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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response Introduction and CSC Framework
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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response Volume 1: Introduction and CSC Framework 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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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. HHSP23320042509XI between the National Academy of Sciences 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 or agencies that provided support for this project. 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 2012016602 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carv- ing from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. Crisis Standards of Care: A Systems Framework for Cata- strophic Disaster Response. Washington, DC: The National Academies Press.
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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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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished schol- ars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and techni- cal matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sci- ences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Acad- emy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org
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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 Acronyms ix Summary 1-1 1 Introduction 1-15 Phase Two: Study Goals and Methods, 1-16 2009 Letter Report: Key Elements and Recommendations, 1-17 Impact of the 2009 Letter Report, 1-21 Organization of the Report, 1-28 References, 1-29 2 Catastrophic Disaster Response: Creating a Framework for Medical Care Delivery 1-31 Conceptualizing a Systems Approach to Disaster Response, 1-31 Fundamental Factors That Influence the Implementation of Crisis Standards of Care, 1-34 Guidance for Disaster Response Stakeholders, 1-41 Milestones for Crisis Standards of Care Planning and Implementation, 1-46 Implementation of the Disaster Response Framework, 1-47 Recommendation, 1-50 References, 1-52 3 Legal Issues in Emergencies 1-55 Medical and Legal Standards of Care, 1-55 The Changing Legal Environment in Declared Emergencies, 1-57 Legal Issues in Declared Emergencies, 1-58 Summary, 1-68 References, 1-69 ix
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4 Cross-Cutting Themes: Ethics, Palliative Care, and Mental Health 1-71 Ethical Framework, 1-72 Palliative Care, 1-78 Mental Health, 1-86 References, 1-94 VOLUME 2: STATE AND LOCAL GOVERNMENT 2-1 5 State and Local Government VOLUME 3: EMS 3-1 6 Prehospital Care: Emergency Medical Services (EMS) VOLUME 4: HOSPITAL 4-1 7 Hospitals and Acute Care Facilities VOLUME 5: ALTERNATE CARE SYSTEMS 5-1 8 Out-of-Hospital and Alternate Care Systems VOLUME 6: PUBLIC ENGAGEMENT 6-1 9 Public Engagement VOLUME 7: APPENDIXES 7-1 Appendixes x CONTENTS
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Acronyms AHRQ Agency for Healthcare Research and Quality AMA American Medical Association APHA American Public Health Association ASPR Assistant Secretary for Preparedness and Response ASTHO Association of State and Territorial Health Officials CDC Centers for Disease Control and Prevention CONOPS concept of operations CSC crisis standards of care DHS Department of Homeland Security DOD Department of Defense EMAC Emergency Management Assistance Compact EMS emergency medical services EMTALA Emergency Medical Treatment and Active Labor Act EOC emergency operations center EUA emergency use authorization FDA Food and Drug Administration HCC health care coalition HCF health care facility HCPHES Harris County Public Health and Environmental Services HHS Department of Health and Human Services HICS hospital incident command system HIPAA Health Insurance Portability and Accountability Act HPP Hospital Preparedness Program xi
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ICU intensive care unit IOM Institute of Medicine MAC medical advisory committee MCE mass casualty event MEMS Modular Emergency Medical System MIMAL Model Intrastate Mutual Aid Legislation MOU memorandum of understanding MRC Medical Reserve Corps MSCC Medical Surge Capacity and Capability MSEHPA Model State Emergency Health Powers Act NACCHO National Association of County and City Health Officials NCCUSL National Conference of Commissioners on Uniform State Laws NDMS National Disaster Medical System NIMS National Incident Management System NLE National Level Exercise NRF National Response Framework NSAID nonsteroidal anti-inflammatory drug OSHA Occupational Safety and Health Administration PACU postanesthesia care unit PC palliative care PHEP Public Health Emergency Preparedness PPE personal protective equipment PREP Public Readiness and Emergency Preparedness PTSD posttraumatic stress disorder RDMAC regional disaster medical advisory committee RMCC regional medical coordination center SARS severe acute respiratory syndrome SDMAC state disaster medical advisory committee SNS Strategic National Stockpile SOFA Sequential Organ Failure Assessment UEVHPA Uniform Emergency Volunteer Health Practitioners Act VA Department of Veterans Affairs VHP volunteer health practitioner VPA Volunteer Protection Act xii ACRONYMS