Intensive Care Medicine

, Volume 36, Issue 3, pp 428–443

Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster

  • Charles L. Sprung
  • Janice L. Zimmerman
  • Michael D. Christian
  • Gavin M. Joynt
  • John L. Hick
  • Bruce Taylor
  • Guy A. Richards
  • Christian Sandrock
  • Robert Cohen
  • Bruria Adini
Special Article



To provide recommendations and standard operating procedures for intensive care units and hospital preparedness for an influenza pandemic.


Based on a literature review and expert opinion, a Delphi process was used to define the essential topics.


Key recommendations include: Hospitals should increase their ICU beds to the maximal extent by expanding ICU capacity and expanding ICUs into other areas. Hospitals should have appropriate beds and monitors for these expansion areas. Establish a management system with control groups at facility, local, regional and/or national levels to exercise authority over resources. Establish a system of communication, coordination and collaboration between the ICU and key interface departments. A plan to access, coordinate and increase labor resources is required with a central inventory of all clinical and non-clinical staff. Delegate duties not within the usual scope of workers’ practice. Ensure that adequate essential medical equipment, pharmaceuticals and supplies are available. Protect patients and staff with infection control practices and supporting occupational health policies. Maintain staff confidence with reassurance plans for legal protection and assistance. Have objective, ethical, transparent triage criteria that are applied equitably and publically disclosed. ICU triage of patients should be based on the likelihood for patients to benefit most or a ‘first come, first served’ basis. Develop protocols for safe performance of high-risk procedures. Train and educate staff.


Mortality, although inevitable during a severe influenza outbreak or disaster, can be reduced by adequate preparation.


Recommendations Intensive care unit Hospital Influenza epidemic Pandemic H1N1 Mass disaster Triage 

Supplementary material

134_2010_1759_MOESM1_ESM.docx (21 kb)
Supplementary material 1 (DOCX 20.5 kb)


