-OT) est3i.mated survival for patients receiving active treatment:

- h4t.tpAsn:/a/dwewquwat.enpicuhlsde .onxiihm.egteorvw/raevesfeoarmrcthra/csinugpported/EPBO/use

As this outcomes tool is based on factors known prior to delivery, this tool may be of assistance in the decision to

initiate a trial of intensive care in infants born at extraordinarily preterm gestational age. Survival estimates may range

by hospital, and as such, the best estimate of survival should be used for scoring purposes. Additional circumstances

that influence the likelihood of survival (SGA, prenatal diagnosis of congenital anomalies, etc.) may also factor into the

decision to initiate a trial of intensive care.
ROSE NMB Version III PETAL Network August 31, 2015

43 | P a g e

NICHD-OT

Score

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2C. Treatment Continuation in Neonates: Score for Neonatal Acute Physiology with Perinatal Extension (SNAPPE)-II
Applies to babies admitted to NICU at < 48 hours of life Assign score based on data collected in first 12 hours after admission to NICU

Birth weight (gm) SGA < 3rd %ile Apgar score at 5 minutes PO2/FiO2 ratio
Mean blood pressure (mm Hg) Lowest serum pH Urine output (mL/kg/hr) Lowest temperature (oF) Multiple seizures

> 1000 750 - 999 < 750 No Yes > 7 < 7 > 250 100-249 30-99 < 30 > 30 20-29 < 20 > 7.20 7.10-7.19 < 7.10 > 1.0 0.1-0.9 < 0.1 >96.0 95.0-96.0 < 95.0 No Yes

Total:

From Richardson DK et al., SNAP-II and SNAPPE-II: Simplified newborn illness severity and mortality risk scores. J Pediatr 2001;138:92-100

Points 0
10 17
0 12
0 18
0 5 16 28 0 9 19 0 7 16 0 5 18 0 8 15 0 19

SNAPPE-II Score
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3. Determine if the patient has any Severely Life Limiting Comorbidities commonly associated with survival < 1 year.

This table provides examples only, and is not a definitive list. There may be circumstances that a patient is deemed to have less than one year of life expectancy based on other well-established evidence.

System Involvement Neurologic

Definition
End-stage neurodegenerative disease

Clinical Indicators
No longer able to participate in rehabilitation

Details

Cardiac Pulmonary

End-stage heart failure
Severe CHD
Severe pulmonary hypertension
End-stage lung disease

Ross Class IV not responsive to medical management or candidate for full repair Known severe PHTN not responsive to medical management

Symptoms at rest such as tachypnea, retractions, grunting, or diaphoresis
Growth failure and marked tachypnea or diaphoresis with feeding in infants or marked dyspnea on exertion in children End-stage: Disabling dyspnea at rest or bed to chair
Baseline hypercapnia PCO2 >50mmHg Hypoxemia requiring O2 to maintain SpO2>92%

Oncologic
Hepatic Immunologic

Metastatic or aggressive cancer not responding to definitive therapy and/or palliative End-stage liver disease and not a transplant candidate End-stage immune failure

CD4<25
ANC<200 not due to recent chemotherapy
SCT >40 days not yet engrafted with additional major organ involvement

Includes palliative chemotherapy and radiation therapy
Major complications: CNS disease, severe systemic infection/sepsis Organ failure: Renal Creatinine > 2x normal
Hepatic INR > 2x normal not on anticoagulants Hematologic Anemia Hbg<7, Thrombocytopenia Plt<10

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4. Calculate base point score: Range 1-7

Points
Pediatrics (48hrs - 17yrs) PELOD-2

1
PELOD-2 <12

2
PELOD-2 12-13

3
PELOD-2 14-16

4
PELOD-2 >16

Neonates (0-<48hrs) SNAPPE-II

SNAPPE-II 0-59

SNAPPE-II 60-69

SNAPPE-II 70-79

SNAPPE-II >80

Periviable Neonates NICHD
(highest estimate of survival range)

NICHD -OT 76-100% predicted survival

NICHD OT 56-75% predicted
survival

NICHD-OT 26-55% predicted
survival

NICHD-OT 0-25% predicted survival

Severe comorbid

Co-morbidities

conditions; death

likely within 1 year

Raw scores range from 1-7. Patients with LOWEST scores are highest priority for critical care resources.

Raw Point Score

5. IF THIS IS A REASSESSMENT, ADJUST SCORE: Score improving within past 48 hours? Subtract 1 point from score Score worsening within past 48 hours? Add 1 point to score
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6. TOTAL POINT SCORE: Calculate total point score, then proceed to step 7 for triage code.

