Pandemic Preparation. Assessing Readiness for a Pandemic Infection by Kevin Kalouris at Stanford School of Medicine. Preparedness Principles. Response and evaluation should be built on generic platforms, structures, mechanisms, and plans for crisis and emergency management. Strengthen existing systems over building new ones. Test implemented systems during the inter-pandemic period and allocate adequate resources for all aspects of pandemic preparedness and response. The planning, implementation, testing, and revision may be even more important than the pandemic plan itself. Finally, the response must be evidence-based and can measure it with the threat. Assessing the Risk. Prior Examples. The coronavirus responsible for SARS had 8,096 documented infections worldwide with 774 deaths. Initial symptoms were nonspecific and may have been a factor in 6% of nurses exposed in a Toronto hospital becoming ill. Influenza A, H1N1 variant. In Canada, 136 out of 168 critically ill patients required mechanical ventilation with a 90-day mortality of 17%. Models to Assess Needs. CDC has models for influenza pandemics, the Flu Surge 2.0 and Community Flu 2.0. To use these models, need to know local population mix and bed capacity. Epidemiologic data on transmission rate, length of stay are also helpful. You can then run these models with different assumptions to create potential patient scenarios. Using the Flu Surge model and inputting the total number of hospital beds and ICU beds in San Francisco, a model can be created to assess how different measures would play out. As one can see in this model, lack of social distancing measures would result in the maximum scenario that overwhelms the system. You can also use these models to assess ICU use. Here we have made assumptions that are consistent with the Wuhan data and see that on week 7, 51% of the ICU capacity is for COVID-19 and 78% of those patients require mechanical ventilation. After modeling to determine needs, the next factor in preparedness is looking at space, i.e. what is the ICU capacity. Need to look at the available ICU beds and what the usual occupancy is. Then what would be the effect of canceling elective cases and expediting transfers or discharges. Also need to look at those rooms that are negative pressure and can be used to accommodate procedures or rooms that have a filter, which would be an acceptable substitute. Additional rooms that can accommodate advanced respiratory support, such as those in acute care, PACU, and the emergency room. And lastly, a plan to cohort all the patients together. The next factor is supplies. Accredited U.S. hospitals are required to plan for 96 hours of autonomous function without resupply. And the strategic national stockpile may be of limited use during a national pandemic. However, this does not imply full functional capacity, but rather the ability to care for existing patients and staff. But note, shortages of routine supplies well within the 96 hours have been described in recent disasters. The supply item is ICU-specific ventilators. When evaluating inventory, need to consider ventilators that are available for rent or share between facilities. However, during an epidemic or pandemic, the ability to procure these units may be limited. So need to consider other resources. Portable ventilators, including transport units, chronic care units, and BiPAP units that can be converted to invasive ventilation are an alternative. Also need to look at ventilators used in anesthesia and those that are being used in ambulatory or surgery centers. After determining the available ventilator supply, also need to assess what non-invasive support devices are available for those patients who do not require mechanical ventilation. These devices may include high-flow nasal cannula and CPAP machine. However, keep in mind that the use of these non-invasive respiratory devices may aerosolize COVID-19 virus, and hence appropriate precautions are needed for their use. Supplies to limit spread of infection. Personal protective equipment. A surgical medical mask is recommended for healthcare workers caring for non-ventilated COVID-19 patients. An N95 mask for ventilated patients or during aerosol generating procedures. Estimate the number of gloves, gowns, and masks needed per patient and how many care visits each patient will receive in 24 hours. Also need to have a plan in place for proper donning and doffing of equipment. And a plan for disposal, keeping in mind that a single Ebola patient in the Netherlands generated 8 55-gallon drums of waste per day. After planning for space and supplies has occurred, the next factor to consider is staff. When considering staff, identify who is critical care trained and who can be trained. However, keep in mind that much of the risk to healthcare workers is a direct result of their actual work. Training and institutional precautions need to be implemented to both protect staff and reduce absenteeism. In Wuhan, 3.8% of laboratory confirmed cases were healthcare workers, most of whom acquired the infection while caring for patients. Almost 15% of these infected healthcare workers had severe or critical illness and unfortunately 5 of them died. And in Italy, 61 healthcare workers have died as of March 31, 2020. To help assist in training staff, SCCM has prepared a site with links to various training programs that are displayed below. The hyperlink to the site is at the bottom of the page. References used in this presentation follow on the following slide. Thank you for your attention during this presentation and good luck in your own preparations in the fight against the novel coronavirus. Thank you.

pandemic preparedness

existing systems

testing implemented systems

allocating adequate resources

evidence-based responses