  1. 1.
    Jain S, Kamimoto L, Bramley AM, Schmitz AM, Benoit SR, Louie J, Sugerman DE, Druckenmiller JK, Ritger KA, Chugh R, Jasuja S, Deutscher M, Chen S, Walker JD, Duchin JS, Lett S, Soliva S, Wells EV, Swerdlow D, Uyeki TM, Fiore AE, Olsen SJ, Fry AM, Bridges CB, Finelli L, The 2009 Pandemic Influenza A (H1N1) Virus Hospitalizations Investigation Team (2009) Hospitalized patients with 2009 H1N1 influenza in the United States, April–June 2009. N Engl J Med 361:1935–1944CrossRefPubMedGoogle Scholar
  2. 2.
    Echevarría-Zuno S, Mejía-Aranguré JM, Mar-Obeso AJ, Grajales-Muñiz C, Robles-Pérez E, González-León M, Ortega-Alvarez MC, Gonzalez-Bonilla C, Rascón-Pacheco RA, Borja-Aburto VH (2009) Infection and death from Influenza A H1N1 virus in Mexico: a retrospective analysis. Lancet. doi:10.1016/S0140-6736(09)61638-X
  3. 3.
    Bishop JF, Murnane MP, Owen R (2009) Australia’s Winter with the 2009 Pandemic Influenza A (H1N1) Virus. N Engl J Med. doi:10.1056/NEJMp0910445
  4. 4.
    Domínguez-Cherit G, Lapinsky SE, Macias AE, Pinto R, Espinosa-Perez L, de la Torre A, Poblano-Morales M, Baltazar-Torres JA, Bautista E, Martinez A, Martinez MA, Rivero E, Valdez R, Ruiz-Palacios G, Hernández M, Stewart TE, Fowler RA (2009) Critically ill patients with 2009 Influenza A (H1N1) in Mexico. JAMA. doi:10.1001/jama.2009.1536
  5. 5.
    The ANZIC Influenza Investigators (2009) Critical Care Services and 2009 H1N1 influenza in Australia and New Zealand. N Engl J Med 361:1925–1934CrossRefGoogle Scholar
  6. 6.
    Rello J, Rodríguez A, Ibañez P, Socias L, Cebrian J, Marques A, Guerrero J, Ruiz-Santana S, Marquez E, Del Nogal-Saez F, Alvarez-Lerma F, Martínez S, Ferrer M, Avellanas M, Granada R, Maraví-Poma E, Albert P, Sierra R, Vidaur L, Ortiz P, Prieto del Portillo I, Galván B, León-Gil C, H1N1 SEMICYUC Working Group (2009) Intensive care adult patients with severe respiratory failure caused by Influenza A (H1N1)v in Spain. Crit Care 13:R148. doi:10.1186/cc8044 CrossRefPubMedGoogle Scholar
  7. 7.
    Kumar A, Zarychanski R, Pinto R, Cook DJ, Marshall J, Lacroix J, Stelfox T, Bagshaw S, Choong K, Lamontagne F, Turgeon AF, Lapinsky S, Ahern SP, Smith O, Siddiqui F, Jouvet P, Khwaja K, McIntyre L, Menon K, Hutchison J, Hornstein D, Joffe A, Lauzier F, Singh J, Karachi T, Wiebe K, Olafson K, Ramsey C, Sharma S, Dodek P, Meade M, Hall R, Fowler RA, Canadian Critical Care Trials Group H1N1 Collaborative (2009) Critically ill patients with 2009 influenza A (H1N1) infection in Canada. JAMA. doi:10.1001/jama.2009.1496
  8. 8.
    Hick JL, Barbera JA, Macintyre AG, Kelen GD (2009) Refining surge capacity: conventional, contingency, and crisis capacity. Disaster Med Public Health Preparedness 3:S59–S67CrossRefGoogle Scholar
  9. 9.
    Devereaux A, Christian MD, Dichter JR, Geiling JA, Rubinson L (2008) Summary of suggestions from the Task Force for Mass Critical Care summit, January 26–27, 2007. Chest 133:1S–7SCrossRefPubMedGoogle Scholar
  10. 10.
    Rubinson L, Hick JL, Curtis JR, Branson RD, Burns S, Christian MD, Devereaux AV, Dichter JR, Talmor D, Erstad B, Medina J, Geiling JA (2007) Definitive care for the critically ill during a disaster: medical resources for surge capacity: from a Task Force for Mass Critical Care summit meeting, January 26–27, 2007, Chicago, IL. Chest 133(5 Suppl):32S–50SGoogle Scholar
  11. 11.
    Tarnow-Mordi WO, Hau C, Warden A, Shearer AJ (2000) Hospital mortality in relation to staff workload: a 4-year study in an adult intensive-care unit. Lancet 356:185–189CrossRefPubMedGoogle Scholar
  12. 12.
    Rubinson L, Hick JL, Hanfling DG, Devereaux AV, Dichter JR, Christian MD, Talmor D, Medina J, Curtis JR, Geiling JA (2008) Definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity: from a Task Force for Mass Critical Care summit meeting, January 26–27, 2007, Chicago, IL. Chest 133:18S–31SGoogle Scholar
  13. 13.
    Hospital Incident Command System. HICS IV (2006) California Emergency Medical Services AuthorityGoogle Scholar
  14. 14.
    Federal Emergency Management Agency-Department of Homeland Security (2008) National Incident Management SystemGoogle Scholar
  15. 15.
    Barbera J, MacIntyre A, Sunday D (2007) Medical surge capacity and capability: a management system for integrating medical and health resources during large-scale emergencies. CNA Corporation, Alexandria (RA 645.5 B276 2004)Google Scholar
  16. 16.
    Christian MD, Kollek D, Schwartz B (2005) Emergency preparedness: what every healthcare worker needs to know. Can J Emerg Med 7:330–337Google Scholar
  17. 17.
    Christian MD, Hawryluck L, Wax RS, Cook T, Lazar NM, Herridge MS, Muller MP, Gowans DR, Fortier W, Burkle FM (2006) Development of a triage protocol for critical care during an influenza pandemic. CMAJ 175:1377–1381PubMedGoogle Scholar
  18. 18.
    Hsu EB, Thomas TL, Bass EB, Whyne D, Kelen GD, Green GB (2006) Healthcare worker competencies for disaster training. BMC Med Educ 6:19–28CrossRefPubMedGoogle Scholar
  19. 19.
    Hsu EB, Jenckes MW, Catlett CL, Robinson KA, Feuerstein C, Cosgrove SE, Green GB, Bass EB (2004) Effectiveness of hospital staff mass-casualty incident training methods: a systematic literature review. Prehosp Disaster Med 19:191–199PubMedGoogle Scholar
