Skip to main content Accessibility help
  • Print publication year: 2007
  • Online publication date: December 2009

10 - Critical care and biological disasters: lessons learned from SARS and pandemic influenza planning

    • By Michael D. Christian, Mount Sinai Hospital and University Health Network Toronto General Toronto Western, and Princess Margaret Hospital Room 18–206 600 University Avenue Toronto M5G 1X5 Ontario Canada, Thomas E. Stewart, Mount Sinai Hospital and University Health Network Toronto General Toronto Western, and Princess Margaret Hospital Room 18–206 600 University Avenue Toronto M5G 1X5 Ontario Canada, Stephen E. Lapinsky, Mount Sinai Hospital and University Health Network Toronto General Toronto Western, and Princess Margaret Hospital Room 18–206 600 University Avenue Toronto M5G 1X5 Ontario Canada
  • Edited by Jeremy Cashman, Michael Grounds
  • Publisher: Cambridge University Press
  • DOI:
  • pp 159-178


Day to day, critical care units in Western society provide highly resourced intense care to patients with complex medical problems or injuries. Typically a relatively small number of patients are managed by highly educated and specialised physicians (intensivists) in collaboration with a large team of health care workers (HCWs), skilled specifically in dealing with critically ill patients including: critical care nurses, respiratory therapists, nutritionists, physiotherapists, pharmacists and other allied HCWs. Critical care is comprised of three core components: intensive nursing care with a 1:1 or 1:2 nurse-to-patient ratio, the provision of life support measures, and invasive monitoring including devices such as arterial lines or pulmonary artery catheters. Life support in this context can include ventilatory support with positive pressure mechanical ventilation, circulatory support with medications to control/support blood pressure (e.g. dopamine) or mechanical support (e.g. intra-aortic balloon pump or temporary transvenous pacemaker), and renal replacement therapy.

Whilst the model of care described above is effective for day-to-day patient management, during a disaster, particularly biological disasters, this model of care is often not sustainable nor an efficient use of limited resources. The term biological disaster is used to refer to events such as infectious disease outbreaks (epidemics and pandemics) or bioterrorism attacks. This chapter will discuss issues related to providing critical care services during biological disasters including preparedness, organisational structure, communication, surge capacity, mass critical care, triage, infection control, and ethical challenges.