7. ASSIGN TRIAGE CATEGORY AND REPORT TO TRIAGE OFFICER

Total Priority Score

Triage Category

LOW PRIORITY

5-6

INTERMEDIATE PRIORITY

Action
Lowest priority for critical care
Consult ethics and palliative care
Intermediate priority for critical care: escalation
of care as resources permit

HIGH PRIORITY

Highest priority for critical care

NO RESPIRATORY FAILURE OR SHOCK

Regular Care

Continue medical management,
Reassess as needed

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Appendix 7. Adult Palliative Care CoVID Pocket Card
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Appendix 8. Palliative Care Communication Card
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Appendix 9. Palliative Care Surge Plan

Capacity

Normal

Contingency

Surge

Surge + Altered Standards

What does it mean?

Spaces, staff, and supplies are consistent with routine daily practices

Spaces, staff, and supplies used are not consistent with daily practices, but provide care to a standard that is functionally equivalent to usual patient care practices.

Adaptive spaces, staff, and supplies are not consistent with usual standards of care but provide sufficiency of care in the setting of a disaster (i.e., provide the best possible care to patients given the circumstances and resources available).

Activates a Crisis Care Triage Team/Triage Officer
Triage tool in play to allocate ICU beds and ventilators

How do we Business as usual know?

This is happening now. Modified work due to planning for surge.

Activated by Stanford Virtual Command Center/CORT

Activated by Governor

Role of palliative care

-Routine triggered consults (LVADs, continuity requests)
-Regular consults for GoC, symptom management, etc
-GIP admissions

Enhanced support to the ICUs, ED and COVID med teams, Onc (daily huddles)
No routine triggered consults
No GIP (RIP) due to hospice shortstaffing & visitors
Co-management for those patients who would be GIP
Visit in-person when necessary

Enhanced support to the ICUs, ED and COVID med teams, Onc (daily huddles)
Comfort care service as co-managers (putting in orders), then surge to primary admitting service for the following:
· COVID19 comfort care patients
· Non-COVID19 comfort care patients
Regular consults covered by redeployed outpatient team members
Coaching support to outpatient clinicians

Enhanced support to the ICUs, ED, COVID med teams, Onc (supporting ICU triage conversations and comfort care transitions)
Comfort care service as a primary admitting service
· COVID19 comfort care patients
· Non-COVID19 comfort care patients
Regular consults covered by redeployed outpatient team members
Coaching support to outpatient clinicians

39 CONFIDENTIAL Please do not disseminate

Appendix 10. Adult Palliative Care Medication Pack
Oral morphine concentrated solution 20 mg/ml Injectable morphine 2mg/ml Hydromorphone oral tablets 2mg Hydromorphone injection 2mg/ml Oral Lorazepam tablets 1mg Injectable Lorazepam 2mg/ml Oral haloperidol Injectable haloperidol Oral and suppository prochlorperazine Ondansetron ODT Oral and suppository acetaminophen Diphenhydramine 12.5mg/ml Diphenhydramine 50mg/ml Phenobarbital injection 130mg/ml Atropine 1% drops Glycopyrrolate 0.2mg/ml can be used IV or sublingual Artificial tears Subcutaneous butterfly needles and subcutaneous pumps Tegaderm Dexamethasone oral 2mg tablets Dexamethasone IV 4m/ml
40 CONFIDENTIAL Please do not disseminate

Appendix 11. Pediatric Palliative Care Medication Pack
Morphine, oral solution 20mg/ml Morphine injection 2mg/ml Hydromorphone oral tablets 2mg Hydromorphone injection 2mg/ml Dexamethasone oral 2mg tablets Dexamethasone IV 4m/ml Ativan tablets 1mg Ativan injection 2mg/ml Valium 5mg rectal suppository Valium 5mg tablets Valium injection 5mg/ml Haloperidol tablets 1mg Haldol IV 5mg/ml Diphenhydramine 12.5mg/ml Diphenhydramine 50mg/ml Phenobarbital injection 130mg/ml Acetaminophen IV 100mg/ml, oral liquid 32mg/ml and 100mg/ml, 120/325/650 as suppository Artificial tears Glycopyrrolate 0.2mg/ml can be used IV or sublingual Scopolamine patches Metoclopramide 10mg tablets and 5mg/ml IV injectable Ondansetron ODT Sucralfate 100mg/ml suspension Ranitidine 25 mg/ml IV, 15mg/ml suspension
41 CONFIDENTIAL Please do not disseminate

Appendix 12. Adult Palliative 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