  20. 20.
    Williams J, Nocera M, Casteel C (2008) The effectiveness of disaster training for health care workers: a systematic review. Ann Emerg Med 52:211–222CrossRefPubMedGoogle Scholar
  21. 21.
    Marshall J, on behalf of the InFact Global H1N1 Collaboration (2010) In fact: a global critical care research response to H1N1. Lancet (in press)Google Scholar
  22. 22.
    Cook D, Burns K, Finfer S, Kissoon N, Bhagwanjee S, Annane D, Sprung C, Fowler R, Latronico N, Marshall J (2010) Clinical research ethics for critically ill patients: a pandemic proposal. Critical Care Med (in press)Google Scholar
  23. 23.
    Pan American Health Organization and World Health Organization (2009) Considerations and interim recommendations for the clinical management of human infection with the pandemic influenza (H1N1) 2009 virus. PAHO/WHO expert consultationGoogle Scholar
  24. 24.
    Rubinson L, Nuzzo JB, Talmor DS, O’Toole T, Kramer BR, Inglesby TV (2005) Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations of the Working Group on Emergency Mass Critical Care. Crit Care Med 33:E2393–E2403CrossRefGoogle Scholar
  25. 25.
    The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators (2009) Extracorporeal membrane oxygenation for 2009 influenza A (H1N1) acute respiratory distress syndrome JAMA. doi:10.1001/jama.2009.1535
  26. 26.
    White DB, Angus DC (2009) Preparing for the sickest patients with 2009 influenza A (H1N1). JAMA. doi:10.1001/jama.2009.1539
  27. 27.
    The Society of Critical Care Medicine Ethics Committee (1994) Consensus statement on the triage of critically ill patients. JAMA 271:1200–1203CrossRefGoogle Scholar
  28. 28.
    Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine (1999) Guidelines for intensive care unit admission, discharge, and triage. Crit Care Med 27:633–638CrossRefGoogle Scholar
  29. 29.
    American Thoracic Society Bioethics Task Force (1997) Fair allocation of Intensive Care Unit resources. Am J Respir Crit Care Med 156:1282–1301Google Scholar
  30. 30.
    Peng PW, Wong DT, Bevan D, Gardam M (2003) Infection control and anesthesia: lessons learned from the Toronto SARS outbreak. Can J Anesth 50:989–997CrossRefPubMedGoogle Scholar
  31. 31.
    Jefferson T, Del Mar C, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, van Driel ML, Foxlee R, Rivetti A (2009) Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. BMJ 339:b3675. doi:10.1136/bmj.b3675 CrossRefPubMedGoogle Scholar
  32. 32.
    Gomersall CD, Joynt GM, Ho OM, Ip M, Yap F, Derrick JL, Leung P (2006) Transmission of SARS to healthcare workers: the experience of a Hong Kong ICU. Intensive Care Med 32:564–569CrossRefPubMedGoogle Scholar
  33. 33.
    Loeb M, Dafoe N, Mahony J, John M, Sarabia A, Glavin V, Webby R, Smieja M, Earn DJ, Chong S, Webb A, Walter SD (2009) Surgical Mask vs N95 respirator for preventing influenza among health care workers: a randomized trial. JAMA 302:1865–1871CrossRefPubMedGoogle Scholar
  34. 34.
    Yap FH, Gomersall CD, Fung KS, Ho PL, Ho OM, Lam PK, Lam DT, Lyon DJ, Joynt GM (2004) Increase in methicillin-resistant Staphylococcus aureus acquisition rate and change in pathogen pattern associated with an outbreak of severe acute respiratory syndrome. Clin Infect Dis 39:511–516Google Scholar
  35. 35.
    Tang JW, Li Y, Eames I, Chan PKS, Ridgway GL (2006) Factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises. J Hosp Infect 64:100–114CrossRefPubMedGoogle Scholar
  36. 36.
    Christian MD, Devereaux AV, Dichter JR, Geiling JA, Rubinson L (2008) Definitive care for the critically ill during a disaster: current capabilities and limitations: from a Task Force for Mass Critical Care summit meeting, January 26–27, 2007, Chicago, IL. Chest 133(5 Suppl):8S–17SCrossRefPubMedGoogle Scholar
  37. 37.
    Fauci AS (2006) Pandemic influenza threat and preparedness. Emerg Infect Dis 12:73–77PubMedGoogle Scholar
  38. 38.
    Garner A, Lee A, Harrison K, Schultz CH (2001) Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med 38:541–548CrossRefPubMedGoogle Scholar
  39. 39.
    Romig LE (2002) Pediatric triage: a system to JumpSTART your triage of young patients at MCIs. JEMS 27:52–53PubMedGoogle Scholar
  40. 40.
    Robertson-Steel I (2006) Evolution of triage systems. Emerg Med J 23:154–155CrossRefPubMedGoogle Scholar
  41. 41.
    Iserson KV, Moskop JC (2007) Triage in medicine, part I: concept, history, and types. Ann Emerg Med 49:275–281CrossRefPubMedGoogle Scholar
  42. 42.
    Moskop JC, Iserson KV (2007) Triage in medicine, part II: underlying values and principles. Ann Emerg Med 49:282–287CrossRefPubMedGoogle Scholar
  43. 43.
    Hick JL, O’Laughlin DT (2006) Concept of operations for triage of mechanical ventilation in an epidemic. Acad Emerg Med 13:223–229CrossRefPubMedGoogle Scholar
  44. 44.
    Devereaux AV, Dichter JR, Christian MD, Dubler NN, Sandrock CE, Hick JL, Powell T, Geiling JA, Amundson DE, Baudendistel TE, Braner DA, Klein MA, Berkowitz KA, Curtis JR, Rubinson L (2008) Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care: from a Task Force for Mass Critical Care summit meeting, January 26–27, 2007, Chicago, IL. Chest 133:51S–66SGoogle Scholar
