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Crisis Standards
of Care
A Systems Framework for
Catastrophic Disaster Response
Alternate Care Systems
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Crisis Standards of Care
A Systems Framework for Catastrophic Disaster Response
Volume 5: Alternate Care Systems
Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations
Board on Health Sciences Policy
Dan Hanfling, Bruce M. Altevogt, Kristin Viswanathan, and Lawrence O. Gostin, Editors
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and the Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations
expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations
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Library of Congress Cataloging-in-Publication Data
Crisis standards of care : a systems framework for catastrophic disaster
response / Committee on Guidance for Establishing Standards of Care for Use in
Disaster Situations, Board on Health Sciences Policy ; Dan Hanfling ... [et al.], editors.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-309-25346-8 (hardcover) — ISBN 978-0-309-25347-5 (pdf ) I. Hanfling, Dan.
II. Institute of Medicine (U.S.). Committee on Guidance
for Establishing Standards of Care for Use in Disaster Situations.
[DNLM: 1. Disaster Medicine—standards—United States. 2. Emergency
Medical Services—standards—United States. 3. Emergency Treatment—
standards—United States. WA 295]
363.34—dc23
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Copyright 2012 by the National Academy of Sciences. All rights reserved.
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Suggested citation: IOM (Institute of Medicine). 2012. Crisis Standards of Care: A Systems Framework for Cata-
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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COMMITTEE ON GUIDANCE FOR ESTABLISHING STANDARDS OF CARE
FOR USE IN DISASTER SITUATIONS
LAWRENCE O. GOSTIN (Chair), O’Neill Institute for National and Global Health Law, Georgetown
University Law Center, Washington, DC
DAN HANFLING (Vice-Chair), Inova Health System, Falls Church, VA
DAMON T. ARNOLD, Illinois Department of Public Health, Chicago (retired)
STEPHEN V. CANTRILL, Denver Health Medical Center, CO
BROOKE COURTNEY, Food and Drug Administration, Bethesda, MD
ASHA DEVEREAUX, California Thoracic Society, San Francisco, CA
EDWARD J. GABRIEL,* The Walt Disney Company, Burbank, CA
JOHN L. HICK, Hennepin County Medical Center, Minneapolis, MN
JAMES G. HODGE, JR., Center for the Study of Law, Science, and Technology, Arizona State University,
Tempe
DONNA E. LEVIN, Massachusetts Department of Public Health, Boston
MARIANNE MATZO, University of Oklahoma Health Sciences Center, Oklahoma City
CHERYL A. PETERSON, American Nurses Association, Silver Spring, MD
TIA POWELL, Montefiore-Einstein Center for Bioethics, Albert Einstein College of Medicine,
New York, NY
MERRITT SCHREIBER, University of California, Irvine, School of Medicine
UMAIR A. SHAH, Harris County Public Health and Environmental Services, Houston, TX
JOLENE R. WHITNEY, Bureau of Emergency Medical Services (EMS) and Preparedness, Utah
Department of Health, Salt Lake City
Study Staff
BRUCE M. ALTEVOGT, Study Director
ANDREW M. POPE, Director, Board on Health Sciences Policy
CLARE STROUD, Program Officer
LORA TAYLOR, Senior Project Assistant (until January 2012)
ELIZABETH THOMAS, Senior Project Assistant (since February 2012)
KRISTIN VISWANATHAN, Research Associate
RONA BRIER, Editor
BARBARA FAIN, Consultant for Public Engagement
* Resigned from the committee October 2011.
