Canadian Neighbor Pharmacy: Definitive Care for the Critically III Patients
Within an effective command and control system to coordinate regional response, surge capacity in critical care depends on three crucial elements: (1) “stuff,” medical equipment and supplies; (2) “staff,” appropriately trained health professionals to competently care for critically ill and injured patients; and (3) “space,” the physical location suitable for safe provision of critical care. Although a rather simplistic conceptual approach, one can confidently state that a system that fails to meet any one of these requirements will not be able to cope with a large surge. Medical response to disasters, including the critical care response, is dependent on a number of non-clinical medical institution services (eg, logistics and procurement, environmental services, food services) and external services (eg, transportation, consistent functional utilities, commerce infrastructure). For expediency, this article will focus on critical care-specific capabilities.
Mechanical ventilators are unique to the critical care environment, and they are essential equipment for the management of respiratory failure. There are no realistic substitutes for ventilators. Proposals to train hundreds of volunteers to provide manual ventilation to patients during a pandemic are naive and fraught with serious logistical and scientific shortfalls, such as the lack of staff or volunteers during bioevents as well as the risk of secondary transmission to the caregivers who must remain at the bedside and the adverse consequences of prolonged manual ventilation.
Estimates of the total number of full-feature ICU ventilators available in the United States vary widely, One study reported 105,000 ventilators (35 ventilators per 100,000 population); other published studies and unpublished data place the estimate between 53,00044 and 70,000 (17 to 23 per 100,000 population). These devices are distributed among the 72.000 to 87,500 non-federal ICU beds in the United States. A 2006 review of ventilators in Ontario, Canada, reported similar quantities when corrected for population size: 1,990 ICU ventilators (16 per 100.000 population) [A. Stuart; Emergency Management Unit, ON Ministry of Health & Long Term Care; personal communication; May 16, 2006].
For immediate surge capacity, available ventilators are more important than the total number. Most institutions often have only a minimal number of reserve ventilators on site at any time. When all of the full-feature hospital ventilators are occupied, additional units are usually rented from a vendor. A study by Kaji and Lewis in Los Angeles found that 71% of hospitals in the Los Angeles area had fewer than six ventilators available for immediate use at any time. If several local hospitals require additional ventilators, rental supplies may be insufficient to meet need, as it is common for vendors to contract to provide the same finite pool of ventilators to several institutions.
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Data from the National Healthcare Safety Net-work show that the majority of ICUs have, on average, < 70% of their occupied beds filled with patients receiving invasive mechanical ventilation. Based on these data, at least 10,000 full-feature ventilators are likely available across the United States at any time for use during a disaster. This predicted available national mechanical ventilator quantity may at first seem reassuring, but it also has potential to mislead. Numerous logistic hurdles will hamper immediate distribution to areas of need during a disaster. Thousands of ventilators may be available at hospitals nationwide, yet an affected community requiring just hundreds of additional devices may not be able to get them in a timely manner. Also, published and unpublished models of varying sophistication portend there will still be a large gap between the total number of ventilators required during the peak of a serious influenza pandemic and available devices.’ In all models, the predicted need will far exceed even the tens of thousands of available ventilators. Hence, strategies for rational augmentation of positive pressure ventilation capacity are necessary.
In the United States and Canada, stockpiles of ventilators are available from government sources. Currently the strategic national stockpile in the United States has approximately 4,600 ventilators, and there is a stated intention to purchase additional ventilators. Furthermore, some local institutions, municipalities, and states are also developing stockpiles. For some events, these devices, together with staff augmentation strategies, may allow for many additional patients to survive (see Definitive Care for the Critically Ill During a Disaster: A Framework for Optimizing Critical Care Surge Capacity and Definitive Care for the Critically Ill During a Disaster: Medical Resources for Surge Capacity). For more catastrophic events, these additional ventilators may be beneficial but still insufficient to serve all in need; in such cases, scarce mechanical ventilators will need to be allocated to those patients who are prioritized (see Definitive Care for the Critically Ill During a Disaster: A Framework for Allocation of Scarce Resources in Mass Critical Care). Care is very important in case of health difficulties and Canadian Neighbor Pharmacy takes care about its customers providing them with high quality and low prices. It is the most convenient way to order drugs because the procedure is so simple really speaking.
