Meeting clients' special needs clients is part of health care facilities' everyday activities.  However, during a mass casualty incident affecting the community and its infrastructure, the number of special needs clients can escalate quickly and overwhelm hospitals' ability to accommodate.

The biggest challenge is patients who require ventilatory support that is dependent on electricity. Most ventilators have the ability to use battery backup power six to 12 hours (or more), but after that they require a power source to ensure continuity of support. Often these patients first will go to fire stations, paramedic outposts, and police stations for a short period, but as the impact of the MCI draws on manpower and resources, these solutions become unmanageable. At that point, patients who use ventilators are transported to the nearest health care facility's emergency unit, where they can access independent power supplies, oxygen, and suction capabilities.

Identifying the size of your community's ventilator-dependent population, the levels of care they require, and the types of equipment they use can determine how successfully your facility responds to an infrastructure MCI.

Few respiratory therapists are aware that in a city of 1 million there can be more than 500 ventilated patients (invasive, noninvasive, and bilevel support) in the community. These patients usually have a chronic and stable condition, so they require a reduced level of support compared to acutely ventilated patients. Primarily, they need a place to stay, electrical power, and access to their basic care needs. Even though the manpower requirements to care for these patients are low, it still puts a drain on critically needed resources during a time of crisis.

It is prudent for health care facilities to be proactive by seeking a community support network for these special needs patients. A local pulmonary rehabilitation facility or home care company would be a good starting point. They can provide the local contacts to establish a planning team to develop a sustainable MCI support system. Working with the municipal government and emergency management systems to identify centers that can provide support by centralizing resources (community center, city hall, or other safe identified location) will reduce the need for patients to turn to acute care facilities.

Ventilator-dependent residents of chronic care facilities have medical needs that tend to be at a higher level than the medical needs of ventilator patients who live independently at home. It is important that these facilities develop a plan to respond to an electrical infrastructure failure secondary to an MCI. If the chronic care facility's plan is to transfer patients to the nearest acute care facility, both facilities should develop a coordinated approach. One possibility is a mutual support agreement that states the acute care facility would transfer some of their non-ventilated chronic or near chronic patients to the long-term care facility in return for accepting the transfer of chronic ventilated patients.

Many patients who require ventilator support often have advanced directives known to their long-term care facility. However, if they do not present these advance directives to the acute care facility, they create an unintended draw on resources, and the health care providers may be unaware of the patients' wishes. Through advanced planning and with a patient's consent, a file of the patient's specific care requirements and advanced directives can be delivered to the acute care facility as part of the patient transfer process.  

An additional twist is the number of pediatric patients who are ventilator dependent in the community. In most cases, the local pediatric hospital does not have the physical resources to handle a sudden influx of ventilated pediatric patients into their emergency room. Ensure that your acute care facility's staff is aware of this patient population and are prepared to provide care in the event that pediatric patients arrive through your doors during an MCI. Your disaster response plan should include a list of what equipment and supplies are available in pediatric sizes or modes.    

Another challenge in helping community-based ventilator-dependent patients is acute care staffs' lack of familiarity with home ventilators. Clinicians' quick access to online equipment manuals may be the difference in a patient continuing to use their home unit or a clinician having to use a full-feature critical care ventilator at a time when resources are challenged. Ontario's Ventilator Equipment Pool website http://www.ontvep.ca/ offers an icon that health care providers can use to find equipment manuals for many ventilators or home positive airway pressure units. Ventilator manufacturers offer similar services on their web sites, and acute care facilities should maintain a list of these addresses as a disaster response resource.    

Dave Swift, RRT, is campus coordinator, professional practice respiratory therapy, at Ottawa Hospital - Civic Campus, Ottawa, Ontario, Canada. He is also respiratory therapy lead/subject matter expert, for the National Office of the Healthcare Emergency Response Team, Public Health Canada. If you'd like to submit a question about disaster response, email dswift@ottawahospital.on.ca or kmastiff@magma.ca.