v
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Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and techni-
cal expertise, in accordance with procedures approved by the National Research Council’s Report Review
Committee. The purpose of this independent review is to provide candid and critical comments that will
assist the institution in making its published report as sound as possible and to ensure that the report meets
institutional standards for objectivity, evidence, and responsiveness to the study charge. The review com-
ments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish
to thank the following individuals for their review of this report:
Richard Alcorta, Maryland Institute for Emergency Medical Services Systems
Knox Andress, Louisiana Poison Center
Connie Boatright-Royster, MESH Coalition
Susan Cooper, Tennessee Department of Health
Lance Gable, Wayne State University Center for Law and the Public’s Health
Carol Jacobson, Ohio Hospital Association
Amy Kaji, Harbor-UCLA Medical Center
Jon Krohmer, Department of Homeland Security
Onora Lien, King County Healthcare Coalition
Suzet McKinney, The Tauri Group
Peter Pons, Denver Health Medical Center
Clifford Rees, University of New Mexico School of Law
Linda Scott, Michigan Department of Community Health
Robert Ursano, Uniformed Services University School of Medicine
Lann Wilder, San Francisco General Hospital and Trauma Center
Matthew Wynia, American Medical Association
Although the reviewers listed above have provided many constructive comments and suggestions, they were
not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before
vii
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its release. The review of this report was overseen by Dr. Georges Benjamin, American Public Health Asso-
ciation. Appointed by the Institute of Medicine, he was responsible for making certain that an independent
examination of this report was carried out in accordance with institutional procedures and that all review
comments were carefully considered. Responsibility for the final content of this report rests entirely with the
authoring committee and the institution.
viii REVIEWERS
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Contents
VOLUME 1: INTRODUCTION AND CSC FRAMEWORK
Summary 1-1
1 Introduction 1-13
2 Catastrophic Disaster Response: Creating a Framework for Medical Care Delivery 1-29
3 Legal Issues in Emergencies 1-53
4 Cross-Cutting Themes: Ethics, Palliative Care, and Mental Health 1-69
VOLUME 2: STATE AND LOCAL GOVERNMENT
5 State and Local Governments 2-1
VOLUME 3: EMS
6 Prehospital Care: Emergency Medical Services (EMS) 3-1
VOLUME 4: HOSPITAL
7 Hospitals and Acute Care Facilities 4-1
VOLUME 5: ALTERNATE CARE SYSTEMS
Acronyms ix
8 Out-of-Hospital and Alternate Care Systems 5-1
Roles and Responsibilities of Out-of-Hospital and Alternate Care Systems, 5-2
Operational Considerations, 5-9
ix
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Template Description, 5-13
Template 8.1. Core Functions of the Out-of-Hospital and Alternate Care Systems in CSC
Planning and Implementation, 5-22
References, 5-47
VOLUME 6: PUBLIC ENGAGEMENT
9 Public Engagement 6-1
VOLUME 7: APPENDIXES 7-1
Appendixes
x CONTENTS
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(private sites are established by the health care facilities that operate
them).
Function 4. Control
Task 1
MAC group and ACS site staff understand the interface for resource
requests and the acquisition process (as well as any existing plans
for resource triage/allocation) with local and state emergency
management.
Task 2
Emergency management agreements/plans reflect how public health
and health care facilities support sheltered populations with medical
needs.
Task 3
ACS site staff understand the need for security/access controls and
community law enforcement support options as appropriate.
Task 4
ACS options reflect a phased expansion of surge capacity/capabilities
for conventional, contingency, and crisis care situations (from electronic
to augmented services at private and public sites).
Task 5
MAC group has a process for ongoing incident analysis to maintain
situational awareness and facilitate ACS decisions.
Function 5. Communications
Task 1
Public health agencies have policies and procedures for exchanging
situational updates with hospitals/outpatient care facilities, EMS, and
emergency management.
Task 2
MAC group/center has a means of communicating with key
stakeholders (including those listed under Function 2, Task 1)
to maintain incident communications (including redundant
communications mechanisms as required).
Function 6. Coordination
Task 1
MAC group understands the interfaces among local public health
and emergency management agencies and local/regional hospital
coalitions, including existing agreements.
Task 2
MAC group understands the function of the state disaster medical
5-40 CRISIS STANDARDS OF CARE
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advisory committee and any regional medical coordination center
or regional disaster medical advisory committees, and can activate/
facilitate regional groups according to local plans.
Function 7. Public Information
Notes and Resources
Task 1
MAC group ensures that appropriate risk communications relevant to See http://www.fema.
ACS are developed for the public regarding when and where to seek gov/emergency/nims/
care (e.g., traditional media, websites, calling programs, e-mail, social PublicInformation.
media). This includes the ability to reach key cultural groups served by shtm.
ACS.
Task 2
MAC group or public health agencies coordinate information with other
agencies and participate in JIS and JIC activities when implemented by
the jurisdiction, state, or coalition.