  45. 45.
    Powell T, Christ KC, Birkhead GS (2008) Allocation of ventilators in a public health disaster. Disaster Med Public Health Prep 2:20–26CrossRefPubMedGoogle Scholar
  46. 46.
    Lecuyer L, Chevret S, Thiery G, Darmon M, Schlemmer B, Azoulay E (2007) The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation. Crit Care Med 35:808–814CrossRefPubMedGoogle Scholar
  47. 47.
    Ferreira FL, Bota DP, Bross A, Melot C, Vincent JL (2001) Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 286:1754–1758CrossRefPubMedGoogle Scholar
  48. 48.
    Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The sepsis-related organ failure assessment (SOFA) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 22:707–710CrossRefPubMedGoogle Scholar
  49. 49.
    Lapinsky SE, Hawryluck L (2003) ICU management of severe acute respiratory syndrome. Intensive Care Med 29:870–875PubMedGoogle Scholar
  50. 50.
    Gomersall CD, Tai DY, Loo S, Derrick JL, Goh MS, Buckley TA, Chua C, Ho KM, Raghavan GP, Ho OM, Lee LB, Joynt GM (2006) Expanding ICU facilities in an epidemic: recommendations based on experience from the SARS epidemic in Hong Kong and Singapore. Intensive Care Med 32:1004–1013CrossRefPubMedGoogle Scholar
  51. 51.
    Mount Sinai Critical Care Unit SARS Resources. Accessed 8 Sept 2009
  52. 52.
    London DH (2007) Pandemic flu: a national framework for responding to an influenza pandemic.
  53. 53.
    Lau JT, Fung KS, Wong TW, Kim JH, Wong E, Chung S, Ho D, Chan LY, Lui SF, Cheng A (2004) SARS transmission among hospital workers in Hong Kong. Emerg Infect Dis 10:280–286PubMedGoogle Scholar
  54. 54.
    Rebmann T, English JF, Carrico R (2007) Disaster preparedness lessons learned and future directions for education: results from focus groups conducted at the 2006 APIC Conference. Am J Infect Control 35:374–381CrossRefPubMedGoogle Scholar
  55. 55.
    Bero L, Grilli R, Grimshaw J (1998) Closing the gap between research and practice: an overview of systematic reviews of interventions to promote implementation of research findings by health care professionals. BMJ 317:465–468PubMedGoogle Scholar
  56. 56.
    Cheng SM, Melanee EC, Rawson B (2008) Infection prevention and control learning preferences of nurses sampled at a teaching hospital. Can J Infect Control 165:168–171Google Scholar
  57. 57.
    Marshall CS, Yamada S, Inada MK (2008) Using problem-based learning for pandemic preparedness. Kaohsiung J Med Sci 24(Suppl 3):S39–S45CrossRefPubMedGoogle Scholar
  58. 58.
    Abrahamson SD, Canzian S, Brunet F (2006) Using simulation for training and to change protocol during the outbreak of severe acute respiratory syndrome. Crit Care 10:R3. doi:10.1186/cc3916 CrossRefPubMedGoogle Scholar
  59. 59.
    Booth CM, Stewart TE (2005) Severe acute respiratory syndrome and critical care medicine: the Toronto experience. Crit Care 33(Suppl):S53–S60CrossRefGoogle Scholar
  60. 60.
    Wang C, Wei S, Xiang H, Xu Y, Han S, Mkangara OB, Nie S (2008) Evaluating the effectiveness of an emergency preparedness training programme for public health staff in China. Public Health 122:471–477Google Scholar
  61. 61.
    Daugherty EL, Perl TM, Needham DM, Rubinson L, Bilderback A, Rand CS (2009) The use of personal protective equipment for control of influenza among critical care clinicians: a survey study. Crit Care Med 37:1210–1216CrossRefPubMedGoogle Scholar
  62. 62.
    Shigayeva A, Green K, Raboud JM, Henry B, Simor AE, Vearncombe M, Zoutman D, Loeb M, McGeer A, SARS Hospital Investigation Team (2007) Factors associated with critical-care healthcare workers’ adherence to recommended barrier precautions during the Toronto severe acute respiratory syndrome outbreak. Infect Control Hosp Epidemiol 28:1275–1283CrossRefPubMedGoogle Scholar
  63. 63.
    Yassi A, Lockhart K, Copes R, Kerr M, Corbiere M, Bryce E, Danyluk Q, Keen D, Yu S, Kidd C, Fitzgerald M, Thiessen R, Gamage B, Patrick D, Bigelow P, Saunders S, SARS Study Team (2007) Determinants of healthcare workers’ compliance with infection control procedures. Healthc Q 10:44–52PubMedGoogle Scholar
  64. 64.
    Chua SE, Cheung V, Cheung C, McAlonan GM (2004) Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers. Can J Psych 49:391–393Google Scholar
  65. 65.
    Schünemann HJ, Hill SR, Kakad M, Bellamy R, Uyeki TM, Hayden FG, Yazdanpanah Y, Beigel J, Chotpitayasunondh T, Del Mar C, Farrar J, Tran TH, Ozbay B, Sugaya N, Fukuda K, Shindo N, Stockman L, Vist GE, Croisier A, Nagjdaliyev A, Roth C, Thomson G, Zucker H, Oxman AD, WHO Rapid Advice Guideline Panel on Avian Influenza (2007 WHO Rapid Advice Guidelines for pharmacological management of sporadic human infection with avian influenza A (H5N1) virus. Lancet Infect Dis 7:21–31Google Scholar
  66. 66.
    American Thoracic Society: Salvage Therapies for H1N1-induced ARDS. Accessed 19 Oct 2009
  67. 67.
    Anonymous (2003) Mechanical ventilation of SARS patients: safety issues involving breathing-circuit filters. Health Devices 32:220–222Google Scholar
  68. 68.
    Thompson AK, Faith K, Gibson JL, Upshur RE (2006) Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Med Ethics 7:12CrossRefGoogle Scholar