42 CONFIDENTIAL Please do not disseminate

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

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 20mg/ml oral solution

5-10mg, oral, every 3 hours prn

morphine 2mg/ml

1-4mg, Subcutaneous or IV, every 2 hours prn

morphine 1mg/ml IV PCA
hydromorphone 2mg/ml hydromorphone 2mg oral tablet

0.5-4mg/hr, Intravenous, at 0.5-4ml/hr, continuous.
0.5-1mg, Subcutaneous or IV, every 2 hours prn
2-4mg, oral, every 3 hrs prn

43 CONFIDENTIAL Please do not disseminate

dexamethasone 4mg oral tablet dexamethasone 4mg/ml Antihistamines

4mg, oral, every 12 hours prn 4mg, IV, every 12 hours prn

diphenhydramine (Benadryl) 12.5mg/5ml oral solution
diphenhydramine (Benadryl) 50mg/ml

12.5-25mg, oral, every 6 hours prn 12.5-25mg, intravenous, every 6 hours prn

Antiemetics
Choose EITHER prochlorperazine OR metoclopramide.
prochlorperazine tablet

I added the either/or statement, to avoid the use of these two counteractive anti-emetics (anticholinergic vs a pro-cholinergic).
5-10mg, oral, every 6 hours, prn

prochloperazine 5mg/ml injection

5-10mg, intravenous, every 6 hours, prn

prochlorperazine 25mg suppository

25mg, rectal, every 12 hours prn

ondansetron 4mg oral disintegrating tablet dexamethasone 4mg oral tablet Antianxiety

4-8mg, oral, every 6 hours prn 4mg, oral, every 12 hours prn

lorazepam tablet

0.5-1mg, oral, every 4 hours prn

lorazepam tablet

0.5-1mg, sublingual, every 4 hours prn

lorazepam 2mg/ml syringe Delirium

0.5-1mg, IV, every 4 hours prn

44 CONFIDENTIAL Please do not disseminate

haloperidol tablet
haloperidol injection Fever Management
acetaminophen tablet
acetaminophen suppository
Eye care
hydroxypropyl methylcellulose 0.5% ophthalmic solution Excess secretions
atropine (isopto atropine) 1% ophthalmic solution (Ophthalmic drops can be used for sublingual administration) glycopyrrolate injection
CODE STATUS ORDER SET DNR

0.5-1mg, oral, every 6 hours prn 0.5-1mg, intravenous, every 6 hours prn
650mg, oral, every 4 hours prn 650mg, rectal, every 4 hours prn
2 drops, both eyes, every hour prn
2 drops, sublingual, every 4 hours prn 0.1-0.2mg, intravenous, every 4 hours prn
DNR means no efforts are to be made to restore cardiac or pulmonary function following a cardiac or pulmonary arrest.

45 CONFIDENTIAL Please do not disseminate

Appendix 13. Pediatric Crisis Comfort Care Order Set

Patient Name: ___________ MRN: ____________

Weight: _______ kg

Height: _______ cm

Allergies: Reviewed in EPIC and accurate as documented Reviewed in EPIC:

o add _____________________________

o cancel ___________________________

Service: ______________________________________________________________

Admit to: Inpatient _____________ Observation (Less than 24 hours)

Orders to start on: _________________

Diagnosis: __________________________________________

MEDICATIONS

Analgesics (non-narcotic)

1. Acetaminophen oral Susp (Dose: 10-15mg/kg; Max: 60 mg/kg/day, or 3g/day)

_______mg

40mg

60mg 80mg

100mg

po q6hr prn pain/fever

po q4hr prn pain/fever (max 4 doses/day)

Dispense # 1 bottle 120ml

2. Acetaminophen tablets (Dose: 10-15mg/kg; Max: 60 mg/kg/day, or 3g) 325mg 500mg po q6hr prn pain/fever po q4hr prn pain/fever (max 4 doses/day)

Dispense # 1 bottle: 325mg tablets 500mg tablets

3. Acetaminophen rectal suppository (Dose: 10-15mg/kg; Max: 60 mg/kg/day, or 3g/day) 40mg 60mg 80mg 325mg 500mg rectally q6hr prn pain/fever rectally q4hr prn pain/fever (max 4 doses/day) Dispense # 12 x _____ mg suppositories

4. Ibuprofen oral suspension 100mg/5ml (Dose: 5-10mg/kg) ______ mg po q6hr prn pain/discomfort 50mg po q6hr prn pain/discomfort 75mg po q6hr prn pain/discomfort 100mg (5ml) po q6hr prn pain/discomfort 200mg (10ml) po q6hr prn pain/discomfort