Function 8. Operations
Task 1
Local/state public health agencies maintain an inventory of usual and
surge medical resources.
Task 2
Local/state public health agencies understand private/public ACS
capacities to augment health system capacity, including
• elephone hotlines and other “electronic care” (including
t
coordination with private and public safety answering points);
• mbulatory care (“flu centers” or triage/casualty collection
a
points); and
• onambulatory care (shelter-based care, hospital overflow,
n
federal medical station integration, limited emergency/surgical
care).
Task 3
For each of these public sites (or for similar sites that are incident
specific) MAC group understands the activation process (and any
authorities or agreements involved).
Task 4
Plans are made for patient registration, tracking, and record keeping,
including access to and storage of medical records.
Task 5
Plans are made for laboratory and pharmacy services appropriate to
the site, including clinical ordering and results systems.
OUT-OF-HOSPITAL AND ALTERNATE CARE SYSTEMS 5-41
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Task 6
Scope of clinical operations is defined and modified according to the
evolving needs of the incident and the supplies available.
Task 7
ACS site has staff trained to provide psychological first aid to patients/
evacuees, can implement psychological triage processes (such as
PsySTART) as required, and has a referral/management plan for those
with acute mental health needs.
Task 8
ACS policies and education address the provision of palliative care
(either on site or facilitated in the home environment).
Function 9. Logistics
Staffing
Task 1
Local public health agencies identify sources of potential staffing (e.g.,
health care systems/coalitions, Medical Reserve Corps, EMS) for the
various types of public ACS sites.
Task 2
ACS credentialing policies and procedures are congruent with
applicable regulations and statutes.
Task 3
Plans are made for staff orientation, education, and supervision.
Task 4
Capacity of nontraditional resources (family members, volunteers) to
provide nonmedical care is examined and addressed as needed within
the ACS operations plan.
Task 5
Legal liability, worker’s compensation, compensation, and other issues
are addressed according to the source of the staff (e.g., hospital,
volunteer, MAC group).
Supplies
Task 1
Supply lists for each type of ACS (shelter, ambulatory, nonambulatory)
are developed, optimally, including the source of initial supply and
resupply.
Task 2
Emergency management and public health agencies, health care
facilities, and medical supply vendors understand their role in the ACS
setup, resupply, and delivery processes.
5-42 CRISIS STANDARDS OF CARE
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Task 3
For local or state cached supplies (such as a local pharmaceutical
cache) or SNS supplies, MAC group/ACS facility understands the
process for request, receipt, and distribution of these supplies.
Space
Task 1
Health care facilities identify privately owned spaces for ACS
establishment on site or at other owned and modified sites.
Task 2
Public health and emergency management agencies identify public
spaces for major ACS facilities and establish any necessary agreements
or authorities required to utilize them (recognizing that no-notice
incidents may require ACS sites at ad hoc locations).
Special Considerations
Task 1
Patient groups requiring special consideration are identified, and, to the
degree possible, equipment and supplies to address the needs of these
groups are purchased and/or stockpiled in relation to the expected size
of the alternate care site, potentially including
• p
ediatric patients,
• p
atients with behavioral and cognitive impairment,
• t
he need for isolation/infection control, and
• t
he need for contamination assessment (post-HAZMAT or
radiological dispersal device with population-based exposure).
Task 2
Facility understands any regional plans or resources for specific groups
(e.g., pediatric-specific disaster supplies, regional pediatric or dialysis
networks) and the ACS site’s role in these plans.
Function 10. Planning
Task 1
Technical specialists are available as needed to provide input on
infection control, clinical care, and other issues arising at the ACS site.
This may include input from the regional or state disaster medical
advisory committee.
Task 2
Planning section maintains situational awareness and modifies clinical
care guidelines or supply/staffing requests to meet demand/anticipated
demand.
Task 3
Planning section addresses policy modifications and demobilization
based on incident demands.
OUT-OF-HOSPITAL AND ALTERNATE CARE SYSTEMS 5-43
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Function 11. Administration
Notes and Resources
Authority
Task 1
Public health and emergency management examine their delegation of
authority to public ACS site incident commanders during a disaster and
make any changes necessary to ensure that CSC decisions to open an
ACS site are supported (i.e., that the incident commander is acting with
the authority of the agency and any necessary political entities). During
a crisis, the administration may require additional communications and
coordination with the incident commander.