Copyright information

© Copyright jointly hold by Springer and ESICM 2010

Authors and Affiliations

  • Charles L. Sprung
    • 1
    • 11
  • Janice L. Zimmerman
    • 2
  • Michael D. Christian
    • 3
  • Gavin M. Joynt
    • 4
  • John L. Hick
    • 5
  • Bruce Taylor
    • 6
  • Guy A. Richards
    • 7
  • Christian Sandrock
    • 8
  • Robert Cohen
    • 9
  • Bruria Adini
    • 10
  1. 1.Department of Anesthesiology and Critical Care MedicineHadassah Hebrew University Medical CenterJerusalemIsrael
  2. 2.Critical Care Division, Department of Medicine, The Methodist HospitalWeill Cornell Medical CollegeHoustonUSA
  3. 3.Department of Medicine, Infectious Diseases and Critical CareMount Sinai Hospital & University Health Network, University of TorontoTorontoCanada
  4. 4.Department of Anesthesia and Intensive Care, Prince of Wales HospitalThe Chinese University of Hong Kong, Prince of Wales HospitalHong KongPeople’s Republic of China
  5. 5.Department of Emergency MedicineHennepin County Medical CenterMinneapolisUSA
  6. 6.Department of Critical CarePortsmouth Hospitals NHS TrustPortsmouthUK
  7. 7.Department of Intensive Care, Johannesburg HospitalUniversity of the WitwatersrandJohannesburgSouth Africa
  8. 8.Intensive Care Unit, Division of Pulmonary and Critical Care Medicine, Infectious DiseasesUC Davis School of MedicineSacramentoUSA
  9. 9.Emergency Medical ServicesIsraeli Ministry of Health, Hebrew University Faculty of MedicineTel Aviv, JerusalemIsrael
  10. 10.Emergency Medical ServicesIsraeli Ministry of Health, Ben-Gurion University of the NegevTel Aviv, Beer ShevaIsrael
  11. 11.General Intensive Care UnitHadassah Hebrew University Medical CenterJerusalemIsrael

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