Pandemic Levels

Level 1

• Recognize the need to surge bed capacities
• ED experiencing increased numbers
• In rapidly progressing pandemic start with level 2

Level 2

• Hospital has surged to maximum bed capacity and ED is overwhelmed
• There are not enough beds to accommodate all patients needing hospital admission, and not enough ventilators
• Hospitals staff absenteeism is 20-30%

Level 3

• Hospital has already implemented altered standards of care regarding nurse/patient ratios and have added patients to already occupied hospital rooms
• Hospital Staff absenteeism is 30-40%

The following is expected to be followed if hospital reaches Level 2 or Level 3 in the Pandemic Plan. The assumption is that at Level 2 effort would be made to not admit these patients to the hospital and patients meeting the exclusion criteria will not be admitted to the ICU. At Level 3 the efforts to keep these patients from being admitted to the hospital increase.

• All efforts should be made to not admit or refer patients to the ED for evaluation the patients meeting the exclusion criteria suspected of having the pandemic illness.
• Specifically, patients diagnosed or suspected of having the pandemic illness that reside in a nursing home meeting these exclusion criteria should remain in the nursing home.
• Patients meeting the criteria should not be transferred to Hospital ED for assessment of any other condition locally or from regional facilities.

Patients meeting the following exclusion criteria should be excluded from hospital admission or transferred to the ICU if one of the following criteria are met:

1. SOFA (Sequential Organ Failure Assessment) score > 11. Note that in severe pandemics (Level 3) priority for hospital care is given to patients with a score of 8 or less
2. Known POLST that indicates Comfort Care Only
3. Severe and irreversible chronic neurologic condition with chronic coma or vegetative state
4. Acute severe neurologic event with minimal chance of functional neurologic recovery (physician judgement). Includes traumatic brain injury, severe hemorrhagic stroke, hypoxic ischemic brain injury, and intracranial hemorrhage.
5. Severe acute trauma with a REVISED TRAUMA SCORE < 2
6. Cardiac arrest not responsive to ACLS within 20-30 minutes
7. Known severe dementia requiring assistance with activities of daily living
8. Advanced untreatable neuromuscular disease (such as ALS, end-stage MS, or SMA) requiring assistance in ADLs or chronic ventilator support
9. Incurable metastatic malignant disease
10. End-stage organ failure meeting the following criteria:
    a.       Heart: NYHA Functional Classification Class III or IV
    b.       Lung (any of the following)
           i.      Severe Lung disease with ongoing Oxygen requirements of 4 or more liters.
          ii.      Primary pulmonary hypertension with NYHA class III or IV heart failure.
    c. Liver: PUGH score > 7
11. Age: 
    a.       Triage Level 1: > 95 years
    b.       Triage Level 2: > 90 years
    c.       Triage Level 3: > 85 years
12. Acute Renal Failure
    a.       At Level 3 patients with acute renal failure will not be admitted to the ICU for CRRT.