Task 2
Public health and emergency management agencies understand their
authorities to open and provide ACS services, including the ability
to facilitate private ACS sites through use of regulatory relief and
emergency orders.
Regulatory and Legal Issues
Task 1
Health care facilities and emergency management agencies understand See Chapter 4 for
relevant changes to agency/facility authorities and protections when a more detailed
state declarations of emergency/public health emergency are made, discussion.
including legal protections or obligations for medical providers (e.g.,
duty to serve).
Task 2
Agency heads/political leaders are aware of surge capacity/CSC plans
and implications for patient care, including ACS sites.
Task 3
Legal counsel identify state and local laws and regulations that would
constrain public and private ability to open ACS sites and potential
relief mechanisms.
Core Functions of the Outpatient Sector in CSC Planning
and Implementation
Out-of-Hospital Providers
Function 1. Notification
Task 1
Providers ensure that up-to-date contact information and
acknowledgment of receipt of exercise and incident messaging are
provided to employers (and any other relevant groups, such as the
MRC).
5-44 CRISIS STANDARDS OF CARE
OCR for page 341
Function 2. Command, Control, Communications, and Coordination
Task 1
When a disaster occurs that affects the providers’ facility/agency,
providers understand where they report, to whom they answer,
and how to execute their roles. They also understand the range of
their potential roles within the rest of the health care system and
opportunities for volunteer assignment (for example, reassignment to
an alternate care site or a hospital within the corporate system).
Task 2
Providers know how to contact and provide situational updates to and/
or request resources from their administrator/emergency operations
center/command center as applicable to the facility/agency plan.
Task 3
Providers receive incident command training appropriate to their role in
the command structure, including
• nowledge of the location of plans and actions for the full
k
continuum of care in their area, including the use of crisis spaces
and staffing; and
• nderstanding of appropriate resources (job aids) to guide
u
capacity expansion decisions or other unit-based plans.
Function 3. Public Information
Task 1
Providers understand key sources of facility/community information in a
disaster (e.g., web, social media, e-mail, hotline).
Function 4. Operations
Notes and Resources
Task 1
Providers understand facility-based actions during expansion of care
from conventional to crisis (e.g., expanded facility hours, scheduling
changes, triage of appointments, use of ancillary spaces).
Task 2
Providers are prepared to perform triage as it relates to their role (may
involve triage of appointments, or may involve another triage role
within their system, such as telephone triage).
Task 3
Providers likely to perform triage (both reactive and proactive) See the ethics section
understand the criteria they may consider (as well as what not to of Chapter 4.
consider) when making triage decisions.
OUT-OF-HOSPITAL AND ALTERNATE CARE SYSTEMS 5-45
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Task 4
Providers understand sources of employee mental health support. See the mental health
and palliative care
Task 5 sections of Chapter
Providers understand normal stress reactions and coping mechanisms, 4 for a more detailed
as well as danger signs, and receive training in psychological first aid discussion.
and psychological triage appropriate for their roles.
Task 6
Providers understand their potential role in providing/facilitating
palliative care during a disaster.
Function 5. Logistics
Task 1
Providers understand the utilization of space in their facility and other
expansion plans that involve their department/unit.
Task 2
Providers understand how their unit staffing and hours may change
during a disaster.
Task 3
Providers understand how their role may be changed/expanded during
a crisis, including incorporation of staff from outside the unit or facility,
and any potential roles at other sites within their health system (if
applicable).
Task 4
Providers understand how record keeping and other duties may change
in crisis situations (e.g., where to find and how to use paper forms).
Task 5
Providers understand the process for requesting necessary clinical
resources during an incident.
Function 6. Legal Issues
Notes and Resources
Task 1
Providers understand legal obligations and liabilities for practice both Chapter 3 provides
within and outside of their facility/agency when a more detailed
discussion.
• disaster or public health emergency has been declared,
a
• disaster or public health emergency has not been declared,
a
and
• hen providing other disaster relief functions (for example,
w
if serving as a Medical Reserve Corps or disaster medical
assistance team member).
5-46 CRISIS STANDARDS OF CARE
OCR for page 343
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