Volume 1 Summary

Catastrophic disasters occurring in 2011 in the United States and worldwide—from the tornado in Joplin, Missouri, to the earthquake and tsunami in Japan, to the earthquake in New Zealand—have demonstrated that even prepared communities can be overwhelmed. In 2009, at the height of the influenza A (H1N1) pandemic, the Assistant Secretary for Preparedness and Response (ASPR) at the Department of Health and Human Services (HHS) asked the Institute of Medicine (IOM) to convene a committee of experts to develop national guidance for use by state and local public health officials and health-sector agencies and institutions in establishing and implementing standards of care that should apply in disaster situations—both naturally occurring and manmade—under conditions of scarce resources.

In its letter report, released the same year, the Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations defined these “crisis standards of care” (CSC) to be a “substantial change in the usual health care operations and the level of care it is possible to deliver . . . justified by specific circumstances and . . . formally declared by a state government in recognition that crisis operations will be in effect for a sustained period” (IOM, 2009, p. 3). CSC, planned and implemented in accordance with ethical values, are necessary for the allocation of scarce resources. Public health disasters justify temporarily adjusting practice standards and/or shifting the balance of ethical concerns to emphasize the needs of the community rather than the needs of individuals. Therefore, professional care delivered in a catastrophic disaster may need to be modified to address the demands of the situation, including by focusing more intently on the needs of the entire affected community.

The committee’s 2009 letter report also enumerated five key elements that should underlie all CSC plans:

 

    a strong ethical grounding that enables a process deemed equitable based on its transparency, consistency, proportionality, and accountability;

    integrated and ongoing community and provider engagement, education, and communication;

    the necessary legal authority and legal environment in which CSC can be ethically and optimally implemented;

    clear indicators, triggers, and lines of responsibility; and

    evidence-based clinical processes and operations.



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 1
Summary Volume 1 Catastrophic disasters occurring in 2011 in the United States and worldwide—from the tornado in Joplin, Missouri, to the earthquake and tsunami in Japan, to the earthquake in New Zealand—have demonstrated that even prepared communities can be overwhelmed. In 2009, at the height of the influenza A (H1N1) pandemic, the Assistant Secretary for Preparedness and Response (ASPR) at the Department of Health and Human Services (HHS) asked the Institute of Medicine (IOM) to convene a committee of experts to develop national guidance for use by state and local public health officials and health-sector agencies and institutions in establishing and implementing standards of care that should apply in disaster situations— both naturally occurring and manmade—under conditions of scarce resources. In its letter report, released the same year, the Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations defined these “crisis standards of care” (CSC) to be a “substantial change in the usual health care operations and the level of care it is possible to deliver . . . justified by specific cir- cumstances and . . . formally declared by a state government in recognition that crisis operations will be in effect for a sustained period” (IOM, 2009, p. 3). CSC, planned and implemented in accordance with ethical values, are necessary for the allocation of scarce resources. Public health disasters justify temporarily adjust- ing practice standards and/or shifting the balance of ethical concerns to emphasize the needs of the com- munity rather than the needs of individuals. Therefore, professional care delivered in a catastrophic disaster may need to be modified to address the demands of the situation, including by focusing more intently on the needs of the entire affected community. The committee’s 2009 letter report also enumerated five key elements that should underlie all CSC plans: • a strong ethical grounding that enables a process deemed equitable based on its transparency, con- sistency, proportionality, and accountability; • integrated and ongoing community and provider engagement, education, and communication; • the necessary legal authority and legal environment in which CSC can be ethically and optimally implemented; • clear indicators, triggers, and lines of responsibility; and • evidence-based clinical processes and operations. 1-1

OCR for page 1
Following publication of the 2009 letter report, ASPR, the Department of Veterans Affairs, and the National Highway Traffic Safety Administration requested that the IOM reconvene the committee to con- duct phase two of the study, which involved building on that report, examining its impact, and developing templates to guide the efforts of individuals and organizations responsible for CSC planning and imple- mentation. The committee also was charged with identifying metrics to assess the development of crisis standards of care protocols and developing a set of tools for use at the state and local levels in engaging the public as a necessary step in the development of CSC plans. REPORT DESIGN AND ORGANIZATION This report has a functional format and design that reflect its purpose of providing a resource manual for all stakeholders involved in a disaster response. It is organized as a series of stand-alone resources for ease of use and reference. The first volume includes Chapters 1 through 4. Chapter 1 provides an introduction to the report, including a summary of key elements of CSC identified in the committee’s 2009 letter report, the recommendations from that report, and discussion of the report’s impact as essential context for phase two of the committee’s work. The next three chapters establish a framework for a systems approach to the development and implementation of CSC plans (Chapter 2), and address the legal issues (Chapter 3) and the ethical, palliative care, and mental health issues (Chapter 4) that agencies and organizations at each level of a disaster response should address. The next four chapters are bound as separate volumes, each aimed at a key stakeholder group—state and local governments (Chapter 5), emergency medical services (EMS) (Chapter 6), hospitals and acute care facilities (Chapter 7), and out-of-hospital and alternate care systems (Chapter 8). The text of the chapters defines the roles and responsibilities of these stakeholders, describes operational considerations associated with their development and implementation of CSC plans, and provides brief descriptions of templates that outline the specific functions and tasks for each stakeholder when allocating scarce resources in response to a disaster. The templates are easily located at the end of each chapter by the red bar that runs the length of each page. Chapter 9, again published as a separate volume, includes a brief description of the committee’s work to design the public engagement toolkit and the tools themselves.1 The final volume of the report consists of six appendixes: a glossary of terms used in the report (Appen- dix A), a sample hospital CSC plan (Appendix B), a listing of potentially scarce medical resources (Appendix C), a listing of resource challenges by disaster type (Appendix D), the committee’s statement of task (Appen- dix E), and biographical sketches of the committee members (Appendix F). FRAMEWORK FOR A SYSTEMS APPROACH TO CRISIS STANDARDS OF CARE CSC are just one aspect of broader disaster planning and response efforts; they are a mechanism for respond- ing to situations in which the demand on needed resources far exceeds the resources’ availability. A systems 1 The templates in Chapters 5-8 and the public engagement toolkit can also be downloaded via the project’s website: http://iom.edu/ Activities/PublicHealth/DisasterCareStandards.aspx. 1-2 CRISIS STANDARDS OF CARE

OCR for page 1
approach to disaster planning and response is therefore required to integrate all of the values and response capabilities necessary to achieve the best outcomes for the community as a whole. Successful disaster response depends on coordination and integration across the full system of the key stakeholder groups: state and local governments, EMS, public health, emergency management, hospital facilities, and the outpatient sector. Vertical integration among agencies at the federal, state, and local levels also is crucial. At the cornerstone of this coordination and integration is a foundation of ethical obligations— the values that do not change even when resources are scarce—and the legal authorities and regulatory envi- ronment that allow for shifts in expectations of the best possible care based on the context of the disaster in which that care is being provided. Conceptualizing a Systems Approach to Disaster Response This section broadly outlines a systems framework for disaster response of which CSC is only one, albeit a critical, aspect. However, the development and implementation of CSC plans are the means to mount a response to an incident that far exceeds the usual health and medical capacity and capabilities. Therefore, the same elements that come together to build any successful disaster response should also be used to develop robust CSC plans and guide their implementation. A systems approach is defined as a “management strategy that recognizes that disparate components must be viewed as interrelated components of a single system, and so employs specific methods to achieve and maintain the overarching system. These methods include the use of standardized structure and processes and foundational knowledge and concepts in the conduct of all related activities” (George Washington Uni- versity Institute for Crisis, Disaster and Risk Management, 2009, p. 59). The systems framework that the committee believes should inform the development and implementa- tion of CSC plans (see Figure 2-1) is based on the five key elements of planning set forth in the 2009 letter report. These key elements served as the starting point for the development of the committee’s recommen- dations in that report and are foundational for all disaster response planning. The two cornerstones for the foundation of this framework are the ethical considerations that govern planning and implementation and the legal authority and legal environment within which plans are devel- oped. Ethical decision making is of paramount importance in the planning for and response to disasters. Without it, the system fails to meet the needs of the community and ceases to be fair, just, and equitable. As a result, trust—in professionals, institutions, government, and leadership—is quickly lost. The legal author- ity and legal environment within which CSC plans are the other cornerstone of the framework’s foundation. The legal authority and environment support the necessary and appropriate actions in response to a disaster. Between those two cornerstones of the foundation are the steps needed to ensure that the development and implementation of CSC plans occur. They include provider and community engagement efforts, development of a process that permits individual communities to identify regionally coordinated and consistent indicators that denote a change in the usual manner of health care delivery during a disaster, and the triggers that must be activated in order to implement CSC. These lead to the top step, the implementation of clinical processes and operations that support the disaster response. All of these efforts are supported and sustained by an ongo- ing performance improvement process, an important element of any systems approach to monitor demand (ensuring situational awareness), evaluate the impact of implementation actions, and establish/share best SUMMARY 1-3

