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

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to deliver; (4) ICU care and treatments may have to be withheld from patients likely to die even with ICU care and withdrawn after a trial in patients who do not improve or deteriorate; (5) triage criteria should be objective, ethical, transparent, applied equitably and be publically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