Related content

Powered by UNSILO
Rubinson, L, O'Toole, T.Critical care during epidemics. Crit Care 2005; 9: 311–13.
Christian, MD, Poutanen, SM, Loutfy, MR, Muller, MP, Low, DE.Severe acute respiratory syndrome. Clin Infect Dis 2004; 38: 1420–27.
Booth, CM, Matukas, LM, Tomlinson, GAet al. Clinical features and short-term outcomes of 144 patients with SARS in the greater Toronto area. JAMA 2003; 289: 2801–09.
Poutanen, SM, Low, , Henry, Bet al. Identification of severe acute respiratory syndrome in Canada. N Engl J Med 2003; 348: 1995–2005.
Christian, MD, Loutfy, M, McDonald, LCet al. Possible SARS coronavirus transmission during cardiopulmonary resuscitation. Emerg Infect Dis 2004; 10: 287–93.
Wallington, T, Berger, L, Henry, Bet al. Update: severe acute respiratory syndrome – Toronto, 2003. Can Commun Dis Rep 2003; 29: 113–17.
Wong, T, Wallington, T, McDonald, LCet al. Late recognition of SARS in nosocomial outbreak, Toronto. Emerg Infect Dis 2005; 11: 322–5.
Fowler, RA, Guest, CB, Lapinsky, SEet al. Transmission of severe acute respiratory syndrome during intubation and mechanical ventilation. Am J Respir Crit Care Med 2004; 169: 1198–202.
Hawryluck, L, Lapinsky, S, Stewart, T.Clinical review: SARS – lessons in disaster management. Crit Care 2005; 9: 384–9.
Lapinsky, SE, Hawryluck, L.ICU management of severe acute respiratory syndrome. Intensive Care Med 2003; 29: 870–5.
Lapinsky, SE, Granton, JT.Critical care lessons from severe acute respiratory syndrome. Curr Opin Crit Care 2004; 10: 53–8.
Ofner, M, Lem, M, Sarwal, S, Vearncombe, M, Simor, A.Cluster of severe acute respiratory syndrome cases among protected health care workers Toronto, April 2003. Can Commun Dis Rep 2003; 29: 93–7.
Scales, DC, Green, K, Chan, AKet al. Illness in intensive care staff after brief exposure to severe acute respiratory syndrome. Emerg Infect Dis 2003; 9: 1205–10.
Karwa, M, Bronzert, P, Kvetan, V.Bioterrorism and critical care. Crit Care Clin 2003; 19: 279–313.
Andresen, M.“Imminent” flu pandemic: Are we ready?CMAJ 2004; 170: 181.
Fauci, AS.Pandemic influenza threat and preparedness. Emerg Infect Dis 2006; 12: 73–7.
Osterholm, MT.Preparing for the next pandemic. N Engl J Med 2005; 352: 1839–42.
Koopmans, M, Wilbrink, B, Conyn, Met al. Transmission of H7N7 avian influenza A virus to human beings during a large outbreak in commercial poultry farms in the Netherlands. Lancet 2004; 363: 587–93.
Webster, RG, Peiris, M, Chen, H, Guan, Y.H5N1 outbreaks and enzootic influenza. Emerg Infect Dis 2006; 12: 3–8.
Schoch-Spana, M.Implications of pandemic influenza for bioterrorism response. Clin Infect Dis 2000; 31: 1409–13.
Christian, MD, Kollek, D, Schwartz, B.Emergency preparedness: what every healthcare worker needs to know. Can J Emerg Med 2005; 7: 330–7.
Dara, SI, Ashton, RW, Farmer, JC.Engendering enthusiasm for sustainable disaster critical care response: why is this of consequence to critical care professionals?Crit Care 2005; 9: 125–7.
Gani, R, Hughes, H, Fleming, Det al. Potential impact of antiviral drug use during influenza pandemic. Emerg Infect Dis 2005; 11: 1355–62.
Hirshberg, A, Stein, M, Walden, R.Surgical resource utilization in urban terrorist bombing: a computer simulation. J Trauma 1999; 47: 545–50.
Smith, DJ.Predictability and preparedness in influenza control. Science 2006; 312: 392–4.
Christen H, Maniscalco P, Vickery A, Winslow F. An Overview of Incident Management Systems, 4, 2001. Belfer Center for Science and International Affairs, Harvard University:
Shamir, MY, Weiss, YG, Willner, Det al. Multiple casualty terror events: the anesthesiologist's perspective. Anesth Analg 2004; 98: 1746–52.
Honorable Mr Justice Archie Campbell. The SARS Commission Interim Report: SARS and Public Health in Ontario 2004; 12.
Naylor D, Basrur S, Bergeron MG et al. A Report of the National Advisory Committee on SARS and Public Health Learning from SARS – Renewal in Public Health in Canada 2003.
United States of America Federal Emergency Measures Agency. National Incident Management. Homeland Security, System 2004. Resource/assets/NIMS-90-web.pdf.
Hick, JL, Hanfling, D, Burstein, JLet al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med 2004; 44: 253–61.
Cushman, JG, Pachter, HL, Beaton, HL.Two New York City hospitals' surgical response to the September 11, 2001, terrorist attack in New York City. J Trauma 2003; 54: 147–54.
Booth, CM, Stewart, TE.Communication in the Toronto critical care community: important lessons learned during SARS. Crit Care 2003; 7: 405–6.
Klein, JS, Weigelt, JA.Disaster management. Lessons learned. Surg Clin North Am 1991; 71: 257–66.