46 CONFIDENTIAL Please do not disseminate

Dispense # 1 bottle 120ml
5. Ibuprofen tablets 200mg (Dose: 10mg/kg) 200mg po q6hr prn pain/discomfort 400mg po q6hr prn pain/discomfort
Dispense #1 bottle 200mg tab
6. Ketorolac (15 or 30 mg/ml vial) (Dose: 0.5 mg/kg, Max dose: 60mg; max 20 doses) _______ 15 mg q6 hrs prn pain 30 mg q6hrs prn pain
Dispense 15mg 30mg #20 vials
7. Dexamethasone (Dose 0.1 mg/kg; Max: 10mg) Oral solution 1mg/ml IV 4mg/ml Dose ____mg PO IV IM x once prn pain
Dispense: Dexamethasone oral solution (1mg/ml) 10 ml Dexamethasone IV 4mg/ml # 3 vials
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 solution (2mg/ml)*** Dose: 0.05-0.15 mg/kg 0.25mg orally q4hr prn pain 0.5mg orally q4hr prn pain 1 mg orally q4hr prn pain 2 mg orally q4hr prn pain _____mg orally q4hr prn pain
Dispense 2mg/ml oral solution 15ml 30ml
2. Morphine IV*** Dose 0.05-0.1mg/kg 0.25mg IV q4hr prn pain
47 CONFIDENTIAL Please do not disseminate

0.5mg IV q4hr prn pain 1mg IV q4hr prn pain 2 mg IV q4hr prn pain _____mg IV q4hr prn pain
Dispense 2mg/ml syringes #10 syringes
3. Hydromorphone IV*** Dose: 0.015mg/kg 0.05mg mg IV q4hr prn severe pain 0.1mg IV q4hr prn severe pain 0.2mg IV q4hr prn severe pain 0.4mg IV q4hr prn severe pain _____mg IV q4hr prn severe pain
Dispense 2mg/ml vials: 10 vials #_____
4. Oxycodone oral*** 0.015-0.15mg/kg 0.25mg po q6hr prn severe pain 0.5mg po q6hr prn severe pain 1mg po q6hr prn severe pain 2 mg po q6hr prn severe pain ____mg q6hr prn severe pain
Dispense oral solution 1mg/ml #20 ml

#20 syringes 20 vials #_______

Anxiolysis
1. Lorazepam 2mg/ml (Dose: 0.01-0.05 mg/kg/dose) 0.25mg q6hr prn IM IV PO 0.5mg q6hr prn IM IV PO 1mg q6hr prn IM IV PO 2mg q6hr prn IM IV PO _________mg q6hr prn IM IV PO

anxiolysis anxiolysis
anxiolysis anxiolysis anxiolysis

Dispense # 15 vials 2mg/ml vials

2. Diazepam (Dose: 0.1-0.2 mg/kg/dose) Oral solution 1mg/ml Tablets 2mg or 5 mg IV 5mg/ml Diastat: 2.5mg or 10mg or 20mg (AcuDial delivery system)

_____mg 0.5 mg 1 mg 2.5 mg

PO IM IV PR PO IM IV PR PO IM IV PR PO IM IV PR

48 CONFIDENTIAL Please do not disseminate

2mg

PO IM IV PR

5 mg

PO IM IV PR

10 mg

PO IM IV PR

Dispense:

Diazempam IV 10mg/2ml # 10 syringes/vials

Diazepam oral solution 1mg/ml # 1 bottle

Diazepam tablets 2mg 5mg #10 tablets

3. Clonidine (Dose: 0.002 mg/kg) Oral suspension 0.01 mg/ml (prepared by pharmacy) IV 100 mcg/ml (can be taken PO) Tab 0.1mg extended release tab ______mg prn anxiety 0.1 mg prn anxiety Dispense Oral solution: 10 ml Tablets: 5 tabs IV: 1 vial 100 mcg/ml with TB syringe

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 # 8 vials

5. Lorazepam (Dose: 0.05-0.1mg/kg)

_____mg IM IV PO q6hr prn

0.25mg IM IV PO q6hr prn

0.5mg

IM IV PO q6hr prn

1 mg

IM IV PO q6hr prn

2mg

IM IV PO q6hr prn

4mg

IM IV PO q6hr prn

seizures agitation seizures agitation seizures agitation seizures agitation seizures agitation seizures agitation

Dispense Lorazepam (2mg/ml vials) #15 - 1ml vials

6. Diazepam (Dose: 0.1-0.3mg/kg)

_____mg