OCR for page 1
practices. This process includes education of and information sharing among organizations and individuals responsible for both the planning and response phases of a disaster. The pillars of medical surge response—hospital and outpatient medical care; public health; EMS; and emergency management/public safety agencies, organizations, and authorities—stand on this strong base. Each of these pillars is an element of the disaster response system, representing a distinct discipline, but all need to be well integrated to ensure a unified disaster response. One acting independently of the others may delay, deter, and even disrupt the delivery of medical care in a disaster. Many of these disciplines work together during daily operations. For example, EMS transports bridge the outpatient and hospital com- munities, public health bridges the public safety and hospital communities, and emergency management bridges the hospital and public health communities. But rarely, and in few communities, do all of these response elements come together in a manner that can ensure oversight and care for an overwhelming num- ber of disaster victims. The more complex and dynamic the incident, the more important strong and effective coordination and integration among the pillars becomes, as emphasized by a systems approach. Priorities and objectives should be shared across the entire system to inform the development of unified strategies and the coordinated tactics required to implement them. Applying National Incident Management System/ National Response Framework principles and systems can help improve coordination and ensure the desired outcomes. Atop the pillars are local, state, and federal government functions. Government at all three levels has an overarching responsibility for the development, institution, and proper execution of CSC plans, policies, protocols, and procedures. Good governance encompasses the functions of monitoring and evaluation, as well as accountability and meaningful contributions to policy development (Gostin and Powers, 2006). These functions are especially important in developing plans related to incidents in which the confidence of the public in government institutions may come into question, and the risk of cascading failures and multi- sector disruption, exacerbated by a lack of coordinated response, can mean the difference between thousands of lives lost and saved. Milestones to Guide CSC Planning To ensure that this systems coordination and integration occur, the committee offers specific milestones, enumerated in Box S-1. This systems approach to CSC, and disaster response more generally, provides the context for this report. It balances the specific functions and tasks of each stakeholder group, but also provides a structure for coordinating and integrating their operations to enable a more flexible and dynamic overall response effort while still emphasizing a robust, efficient chain of command. LEGAL ISSUES An array of relevant legal issues should be identified and addressed before disaster strikes. For example, states should evaluate what legal liability protections are in place for their health care workers, volunteers, and health care coalitions, and should determine whether these protections are sufficient or require augmenta- tion. Health care personnel and entities, too, should understand what protections are available to them and 1-4 CRISIS STANDARDS OF CARE

OCR for page 1
BOX S-1 Milestones for Planning and Implementation for Crisis Standards of Carea Establish a State Disaster Medical Advisory Committee.b  1.  2. Ensure the development of a legal framework for CSC implementation.  3. Promote understanding of the disaster response framework among elected of- ficials and senior (cabinet-level) state and local government leadership.  4. Develop a state health and medical approach to CSC planning that can be ad- opted at the regional/local level by existing health care coalitions, emergency re- sponse systems (including the Regional Disaster Medical Advisory Committee),c and health care providers.  5. Engage health care providers and professional associations by increasing their awareness and understanding of the importance and development of a CSC framework.  6. Encourage participation of the outpatient medical community in planning.  7. Ensure that local and state CSC plans include clear provisions that permit adap- tation of EMS systems under disaster response conditions.  8. Develop and conduct public community engagement sessions on the issue of CSC.  9. Support surge capacity and capability planning for health care facilities and the health care and public health systems. 10. Plan for an alternate care system capability.   11. Support scarce resource planning by the RDMAC (if developed) for health care facilities and the health care system. 12. Incorporate crisis/emergency risk communication strategies into CSC plans. 13. Exercise CSC plans at the local/regional and interstate levels. 14. Refine plans based on information obtained through provider engagement, public/community engagement and exercises, and real-life events. 15. Develop a process for continuous assessment of disaster response capabilities. a Given the variability in both how state and local agencies are organized, CSC planning and potential acti- vation will need to take into account varying structures and relationships of governments across states and localities throughout the United States. b See Appendix A, Volume 7 for definition. c See Appendix A, Volume 7 for definition. the fact that these may be role and location dependent. The potential complexity and consequences of the financing and reimbursement of disaster response efforts also should be understood and addressed within and between communities. Thorough comprehension of these legal issues among relevant response stake- holders is crucial to their being resolved prior to a disaster—an opportunity not always afforded for other issues and challenges involved in CSC implementation. In considering the legal environment in a CSC situation, policy makers at all levels must insist that professionals act professionally. There is never a justifica- tion for careless decision making or willful misconduct, especially in the setting of a disaster response, when patients are at their most vulnerable. SUMMARY 1-5

OCR for page 1
CROSS-CUTTING ISSUES: ETHICS, PALLIATIVE CARE, AND MENTAL HEALTH A number of issues are relevant to all four stakeholder groups—governments, EMS, health care facilities, and out-of-hospital and alternate care systems—with roles in the development and implementation of CSC plans. These cross-cutting issues, reviewed briefly below, are incorporated into the guidance and templates provided in this report for each stakeholder group. Ethics Plans and protocols that shift desired patient care outcomes from the individual to the population must be grounded in the ethical allocation of resources, which ensures fairness to everyone. Developing consensus on what a reasonable health care practitioner would do in the event of a disaster will facilitate the transition from conventional to contingency and crisis response during such an incident.2 The emphasis in a public health emergency must be on improving and maximizing the population’s health while tending to the needs of patients within the constraints of resource limitations. With respect to fairness, an ethical policy does not require that all persons be treated in an identical fashion, but does require that differences in treatment be based on appropriate differences among individu- als. If particular groups receive favorable treatment, such as in access to vaccines, this priority should stem from such relevant factors as greater exposure or vulnerability and/or promote important community goals, such as helping first responders or other key personnel stay at work. Policies should account for the needs of the most at risk and support the equitable and just distribution of scarce goods and resources. Implementation of CSC should ideally facilitate the delivery of care to patients to the extent possible by allocating resources to those who are most likely to benefit. The implementation of CSC should ultimately bring better care to more patients and a more equitable distribution of resources to those most likely to ben- efit. The needs of all potentially affected populations must be addressed to ensure fair and equitable plans. Particular attention should also be paid to the needs of the most at-risk and marginalized people, such as the poor and those with mental or physical disabilities. Ultimately, the committee’s understanding of CSC implementation is within the context of support- ing public health efforts through fair and rational processes. The committee’s 2009 letter report outlined an ethical approach to guide CSC planning and responses, and the committee continues to emphasize the importance of an ethical foundation for the fair allocation of scarce medical, public health, and relevant com- munity resources (see previous key principles). The ethical basis for CSC planning has particular implications for policy decisions regarding the allo- cation of scarce resources. Community engagement in the assessment of ethical values that underlie such decisions can help ensure that the decisions are aligned with community values and that those values are integrated by agencies responsible for developing CSC plans where appropriate. The key elements in plan- 2 The surge capacity following a mass casualty incident falls into three basic categories, depending on the magnitude of the incident: con - ventional, contingency, and crisis. These categories also represent a corresponding continuum of patient care delivered during a disaster. As the imbalance increases between resource availability and demand, health care—emblematic of the health care system as a whole—maximizes conventional capacity; then moves into contingency; and, once that capacity is maximized, moves finally into crisis capacity. A crisis situa- tion may lead to an overwhelming demand for services and result in shortages of equipment, supplies, pharmaceuticals, personnel, and other critical resources, necessitating operational adjustments. 1-6 CRISIS STANDARDS OF CARE