The “just-in-time” supply chain management systems used by many hospitals creates a significant threat to successful disaster response as many hospitals maintain only a minimal store of medical supplies on site. Of the typically “consumable” medical supplies required for the provision of critical care some may have the potential for limited disinfection and reuse in a disaster when no alternative exists. There are a variety of inotropes and vassopres-sors that are interchangeable again increasing availability. However, oxygen remains a critical consumable resource which has a limited supply and distribution network. Most hospitals rely on large storage tanks of liquid oxygen. If this source runs low, oxygen must be trucked in from a supplier. The number of suppliers of medical grade oxygen in North America is limited as are the number of tanker trucks available to transport oxygen. Portable oxygen supplies for use during an infrastructure failure or in off-site critical care facilities are very limited, inefficient and not included in the strategic national stockpile.
Like many areas of health care, critical care units face shortages of various team members required for critical care delivery.’’ Data from Ontario show that 49% of critical care units had nursing vacancies and 20% had physician vacancies. ICUs facing staffing shortages are routinely forced to cancel surgeries and divert ED admissions to other hospitals. The need to resort to such actions even in non-surge periods bespeaks the limited surge capacity in the critical care system.
In the past, staff shortages have not typically been a major problem during disasters. However, a report revealed that staffing can be a problem, with staff absenteeism during a disaster ranging from 10 to 60%. The authors described disasters that were prolonged, were of a type rare for the community, or impacted the personal lives of employees (ie, school closures, day-care closures, or elder-care issues) were associated with higher rates of absenteeism. Estimated absenteeism for future bioevents is predicted to be even higher., In bioevents, staff may fail to report for duty for a variety of reasons, including fear of infection or infecting their families. Although volunteers often converge on disaster-stricken com-munities,’ rarely do these volunteers possess the skills necessary to provide critical care; and even if they do, rapidly verifying credentials during a disaster can be logistically challenging.
It is important that the staff available to respond have adequate preparation to do so. Critical care physicians in general are poorly prepared to respond to mass casualty disasters. A study of other physician groups report that preparedness for bioterrorism or public health emergencies are particular areas of weakness, and deficiencies in training to respond to mass casualty events are not limited to physicians. Hospital administrators, who are often called on to lead the response in a health-care facility, also lack appropriate training. The doctors may prescribe you all preparations correctly but in some cases it is brand drugs rather expensive but Canadian Neighbor Pharmacy makes it possible to buy drugs at most favourable price.
Critical care requires specific functionalities, including electricity, oxygen, suction, medical gas, monitoring equipment, and physical space for equipment and patient management. As a result, there are limited areas in which critical care can be provided on a routine basis outside of current critical care areas (ICU, postanesthesia care unit, ED). As with staffing, some hospitals face shortages of critical care spaces, although occupancy varies across the United States. In Ontario in 2006, there were 1,789 critical care beds, 1,057 of which were capable of accommodating mechanical ventilation. The occupancy rate for these beds approaches 90%. Demands on critical care resources are expected to increase in both the United States and Canada as the populations age.
On a day-to-day basis, additional capacity can be created in the critical care system by expanding critical care to areas of the hospital such as the postanesthesia care unit. However, this expansion is still limited by the issues of stuff and staff discussed earlier. Therefore, even though the bed spaces may be available to use for critical care, if the hospital rents its ventilators and has no more on site, the ability to expand critical care remains limited unless specific advanced planning and preparation are undertaken. Finally, although it is possible to convert off-site locations (ie, hotels, gymnasiums, sports fields) into medical treatment facilities, the ability to convert such areas to critical care facilities on a large scale is curtailed because of the functional requirements and logistical challenges, such as large-volume portable oxygen supplies.
While unlimited stockpiles of medical equipment could mitigate the shortfall of critical care resources during a disaster, this is not a realistic solution in part because of the costs of stockpiling. Extrapolating from even an incomplete list of equipment required to care for critically ill patients results in an estimated cost of $1,789,876 to manage 100 critically ill patients for 3 days. This cost does not take into account the cost of the financing to purchase the stockpile or the potential returns from alternative investments those funds could be used for. This considerable expense also does not include the cost of maintaining and storing equipment. Furthermore, the period of treatment being considered is very short and not representative of the typical length of ICU stay. Thus the cost is substantial, imposing significant fiscal limitations on the ability to stockpile. Therefore, a balance must be struck between service provision today and preparation for potential events of the future. Finally, stockpiling does not resolve the staffing issue.