Frykberg, ER.Medical management of disasters and mass casualties from terrorist bombings: how can we cope?J Trauma 2002; 53: 201–12.
Lim, S, Closson, T, Howard, G, Gardam, M.Collateral damage: the unforeseen effects of emergency outbreak policies. Lancet Infect Dis 2004; 4: 697–703.
Burkle, FM, Jr. Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decisions. Emerg Med Clin North Am 2002; 20: 409–36.
Fine, MJ, Stone, RA, Lave, JRet al. Implementation of an evidence-based guideline to reduce duration of intravenous antibiotic therapy and length of stay for patients hospitalized with community-acquired pneumonia: a randomized controlled trial. Am J Med 2003; 115: 343–51.
Hauck, LD, Adler, LM, Mulla, ZD.Clinical pathway care improves outcomes among patients hospitalized for community-acquired pneumonia. Ann Epidemiol 2004; 14: 669–75.
Marrie, TJ, Lau, CY, Wheeler, SLet al. A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin. JAMA 2000; 283: 749–55.
Ontario Ministry of Health and Long Term Care. Ontario Health Pandemic Influenza Plan. 2006.
Public Health Agency of Canada. Canadian Pandemic Influenza Plan. 2005.
University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group. Stand On Guard For Thee: Ethical Considerations in Preparedness Planning for Pandemic Influenza. 2005.
Domres, B, Koch, M, Manger, A, Becker, HD.Ethics and triage. Prehospital Disaster Med 2001; 16: 53–8.
Baskett, PJ.Ethics in disaster medicine. Prehospital Disaster Med 1994; 9: 4–5.
Vollmar LC. Military medicine in war: the Geneva Conventions today. In: Beam, Thomas E., Sparacino, Linette R., eds., Military Medical Ethics. Washington, DC: Office of The Surgeon General Department of the Army, United States of America, 2003.
Murray, M, Bullard, M, Grafstein, E.Revisions to the Canadian Emergency Department Triage and Acuity Scale Implementation Guidelines. Can J Emerg Med 2004; 6: 421–7.
Ethical issues. Health Disaster Management: Guidelines for Evaluation and Research in the “Utstein Style”. Prehospital Disaster Med 17 2002; 17 (Suppl 3): 128–43.
Knaus, WA, Zimmerman, JE, Wagner, DP, Draper, EA, Lawrence, . APACHE-acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 1981; 9: 591–7.
Knaus, WA, Draper, EA, Wagner, DP, Zimmerman, JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13: 818–29.
Knaus, WA, Wagner, DP, Draper, EAet al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 1991; 100: 1619–36.
Christian, MD, Hawryluck, L, Wax, RSet al. A triage protocol for critical care during a pandemic. CMAJ 2006; 175: 1377–81.
Ferreira, FL, Bota, DP, Bross, A, Melot, C, Vincent, JL.Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 2001; 286: 1754–58.
Benson, M, Koenig, KL, Schultz, CH. Disaster triage: START, then SAVE – a new method of dynamic triage for victims of a catastrophic earthquake. Prehospital Disaster Med 1996; 11: 117–24.
Risavi, BL, Salen, PN, Heller, MB, Arcona, S. A two-hour intervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care 2001; 5: 197–9.
Romig, . Pediatric triage. A system to jump start your triage of young patients at MCIs. JEMS 2002; 27: 52–3.
Garner, A, Lee, A, Harrison, K, Schultz, CH. Comparative analysis of multiple-casualty incident triage algorithms. Ann Emerg Med 2001; 38: 541–8.
Fowler, RA, Lapinsky, SE, Hallett, Det al. Critically ill patients with severe acute respiratory syndrome. JAMA 2003; 290: 367–73.
Rosenbaum, RA, Benyo, JS, O'Connor, REet al. Use of a portable forced air system to convert existing hospital space into a mass casualty isolation area. Ann Emerg Med 2004; 44: 628–34.
Muller, MP, McGeer, A. Febrile respiratory illness in the intensive care unit setting: an infection control perspective. Curr Opin Crit Care 2006; 12: 37–42.
Karwa, M, Currie, B, Kvetan, V. Bioterrorism: preparing for the impossible or the improbable. Crit Care Med 2005; 33(Suppl 1): S75–S95.
Gold W, Hawryluck L, Robinson S, McGreer A, Styra R. Post-traumatic Stress Disorder (PTSD) among Healthcare Workers (HCW) at a Hospital Treating Patients with SARS (abstract). Chicago, IL: presented at 43rd Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC); 14–17 September 2003; K–750a.
Straus, SE, Wilson, K, Rambaldini, Get al. Severe acute respiratory syndrome and its impact on professionalism: qualitative study of physicians' behaviour during an emerging healthcare crisis. BMJ 2004; 329: 83.
Loewy, EH. Duties, fears and physicians. Soc Sci Med 1986; 22: 1363–6.
Alexander, GC, Wynia, MK. Ready and willing? Physicians' sense of preparedness for bioterrorism. Health Aff (Millwood) 2003; 22: 189–97.