OCR for page 1
ning and implementing CSC are particularly relevant to ensuring fair access to resources by disadvantaged or at-risk populations. As a general matter, ethical values do not constitute a process for determining what is the most “ethical” course of action. However, a clear grasp of those values helps policy makers and the public determine which options are within the bounds of ethically viable choices. Moreover, an understanding of ethical values often can illuminate clearly wrong decisions, such as those that would place an unreasonably high share of the burden on a single population (e.g., the elderly, the disabled, the uninsured). Therefore, the committee offers guidance on how to adjust clinical practice in the face of severe resource deficits in a man- ner consistent with ethically valid goals and desired outcomes using a population-based approach. Palliative Care Providing palliative care is an important ethical and medical imperative and, especially with regard to end- of-life care, should include a holistic and humane approach to CSC implementation. Setting the expectation that all patients will receive some care, regardless of the availability or scarcity of resources, is an important component of CSC efforts. Incorporating into CSC planning the capabilities necessary to provide palliative care assures the public that even when curative acute care cannot be provided, every attempt to offer pain management and comfort care to disaster victims will be made, even if comfort care may mean nonpharma- ceutical interventions such as holding a hand or offering words of comfort. Mental Health The social consequences of a disaster and the need to implement CSC will certainly impact the mental health of patients, their families, health care providers, and the general public. The very real potential for mass fatalities during such an incident will undoubtedly tax the system as a whole and exacerbate mental health issues at a population level. Setting appropriate expectations and planning for mental health resilience are important considerations at each level of response by all of the stakeholders developing and implement- ing CSC plans. While addressing mental health issues is challenging, there are unique opportunities to miti- gate mental health impacts by incorporating mental health and resilience provisions into the preparedness, response, and recovery components of CSC planning. GOVERNMENTS A systems approach to disaster response requires that federal, state, and local governments work together to plan and implement CSC, even though each level of government has specific and differing authorities and access to resources. Federal Government The federal government should continue to provide leadership in supporting and encouraging the estab- lishment of guidelines for CSC for use in disaster situations at the state and local levels, whether through direct contact with public health departments and other relevant stakeholders or through the relevant state SUMMARY 1-7

OCR for page 1
governors’ offices. These efforts should emphasize the importance of coordinating such planning within the larger context of surge capacity planning, all as part of a disaster response framework. Inclusion of specific language in the HHS Hospital Preparedness Program and the Centers for Disease Control and Prevention’s Public Health Emergency Preparedness cooperative agreements is the best means of ensuring continued emphasis on this planning. In addition, agencies such as the Centers for Medicare & Medicaid Services are important because of their capacity to influence provider practice, reimbursement, and waivers. Finally agencies such as the the Department of Homeland Security, the Department of Defense, the Department of Transportation, and the Department of Veterans Affairs have relevant grant programs that should include funding opportunities for the planning and implementation of CSC. The federal government can positively influence state government planning, and in the context of the framework established, must be the ultimate driver behind such efforts. State Government3 Emergencies rising to a level that necessitates CSC generally are expected to be multijurisdictional, state- wide, or even multistate events that entail various local, regional, state, and federal roles and authorities. Therefore, considerable state-level coordination with intra- and interstate as well as federal partners is essen- tial. As recommended in the committee’s 2009 letter report, states in particular should lead the development and implementation of CSC protocols “both within the state and through work with neighboring states, in collaboration with their partners in the public and private sectors” (IOM, 2009, p. 4). Depending on the spe- cific nature of the incident, various state agencies, as well as private health care entities, should be involved in CSC planning and response activities because no single agency or health or emergency response entity alone can be expected to handle the challenges presented by a CSC incident. Variations in state agency structures and authorities will often dictate emergency response leadership roles. Therefore, states should have the flex- ibility to develop the organizational structure for CSC planning and implementation that makes the most sense for them. Recognizing that a variety of state agencies and leaders will have pivotal CSC roles, however, the state health department is fundamentally the most appropriate agency to lead and coordinate CSC plan- ning and implementation at the state level and to advise state leadership on CSC issues. Local Government When considering the role of local government in CSC efforts, it is important to remember that, based on how states are structured constitutionally and functionally, vastly different local government structures and relationships exist from state to state. Despite these variations, however, the role of local government in CSC planning and implementation remains crucial. Even though a CSC incident may be widespread and require a systems approach that involves coordinating with all providers and across all levels of government, espe- cially as the geographic area of impact increases, all disasters are ultimately local. At some point, the state CSC plan will need to be incorporated into or adapted for local planning efforts (e.g., development of the health and medical annex of the local emergency operations plan) and will help guide local activities during the response to a catastrophic disaster response. 3 For the purposes of this report, the term “states” encompasses states, tribal jurisdictions, and territories. 1-8 CRISIS STANDARDS OF CARE

OCR for page 1
Local political leaders (e.g., mayor, county executive) and agency leadership also will be involved in local decision making and resource requests during a CSC emergency. This means that local CSC coordination, consistent with state planning and response actions, is critical to achieving the envisioned systems-based CSC response. Local governments are uniquely positioned in the organizational structure of states to inter- sect with both state government partners and the communities in their local jurisdiction(s). Therefore, the involvement of both state and local government leadership is paramount to ensuring that CSC planning and implementation occur. This is especially true because public health and government EMS agencies operate under the direct auspices of state and local government authority. Addressing CSC planning outside of the governmental sphere, especially in the private health care sector, is more difficult. In this regard, emphasis on the importance of a systems approach to CSC planning ensures unified efforts, particularly with respect to the consistency of plan development and implementation. PREHOSPITAL CARE: EMERGENCY MEDICAL SERVICES State EMS offices and prehospital care agencies should be actively engaged in the development and imple- mentation of CSC plans. Adjustments to scopes of practice, treatment modalities, and ambulance staffing and call response will all figure significantly into state, local, and EMS agency-specific disaster response plans. Other areas that can be leveraged to maximize scarce EMS resources include the authority to activate restricted treatment and transport protocols, which may entail modifying the emergency medical dispatch criteria implemented at public safety answering points (i.e., 911 call centers). CSC planning should be inte- grated with the efforts of public health planners to ensure consideration of case management (advice line) call centers, poison control, use of alternate care system destination points for ambulance patients, and limi- tation of care to on-scene treatment without transport. It should also be recognized that much EMS activity in the United States is volunteer based and occurs in rural communities, where resources often are limited on a regular, ongoing basis. These limitations should be addressed through the incorporation of EMS-specific disaster response and CSC plans into relevant disaster preparedness grant guidance. In this context, an important factor in operationalizing the CSC framework set forth in the committee’s 2009 letter report and reiterated in Chapter 2 of this report is specific enumeration of EMS roles, respon- sibilities, and actions in CSC plans. Accordingly, the state agency taking the lead role in coordinating a systems-based catastrophic disaster response should establish consistent triggers and thresholds that indicate the transition from conventional to contingency to crisis care, define a clear mechanism for authorizing CSC activation, provide liability protection for EMS personnel and altered modes of transportation, coordinate emergency operations across the affected region, and address reimbursement issues directly. While stan- dardizing this planning will contribute to consistency in implementing CSC, the different environments in which EMS operates also should be taken into account. HOSPITALS AND ACUTE CARE FACILITIES Clinical operations in hospitals, ambulatory care clinics, and private practices make up the largest single element of the response framework in which CSC will be implemented. Implementation of CSC in the hospital setting will occur through the use of a clinical care committee at each hospital, along with a bi- SUMMARY 1-9

OCR for page 1
directional reporting mechanism with state and local governments. Therefore, careful planning is required at both at the local and regional levels, including plans to ensure intraregional coordination and cooperation. Consistent with the Hospital Preparedness Program and Public Health Emergency Preparedness coopera- tive agreements, disaster response plans should delineate protocols for a shift from the conventional standard of care to ensure that essential health care services will be sustained during the response. CSC plans will be implemented under conditions in which the usual safeguards may not be possible and when resources will be insufficient to allow for the delivery of care under usual operating conditions. It is assumed that under cata- strophic disaster response conditions, resources are unavailable or undeliverable to health care facilities from elsewhere in the region or state; similar strategies are being invoked by other health care delivery systems; and patient transfer to other facilities is not possible or feasible, at least not in the short term. Furthermore, it is recognized that access to key medical countermeasures (e.g., vaccines, medications, antidotes, blood products) is likely to be limited, and these resources should be delivered to patients using guidance that aims to optimize benefits and minimize potential harms. It is also assumed that available local, regional, state, and federal resource caches (of key equipment, supplies, and pharmaceuticals) have already been distributed, and no short-term resupply of such stocks is foreseeable. Although hospitals providing acute care to the community are the focus of this discussion, other health care facilities—such as free-standing surgery centers, urgent care facilities, ambulatory clinics, free-standing emergency departments, nursing homes, federally qualified health centers, and other facilities that can be adapted to provide acute or critical care—can play key roles in a surge response and should be included in planning for and implementation of CSC. All health care facilities providing acute medical care to the com- munity have a “duty to plan” for mass casualty and catastrophic disaster incidents, including planning for the expansion of clinical operations. Hospitals should examine their hazard vulnerability analysis and ensure that they are as prepared as possible for the hazards affecting their community, including the ability to operate as autonomously as possible for up to 96 hours ( Joint Commission emergency medicine standards), or more if the risk of isolation of the facility is high. The importance of conducting exercises in crisis situations, from the provider to the incident command level, cannot be overemphasized. The goal of incident management in situations involving mass casualties or catastrophic failure of criti- cal infrastructure is to get the right resources to the right place at the right time. This may involve anticipat- ing shortfalls, adapting responses, partnering with other stakeholder agencies to provide alternate care sites for patient volumes that cannot be accommodated within the usual medical facilities, and other strategies. Therefore, a regionally coordinated response is imperative to facilitate consistent standards of care within all affected communities after a disaster. Regional coordination enables the optimal use of available resources; facilitates obtaining and distributing resources; and provides a mechanism for policy development and situ- ational awareness that is critical to avoiding crisis situations and, when a crisis does occur, ensuring fair and consistent use of resources to provide a uniform level of care across the region. 1-10 CRISIS STANDARDS OF CARE

OCR for page 1
OUT-OF-HOSPITAL AND ALTERNATE CARE SYSTEMS While much of disaster and surge capacity planning focuses on hospital-based care, approximately 89 per- cent of health care is delivered in outpatient settings (Hall et al., 2010; Schappert and Rechtsteiner, 2011). Especially during an epidemic, failure to leverage outpatient resources may result in catastrophic overload of inpatient and hospital-affiliated resources. For this reason, efforts to improve the integration of outpatient care assets into disaster response are critical, not only to ensure the provision of crisis care but also to avoid crisis care. However, the value of the outpatient sector—its diversity—is also its challenge: the numbers and varying types of clinics and providers in a given area (in addition to long-term care, outpatient surgery, and other medical facilities) hamper detailed coordinated planning. Unlike other emergency response entities (e.g., municipal or county-run EMS), private health care facilities and providers cannot simply be “assigned” by public health officials to develop outpatient surge capacity, and private health care cannot assume that public health can provide the clinical leadership or resources (especially medical providers) needed to estab- lish effective alternate care systems. Both have a joint responsibility for and distinct but equally necessary roles in efforts to advance outpatient CSC planning to ensure that the health care goals of catastrophic disaster response can be accomplished through coordinated efforts. PUBLIC ENGAGEMENT The committee’s 2009 letter report highlighted meaningful public engagement as one of the five key ele- ments of CSC planning. Policy makers should involve the public in a structured dialogue about the implica- tions and likelihood of having to allocate health care delivery and essential vaccines or medicines ethically in the event of a catastrophic disaster. To facilitate this involvement, the committee developed a public engagement toolkit. This resource should support CSC planning efforts by enabling state and local health departments and other interested planners to initiate conversations with the community regarding these difficult issues. Community engagement probably is best timed to start after the planning teams (the state and regional disaster medical advisory committees) have had an opportunity to consider all of the pertinent issues and draft a plan, but before a plan is finalized. RECOMMENDATION To enhance and elaborate on the recommendations from its 2009 letter report, which it still fully supports, the committee developed a set of templates identifying the core functions and tasks for individuals and organizations involved in CSC planning and implementation. In developing these resources, the committee emphasized the use of a systems approach that integrates CSC planning into the larger context of overall surge capacity planning. The entire emergency response system—each component acting both indepen- dently and as part of a coherent and integrated group—should adopt such a framework to deliver the best care possible to the largest number of patients. SUMMARY 1-11

OCR for page 1
w Decide what will be done about those expected to die imminently who do not (and establish a process for retriage). o Alternate care sites for palliative care w Decide what equipment (e.g., dialysis, oxygen, monitors/pulse oximeters/labora- tory equipment/x-ray) is needed. w Determine the need for beds/facilities (e.g., nursing homes, retirement commu- nities)—specific spaces vs. integrated. w Will mass casualties require facilities other than the ones they are in at the time of the incident (e.g., target patients in acute care facilities, alternate care sites)? Long-term care providers could provide shelter and daily care to at-risk elderly and disabled persons who ordinarily live at home at a time when home environ- ments are unsafe (lack of power, water, etc.). o What levels of care are to be delivered in what settings and by whom? o Clearly identify lines of authority and responsible personnel. • Address issues related to supplies/drugs (stockpiled where/by whom, how to deliver, shelf life, security, storage, controlled substance administration, subcutaneous but- terfly needles [tegraderm so syringes can be reused to connect to the subcutaneous port for ongoing medication administration]). Consider specific drugs to alleviate symptoms: o opioids—oral and injectable—to treat anxiety, pain, dyspnea, agitation; o antianxiety drugs—benzodiazepines, antipsychotics (oral and injectable); o acetaminophen and other nonprescription, nonopioid comfort medications (non- steroidal anti-inflammatory drugs [NSAIDs], diphenhydramine); o diuretics to treat dyspnea; o steroids to manage pain from inflammation and dyspnea; and o antinausea and antidiarrheal medications. *Note that this determination needs to accord with community expectations/priorities, and any triage scheme should be uniform, not designed to address a specific population (e.g., patients in long-term care). SOURCES: Holt, 2008; Wilkinson et al., 2007. mitigate these impacts by incorporating the social and psychological aspects of disaster response into CSC planning, as proposed in the committee’s 2009 letter report (IOM, 2009). Scope of the Issue and Range of Impact CSC poses unique challenges for all involved in a disaster, including health care providers (and their fami- lies), patients receiving health care, and the public. Although health care providers may confront life-and-death decisions on a daily basis and routinely experience the loss of patients, CSC differs from these experiences both quantitatively and qualitatively. For example, as soon as care shifts from a focus on the needs of individual patients to a focus on the greatest good CROSS-CUTTING THEMES 1-87

OCR for page 1
for the most people, the entire health care team may have very different experiences with life-and-death decisions. If a disaster results in mass casualties, a significant threat to the mental health of the health care workforce may result. If not sufficiently addressed, these foreseeable mental health consequences may further degrade the functionality of the health care system and its ability to implement CSC optimally. Health care workers may bear the double burden of stress due to their professional roles and that due to seeing their families and friends requiring care within the CSC context. In some public health emergencies, moreover (such as the epidemic of severe acute respiratory syndrome [SARS]), health care workers themselves are subject to elevated health and mental health risks (Hawryluck et al., 2004; Lin et al., 2007). Patients and families also will face significant psychosocial impact. The idea that CSC treatment deci- sions are based on the most good for the most people may run counter to their previous experiences, expec- tations, and wishes. If patients encounter CSC decisions that involve life-and-death consequences for their loved ones (which also may include disproportionate numbers of children and their parents), a significant population-level mental health burden and even the potential to unravel the social fabric of communities may result. Relationships between providers and their patients and patients’ families will face unprecedented complexities as CSC decisions are communicated and implemented and their consequences unfold at the clinic or bedside. Following the anthrax attacks in 2001, for example, the complexity of evolving risk com- munications and perceptions of differences in care among patient groups reflected episodic confusion among local and federal public health officials, medical providers, and patients (see Gursky et al. [2003] for a review). Public health emergencies that involve both CSC and social distancing may be particularly chal- lenging as common sources of support, and hence resilience, are reduced (Gostin, 2006). When these issues evolve on a regional or national scale, the potential for the perception of inequal- ity in the application of CSC grows, and the protective impact of the sense that “we are in this together” is diminished, posing a threat to resilience. Although prosocial behavior is by far the most commonly observed collective response after a disaster (Glass and Schoch-Spana, 2002), planning should take into account the potential for negative social behaviors that may include aspects of panic. Indeed, there is limited consensus that certain features of emergency situations can trigger panic-like phenomena. For example, following the Three Mile Island nuclear incident, for every person that was asked to evacuate, 45 actually did, creating unintended gridlock. The prospect of pandemic influenza, which could entail significant morbidity and mortality, may also generate some undesirable collective behaviors among those attempting to avoid conta- gion, such as obtaining nonrecommended antiviral prophylaxis. Following the recent nuclear meltdown in Japan, for example, sales of potassium iodide, a treatment that prevents uptake of radioactive iodine by the thyroid gland, skyrocketed. Worldwide availability of potassium iodide ceased altogether for a period of time despite the quadrupling of prices (Aleccia, 2011). Factors that may be tied to the potential for mass panic in the CSC context include • a belief that there is a small chance of escape from the agent, • perceived high risk, • available but limited treatment resources, • no perceived effective response, and • loss of credibility of authorities (DeMartino, 2001). 1-88 CRISIS STANDARDS OF CARE

OCR for page 1
A high-mortality incident entailing CSC may have sufficient triggers to ignite panic behavior in some individuals and subpopulations. These risks occur against a backdrop of the recent finding that only 35 percent “of the American public is confident in the health care system’s readiness to respond effectively to a deadly flu pandemic” (National Center for Disaster Preparedness, 2005, p. 1). For example, among respondents to the Los Angeles County Health Survey, which included questions regarding terrorism pre- paredness, 17 percent reported having developed an emergency plan and 28 percent maintaining additional supplies of food, water, and clothing (Eisenman et al., 2006). The full range of these impacts at the public level needs to be considered more fully. Traditional risk communications that focus on content are necessary but not sufficient to facilitate resilience and manage the emotional fallout that public health emergencies can engender. Engagement of the public (and health care providers) is essential to maintaining individual and community resilience (see Chapter 9). In fact, it should be regarded as a fundamental component of preparedness such that it is incorporated throughout the stages of response in a public health emergency that requires CSC. Finally, there is a largely uncharted opportunity to leverage social media to facilitate national resil- ience in the face of a disaster. These media could be used to convey the notion that, despite challenges and traumatic outcomes for some, “we are in this together,” and to clarify the use of a common CSC approach governed by the ethical principles outlined in this report. Patients with Psychiatric Emergencies as a Particular Crisis Standards of Care Subpopulation In many communities across the United States, the allocation of scarce resource is already necessary to address chronic shortages of inpatient mental health beds for adults and children (Geller and Biebel, 2006; SAMHSA, 2007). In some communities, patients presenting to the emergency department with life- threatening mental health conditions are never transferred to an appropriate level of care or must wait days in the emergency department environment before receiving definitive psychiatric care (Schumacher Group, 2010). In some disaster scenarios, demand on these resources may be even greater, magnifying the need to develop CSC specific to psychiatric emergencies that entail immediate danger to those gravely disabled by their psychiatric illness or others. The development of CSC specific to the management of highly limited involuntary psychiatric resources will also be necessary. Strategies will need to consider cases in which psy- chiatric patients with comorbid medical conditions require care under CSC (see the HHS [2012] definition of at risk). Operational Guidance to Enhance Resilience and Manage the Mental Health Consequences of Crisis Standards of Care The 2009 letter report offered specific strategies and described several national best-practice initiatives with respect to managing the mental health consequences of mass casualty events (IOM, 2009). Here the com- mittee offers more detailed operational guidance tailored to patients, providers, and the general public. At the various levels of hospital facility, local/regional, and state planning, the following elements are necessary to address the continuum of resilience and mental health issues tied to CSC (see also Box 4-4): CROSS-CUTTING THEMES 1-89

OCR for page 1
BOX 4-4 F unctions for Mental Health Response to Crisis Standards of Care • Suggested: Concept of mental health operations in CSC integrated into incident command system and other response structures and plans • Specific capabilities and capacities required for patients/families, providers, and the general public in response to CSC: o Rapid mental health triage system with “floating triage algorithm” linking di- saster systems of care, including hospitals, clinics, etc., with local/regional and state response systems in near real time (Pynoos et al., 2004; Schreiber, 2005); real-world examples: PsySTART Rapid Triage System in Los Angeles County, State of Minnesota Department of Public Health, American Red Cross’s Disaster Mental Health Triage and Surveillance System Continuum of acute phase evidence-based interventions o Psychological first aid adapted specifically for community resilience/social sup- o port enhancement in a CSC context and for use by the general public, health care workers, and disaster systems of care; example: Los Angeles Department of Pub- lic Health’s community resilience program with “Listen, Protect and Connect— neighbor to neighbor, family to family” psychological first aid/social support Development of behavioral coping component of risk communications (NBSB, o 2008), including creation of new “coping with CSC” messaging Gap analysis with action plan to build key local disaster mental health and spiri- o tual care capacities without mutual aid, including capacity to leverage novel, evidence-based Internet interventions for posttraumatic stress disorder (PTSD), depression, anxiety, and substance abuse Development of health care provider resilience capabilities and approaches o with preincident stress inoculation, “individual/family resilience planning,” acute phase self-triage and Internet-based interventions for higher-risk subset (see Ruggiero et al., 2011); example: the “Anticipate, Plan, and Deter” health protec- tion/resilience system, which includes preincident preparedness (stress inocula- tion), development of responder “resilience plans” (including family plans, social support systems, and basic psychological first aid), and identification of cumula- tive stress burden with Internet-based interventions for those at risk SOURCE: Pynoos et al., 2004; Schreiber, 2005. • A disaster mental health concept of operations and operational disaster mental health plan should be developed. o These plans may guide the disaster mental health response in an all-hazards context but include incidents that trigger CSC (and surge demand) for mental health resources. o The plans should address the full continuum of those affected, from those with pre-existing mental illness, to those directly affected by the implementation of CSC and their families, to health care workers who must implement CSC, to the general public. • Plans should address the anticipated consequences of CSC incidents through a gap analysis of the range of expected mental health impacts versus current resources. When informed by such an 1-90 CRISIS STANDARDS OF CARE

OCR for page 1
analysis, triage decisions reflect a rational allocation of limited disaster mental health resources. During response, near-real-time awareness of needs and resources informs a floating triage algo- rithm of risk levels versus resources, guided by the ethical framework set forth in this report. • Evidence-based interventions should be identified for the high-risk subset of providers; patients; and surviving family members, including children (e.g., trauma-focused cognitive-behavioral ther- apy for children, prolonged-exposure cognitive-behavioral therapy for adults, and other commonly employed techniques [IOM, 2007; Stokes and Jones, 1995]). • Core competencies and training curricula should be developed for o mental health, social services, and spiritual care staff; o health care providers; and o the public—basic strategies for community resilience that community members can use with friends and family (such as very basic psychological first aid, created specifically for these popula- tions) (see also Chapter 9 on public engagement). • Site, local/regional, and state-level incident command operations should be augmented to integrate mental health operations into emergency operations center operations. These efforts should encom- pass mental health needs assessment and operations for patients/disaster victims and responders (including health care workers and their families) to create user-defined situational awareness of acute mental health gaps, including o a user-defined/common operating picture of the continuum of population-level mental health risks (traumatic loss, multiple traumatic losses); o a user-defined/common operating picture of the continuum of mental health risks to health care workers; and o a user-defined/common operating picture of mental health resources, including telephone, tri- age, and novel Internet-based interventions. • Comprehensive resilience programs for health care workers/responders should be developed that integrate personal behavioral coping and agency preparedness. These programs should encompass preincident stress inoculation, development of personal resilience “plans,” simple peer-to-peer psy- chological first aid, self-triage, and linkage to Internet-based interventions for those at higher risk who desire further support. For Patients and Their Families In a mass casualty event involving high rates of illness, injury, and mortality, disaster mental health resources, like health care resources generally, are likely to experience significant surge demand. Although there may be considerable individual and community resilience, many others will be at risk for developing new-incidence comorbid disorders, such as posttraumatic stress disorder, depression, and substance abuse. Others with pre- existing mental health disorders, including those that are severe and persistent, may experience relapse or worsening of illness episodes (NBSB, 2008). The phenomenon known as “traumatic grief ” can result when CROSS-CUTTING THEMES 1-91

OCR for page 1
the death of a loved one occurs in a particularly traumatic context; CSC may be such a context for many and thus could lead to widespread traumatic grief (NCTSN, 2004). When adults or children develop symp- toms of traumatic grief, they require specialized interventions, such as trauma-focused cognitive-behavioral therapy for children and prolonged-exposure cognitive-behavioral therapy for adults (IOM, 2007). While resilience is common after the loss of loved ones, rates of resilience may drop by as much as 50 percent when traumatic grief is present (Norris, 2005; Shear et al., 2005). Therefore, the capacity to provide evidence- based care for traumatic loss is a key requirement under CSC. There is also growing evidence that certain evidence-based interventions, when provided early after a traumatic incident, may significantly reduce long-term mental health consequences (Bisson, 2008; Roberts et al., 2010; Shalev et al., 2012). However, early rapid triage is needed to allocate these resources to those at risk (Schreiber, 2005; Schreiber et al., in press). The ability to provide a continuum of evidence-based care, based on triage risk, is a hallmark of community resilience planning. Both specific coping information on traumatic grief (NCTSN, 2004) and additional coping information specific to expected reactions to CSC need to be developed. Potential risk factors include experiencing traumatic loss (including missing family members); seeing many dead or injured or hearing cries of pain; being trapped or unable to evacuate; and experiencing persistent stressors, such as ongoing injury or illness due to a disaster, home loss, and disaster- induced relocation. Therefore, strategies employed at the population level should utilize evidence-based rapid triage to help identify those at greatest risk for more sustained and serious consequences and allocate limited mental health resources to those at the highest level of evidence-based risk for sustained disorder and impairment. One example is the PsySTART disaster mental health rapid triage system, currently used by the American Red Cross and the Minnesota Department of Health, and available to 83 Los Angeles–area hospitals and community clinic agencies in the Los Angeles County Emergency Medical Services Agency Hospital Pre- paredness Program. Although there are certainly challenges to implementing such strategies, the ability to align and allocate limited mental health resources is necessary to address the needs of those at higher risk for acute psychiatric emergencies and enduring psychological consequences. The Los Angeles EMS agency has operationalized this model in proposed modifications to the hospital incident command system and evalu- ated its use in a recent statewide disaster medical exercise, which revealed acceptable levels of mental health triage accuracy in a simulated countywide mass casualty incident (Schreiber et al., 2011). There are certainly daily challenges in accessing care for psychiatric emergencies. Within the CSC/disaster context, however, there are unique opportunities to advance surge management of risk and to improve population-level resil- ience by employing the combination of rapid disaster mental health triage (using a shifting or “floating” tri- age algorithm of dynamic alignment of resources with highest risk); “stepped” care case management (Zatzick et al., 2011), which involves maximizing population-level mental health impact or reach through timely triage-informed allocation of high-intensity treatment resources and increasing service intensity only after lower-intensity efforts are found insufficient; and evidence-based, nternet-based interventions (Ruggiero et al., 2011), which address surge demands and stigma through targeted modules for depression, posttraumatic stress, substance abuse, and anxiety. 1-92 CRISIS STANDARDS OF CARE

OCR for page 1
For Health Care Providers As noted above, responders and health care workers typically exhibit high levels of resilience following a disaster response. When CSC must be utilized, however, this may not be the case. A number of features of CSC—the potential for dramatically high mortality rates, including pediatric deaths; the stress of imple- menting and communicating about CSC with individual patients, their families, and others—pose severe mental health threats to health care workers. Available research suggests that many or most health care workers expect to face major barriers to their ability and/or willingness to perform hypothetical emergency health care roles (Chaffe, 2009; DiGiovanni et al., 2003; DiMaggio et al., 2005). In this regard, strategies needed for providers mirror those needed for patients—the use of rapid triage to identify those at highest risk and those with other concerns, and to align limited disaster mental health resources rationally and ethi- cally to providers with the greatest needs. A number of localities have developed pilot efforts to enhance resilience in disasters. Los Angeles County, one of several examples, has initiated a provider resilience project, called Anticipate, Plan and Deter, that leverages stress inoculation in the preparedness phase, including aspects of CSC, and self-triage/ monitoring in the response phase for the creation of a “personal resilience plan” for the health care workforce (Schreiber and Shields, 2011; Schreiber et al., in press). Psychological first aid is another approach that can be used by mental health workers, health care pro- viders, and patients and their families, as well as the general public. Currently, there are a number of dif- ferent models for psychological first aid: one that is among the most comprehensive and intended for use by trained mental health care providers (NCTSN, 2006); another that is intended for use by community disaster responders with no mental health background (American Red Cross, 2006); and yet another, called Listen, Protect and Connect, designed specifically for the provision of basic psychological first aid and psy- chosocial support by all members of the community (Gurwitch and Schreiber, 2010). Listen, Protect, and Connect is a method for enhancing social support using three simple principles at the family, neighborhood, and community levels. It is intended as an achievable community resilience capability to strengthen social ties at the most basic levels of social connection. So-called “Mhealth” versions and provider versions for CSC are currently in development as part of the Los Angeles County Community Disaster Resilience Project. Aimed at the general community, Listen, Protect, and Connect has versions for children and parents and for teachers, as well as a “neighbor-to-neighbor, family-to-family” all-ages version. These versions were recently adapted for the Los Angeles County Department of Public Health and its community disaster preparedness partners, including the medical reserve corps, community health clinics, hospitals, public health workers, schools, and first responders.1 These versions are available without cost from http://www.cdms.uci.edu/protect.pdf. 1 CROSS-CUTTING THEMES 1-93

OCR for page 1
REFERENCES ACEP (American College of Emergency Physicians). 2006. Disaster medical services. Irving, TX: ACEP, http://www.acep.org/ Content.aspx?id=29176 (accessed March 4, 2012). ACEP. 2008. Disaster planning and response. Irving, TX: ACEP, http://www.acep.org/Content.aspx?id=40342 (accessed March 4, 2012). AHRQ (Agency for Health Research and Quality). 2005. Altered standards of care in mass casualty events: Bioterrorism and other public health emergencies. Publication no. 05-0043. Rockville, MD: AHRQ. AHRQ. 2007. Mass medical care with scarce resources: A community planning guide. Publication no. 07-0001. Rockville, MD: AHRQ, http://archive.ahrq.gov/research/mce/ (accessed February 28, 2012). Aleccia, J. 2011 (March 17). Popping potassium iodide already? Really bad idea. http://www.msnbc.msn.com/id/42135438/ ns/health-health_care/ (accessed March 4, 2012). American Red Cross. 2006. Psychological First Aid: Helping Others in Times of Stress. DSCLS206A. Washington, DC: Ameri- can Red Cross, http://www.cincinnatiredcross.org/pdf/Psychological%20First%20Aid%20Participant%20Workbook. pdf (accessed March 1, 2012). Berry, P. H., and M. Matzo. 2004. Death and an aging society. In Gerontological palliative care nursing, edited by M. Matzo, and D. W. Sherman. St. Louis, MO: Mosby. Pp. 31-51. Bisson, J. I. 2008. Using evidence to inform clinical practice shortly after traumatic events. Journal of Traumatic Stress 21(6):507-512. Cantrill, S. V., P. T. Pons, C. J. Bonnett, S. Eisert, and S. Moore. 2009. Disaster alternate care facilities: Selection and operation. Prepared by Denver Health under Contract No. 290-20-0600-020. AHRQ Publication no. 09-0062. Rockville, MD: AHRQ. CDC (Centers for Disease Control and Prevention). 2009. 2009 H1N1 vaccination recommendations. http://www.cdc.gov/ h1n1flu/vaccination/acip.htm (accessed March 4, 2012). Census Scope. Social science data analysis network. http://www.censusscope.org/us/chart_age.html (accessed February 25, 2011). Chaffe, M. 2009. Willingness of health care personnel to work in a disaster: An integrative review of the literature. Disaster Medicine and Public Health Preparedness 3(1):42-56. Christian, M. D., L. Hawryluck, R. S. Wax, T. Cook, N. M. Lazar, M. S. Herridge, M. P. Muller, D. R. Gowans, W. Fortier, and F. M. Burkle. 2006. Development of a triage protocol for critical care during an influenza pandemic. Canadian Medi- cal Association Journal 175(11):1377-1381. Cone, D. C., and D. S. MacMillian. 2005. Mass-casualty triage systems: A hint of science. Academic Emergency Medicine 12(8):739-741. DeMartino, R. 2001 (unpublished). Planning for the unexpected: Behavioral health in a new era of bioterrorism [at the National Summit on Addressing Terrorism]. Rockville, MD: SAMHSA (Department of Health and Human Services, Substance Abuse and Mental Health Agency). Devereaux, A. V., J. R. Dichter, M. D. Christian, N. N. Dubler, C. E. Sandrock, J. L. Hick, T. Powell, J. A. Geiling, D. E. Amundson, T. E. Baudendistel, D. A. Braner, M. A. Klein, K. A. Berkowitz, J. R. Curtis, and L. Rubinson. 2008. Defini- tive 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(Suppl. 5):S51-S66. DiGiovanni, C., Jr. 2003. The spectrum of human reactions to terrorist attacks with weapons of mass destruction: Early man- agement considerations. P rehospital and Disaster Medicine 18(3):253-257. DiMaggio, C., D. Markenson, G. Loo, and I. Redlener. 2005. The willingness of U.S. emergency medical technicians to respond to terrorist incidents. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 3(4):331-337. Domres, B., A. Manger, I. Steigerwald, and S. Esser. 2003. The challenge of crisis, disaster, and war: Experience with UN and NGOs. Pain Practice 3(1):97-100. Eisenman, D. P., C. Wold, J. Fielding, A. Long, C. Setodji, S. Hickey, and L. Gelberg. 2006. Differences in individual-level preparedness in Los Angeles County. American Journal of Preventative Medicine 30(1):1-6. Fink, S. 2009. Deadly choices at memorial. NY Times Magazine, August 27. Galea, S., and H. Resnick. 2005. Posttraumatic stress disorder in the general population after mass terrorist incidents: Consid- erations about the nature of exposure. CNS Spectrums 10(2):107-115. 1-94 CRISIS STANDARDS OF CARE

OCR for page 1
Garrett, J. E., D. E. Vawter, K. G. Gervais, A. W. Prehn, D. A. DeBruin, F. Livingston, A. M. Morley, L. Liaschenko, and R. Lynfield. 2011. The Minnesota Pandemic Ethics Project: Sequenced, robust public engagement processes. Journal of Participatory Medicine 3, http://www.jopm.org/evidence/research/2011/01/19/the-minnesota-pandemic-ethics-project- sequenced-robust-public-engagement-processes/ (accessed January 18, 2012). Geller, J. L., and K. Biebel. 2006. The premature demise of public child and adolescent inpatient psychiatric beds. Psychiatric Quarterly 77:251-271. Glass and Schoch-Spana. 2002. Bioterrorism and the people: How to vaccinate a city against panic. Clinical Infectious Diseases 34(2):217-23. Gostin, L. O. 2006. Public health strategies for pandemic influenza. Journal of the American Medical Association 295(14):1700-1704. Gursky, E., T. V. Inglesby, T. O’Toole. 2003. Anthrax 2001: Observations on the medical and public health response. Biosecu- rity and Bioterrorism: Biodefense Strategy, Practice, and Science 1(2):97-110. Gurwitch, R., and M. Schreiber. 2010. Coping with disaster, terrorism and other trauma. In The parent’s guide to psychological first aid, edited by G. Koocher and A. LaGreca. Boston, MA: Oxford University Press. Pp. 342-351. Hawryluck, L., W. Gold, S. Robinson, S. Pogorski, S. Galea, and R. Strya. 2004. SARS control and psychological effects of quarantine, Toronto, Canada. Emerging Infectious Diseases 10(7):1208-1212. HHS (Department of Health and Human Services). 2011. Guidance for integrating culturally diverse communities into planning for and responding to emergencies: A toolkit. Washington, DC: HHS Office of Minority Health, http://www.hhs.gov/ocr/ civilrights/resources/specialtopics/emergencypre/omh_diversitytoolkit.pdf (accessed January 11, 2012). HHS. 2012. At-risk individuals. Washington, DC: HHS, http://www.phe.gov/Preparedness/planning/abc/Documents/at- risk-individuals.pdf (accessed February 13, 2012). Hippen, B., R. Thistlethwaite, and L. Ross. 2011. Risk, prognosis, and unintended consequences in kidney allocation. New England Journal Medicine 364(14):1285-1287. Holt, G. R. 2008. Making difficult ethical decisions in patient care during natural disasters and other mass casualty events. Otolaryngology—Head & Neck Surgery 139(2):181-186. IOM (Institute of Medicine). 2007. Treatment of PTSD: An Assessment of The Evidence. Washington, DC: The National Academies Press. IOM. 2009. Guidance for establishing crisis standards of care for use in disaster situations: A letter report. Washington, DC: The National Academies Press, http://www.nap.edu/catalog.php?record_id=12749 (accessed September 6, 2011). IOM. 2010. P reventing transmission of pandemic influenza and other viral respiratory diseases: Personal protective equipment for healthcare personnel update 2010. Washington, DC: The National Academies Press. Iserson, K.V., and N. Pesik. 2003. Ethical resource distribution after biological, chemical, or radiological terrorism. Cambridge Quarterly of Healthcare Ethics 12(4):455-465. Janousek, J. T., D. E. Jackson, R. A. DeLorenzo, and M. Coppola. 1999. Mass casualty triage knowledge of military medical personnel. Military Medicine 164(5):332-336. Levin, D., R. O. Cadigan, P. D. Biddinger, S. Condon, H. K. Koh; Joint Massachusetts Department of Public Health-Harvard Altered Standards of Care Working Group. 2009. Altered standards of care in an influenza pandemic: Identifying ethical, legal and practical principles to guide decision-making. Disaster Medicine and Public Health Preparedness 3(Suppl. 2):1-9. Lin, C. Y., Y. C. Peng, Y. H. Wu, J. Chang, C. H. Chan, and D. Y. Yang. 2007. The psychological effect of severe acute respira- tory syndrome on emergency department staff. Emerging Medicine Journal 24(1):12-7. Louisiana Department of Health and Hospitals. 2011. Crisis standards of care summary. Baton Rounge, LA: Louisiana Depart- ment of Health and Hospitals, http://new.dhh.louisiana.gov/assets/oph/Center-PHCH/Center-CH/infectious-epi/ Influenza/CSOCPublicFLYERvs210132011.pdf (accessed February 5, 2012). Matzo, M. L. 2004. Palliative care: Prognostication and the chronically ill. American Journal of Nursing 104(9):40-50. Matzo, M., A. Wilkinson, J. Lynn, M. Gatto, and S. J. Phillips. 2009. Palliative care considerations for mass casualty events with scarce resources. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 7(2):199-210. National Center for Disaster Preparedness. 2005. Survey of Confidence in Government’s Abilities in Face of Hurricanes, Pandemic Flu, and Threats of Terrorism. New York: Columbia University Mailman School of Public Health, http://www.ncdp. mailman.columbia.edu/files/Marist%20Survey%202005%20press%20release%20final.pdf (accessed February 28, 2012). CROSS-CUTTING THEMES 1-95

OCR for page 1
NBSB (National Biodefense Science Board). 2008. Disaster mental health recommendations: report of the disaster mental health subcommittee of the National Biodefense Science Board. Washington, DC: NBSB, http://www.phe.gov/Preparedness/legal/ boards/nbsb/Documents/nsbs-dmhreport-final.pdf (accessed February 28, 2012). NCTSN (National Child Traumatic Stress Network). 2004. What is childhood traumatic grief. Los Angeles, CA: NCTSN, http://www.nctsn.org/trauma-types/traumatic-grief/what-childhood-traumatic-grief (accessed January 18, 2012). NCTSN. 2006. Psychological First Aid: field operations guide 2nd edition. Los Angeles, CA: NCTSN, http://www.nctsn.org/ sites/default/files/pfa/english/2-psyfirstaid_final_no_handouts.pdf (accessed March 4, 2012). Norris, F. H. 2005. Range, multitude, and duration of the effects of disasters on mental health: Review update, 2005. Hanover, NH: Dartmouth College and the National Center for PTSD. Organ Procurement and Transplantation Network. 2011. Concepts for kidney allocation. http://optn.transplant.hrsa.gov/ SharedContentDocuments/KidneyConceptDocument.pdf (accessed March 4, 2012). Orr, R. D. 2003. Ethical issues in bioterrorism. Bioterrorism email module #12. Burlington, VT: Fletcher Allen Health Care in conjunction with the University of Vermont College of Medicine. Pandemic Influenza Ethics Initiative Workgroup of the Department of Veterans Affairs. 2009 (April). Meeting the Chal- lenge of Pandemic Influenza: Ethical Guidance for Leaders and Health Care Professionals in the Veterans Health Adminis- tration. Washington, DC: VA (Department of Veterans Affairs), http://www.ethics.va.gov/docs/pandemicflu/ Meeting_the_Challenge_of_Pan_Flu-Ethical_Guidance_VHA_20100701.pdf (accessed March 4, 2012). Pediatric Emergency Mass Critical Care Task Force. 2012. Ethical issues in pediatric emergency mass critical care. Pediatric Critical Care Medicine. Persad, G., A. Wertheimer, and E. Emanuel. 2009. Principles for allocation of scarce medical interventions. Lancet 373:423-431. Peterson, M. 2008. The moral importance of selecting people randomly. Bioethics 22(6):321-327. Public Health-Seattle and King County. 2009. Public engagement project on medical service prioritization during an influenza pandemic: Health care decisions in disasters, September 2009. http://s3.amazonaws.com/propublica/assets/docs/seattle_ public_engagement_project_final_sept2009.pdf (accessed March 4, 2012). Pynoos, R., M. Schreiber, A. Steinberg, and B. Pfefferbaum. 2004. Impact of Terrorism on Children. In Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 8th ed., edited by B. Sadock and V. Sadock. Philadelphia, PA: Lippincott, Williams and Witkins. Pp. 3551-3564. Rebmann, T., R. Wilson, S. LaPointe, B. Russell, and D. Moroz. 2009. Hospital infectious disease emergency preparedness: A 2007 survey of infection control professionals. American Journal of Infection Control 37(1):1-8. Roberts, N. P., N. J. Kitchiner, J. Kenardy, and J. I. Bisson. 2010. Early psychological interventions to treat acute traumatic stress symptoms. Cochrane Database of Systematic Reviews 17(3):CD007944. Ruggiero, K. J., H. S. Resnick, L. A. Paul, K. Gros, J. L. McCauley, R. Acierno, M. Morgan, and S. Galea. 2011. Random- ized controlled trial of an internet-based intervention using random-digit-dial recruitment: The Disaster Recovery Web project. Contemporary Clinical Trials 33(1):237-246. Sacco, W. J., M. Navin, K. E. Fiedler, and R. K. Waddell. 2005. Precise formulation and evidence-based application of resource-constrained triage. Academic Emergency Medicine 12(8):759-771. SAMHSA (Substance Abuse and Mental Health Services Administration). 2007. Prolonged Exposure Therapy for Posttrau- matic Stress Disorders. Rockville, MD: HHS (Department of Health and Human Services), http://nrepp.samhsa.gov/ ViewIntervention.aspx?id=89 (accessed March 1, 2012). Schreiber, M. 2005. Learning from 9/11: Toward a national model for children and families in mass casualty. In On the ground after 9/11: Mental health responses and practical knowledge gained, edited by Y. Daneili. New York: Haworth. Pp. 605-609. Schreiber, M., and S. Shields. 2012. Anticipate, Plan, and Deter: Building resilience in emergency health responders. Pre- sented at the 2012 NACCHO (National Association of City and County Health Officials) Public Health Preparedness Summit, Anaheim, California. Schreiber, M., K. Koenig, C. Schultz, S. Shields, and D. Bradley. 2011. PsySTART Rapid Disaster Mental Health Triage System: Performance During a Full Scale Exercise. Academic Emergency Medicine 18(5):s59 (supplement). Schreiber, M., B. Pfefferbaum, L. Sayegh, and J. Coady. In press. The way forward: The national children’s disaster mental health concept of operations. Disaster Medicine and Public Health. Schumacher Group. 2010. Emergency department challenges and trends: 2010 survey of hospital emergency department admin- istrators. Lafayette, LA: Schumacher Group, http://schumachergroup.com/_uploads/news/pdfs/ED%20Challenges%20 and%20Trends%2012.14.10.pdf (accessed March 4, 2012). 1-96 CRISIS STANDARDS OF CARE

OCR for page 1
Shah, U. 2012 ( January 13). Summary of HCPHES pandemic influenza public and partner engagement projects. Harris County, TX: Harris County Public Health and Environmental Services. Shalev, A. Y., Y. Ankri, Y. Israeli-Shalev, T. Peleg, R. Adessky, and S. Freedman. 2012. Prevention of posttraumatic stress dis- order by early treatment: Results from the Jerusalem trauma outreach and prevention study. Archives of General Psychiatry 69(2):166-76. Shear, K., E. Frank, P. R. Houck, and C. F. Reynolds. 2005. Treatment of complicated grief: A randomized controlled trial. Journal of the American Medical Association 293(21):2601-2608. Society of Critical Care Medicine Ethics Committee. 1994. Consensus statement on the triage of critically ill patients. Journal of the American Medical Association 271(15):1200-1203. Stokes, J., and F. D. Jones. 1995. Combat stress control in joint operations in War Psychiatry. Alexandria, VA: Department of the Army. Wilkinson, A., M. Matzo. M. Gatto, and J. Lynn. 2007. Chapter VII: Palliative care. In Mass medical care with scarce resources: A community planning guide. Publication no. 07-0001. Rockville, MD: AHRQ, http://archive.ahrq.gov/research/mce/ (accessed February 28, 2012). Pp. 101-116. Williams, A. 1997. Intergenerational equity: An exploration of the “fair innings” argument. Health Economics 6(2):117-132. Zatzick, D., F. Rivara, G. Jurkovich, J. Russo, S. G. Trusz, J. Wang, A. Wagner, K. Stephens, C. Dunn, E. Uehara, M. Petrie, C. Engel, D. Davydow, and W. Katon. 2011. Enhancing the population impact of collaborative care interventions: Mixed method development and implementation of stepped care targeting posttraumatic stress disorder and related comorbidi- ties after acute trauma. General Hospital Psychiatry 33(2):123-134. CROSS-CUTTING THEMES 1-97