Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response: Volume 1: Introduction and CSC Framework (2012) / Chapter Skim
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Volume 4--Hospital
Volume 4--Hospital
Pages 213-283
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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response Hospital
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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response Volume 4: Hospital 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
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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 ...
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"Knowing is not enough; we must apply. Willing is not enough; we must do." -- Goethe Advising the Nation.
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The Institute acts under the responsibility given to the National Academy of Sciences 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.
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SHAH, Harris County Public Health and Environmental Services, Houston, TX JOLENE R WHITNEY, Bureau of Emergency Medical Services (EMS)
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The review comments 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.
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Core Functions of Hospital Facilities and Providers in the Implementation of CSC Plans, 4-40 References,4-51 ix
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VOLUME 5: ALTERNATE CARE SYSTEMS 8 Out-of-Hospital and Alternate Care Systems 5-1 VOLUME 6: PUBLIC ENGAGEMENT 9 Public Engagement 6-1 VOLUME 7: APPENDIXES 7-1 Appendixes x CONTENTS
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Acronyms ARDS acute respiratory distress syndrome ASPR Assistant Secretary for Preparedness and Response CDC Centers for Disease Control and Prevention CSC crisis standards of care DMAT disaster medical assistance team ECG electrocardiogram ECMO extracorporeal membrane oxygenation EMS emergency medical services EMTALA Emergency Medical Treatment and Active Labor Act EOC emergency operations center ESAR-VHP Emergency System for Advance Registration of Volunteer Health Professionals HICS hospital incident command system HIPAA Health Insurance Portability and Accountability Act ICS incident command system ICU intensive care unit IOM Institute of Medicine IVIG intravenous immune globulin JIC joint information center JIS joint information system MRC Medical Reserve Corps MSOFA Modified Sequential Organ Failure Assessment xi
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NIMS National Incident Management System PACU postanesthesia care unit PHEP Public Health Emergency Preparedness RDMAC regional disaster medical advisory committee SDMAC state disaster medical advisory committee SNS Strategic National Stockpile SOFA Sequential Organ Failure Assessment VA Department of Veterans Affairs VAMC VA Medical Center VHA Veterans Health Administration VISN Veterans Integrated Service Network xii ACRONYMS
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While this chapter is not intended to provide a review of hospital disaster preparedness, there is some overlap because crisis care depends on good underlying plans. 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 cares, 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 refer to this chapter, as well as the following chapter on out-of-hospital and alternate care systems.
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. Regional management of access to pediatric intensive care units could have a significant beneficial effect on overall mortality in an incident affecting primarily children (Kanter, 2007)
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; provide recom mendations for Scarce Resource Allo cation (SRA) Team members and Asso ciate Director for Nursing Triage Team members Emergency Preparedness Coordinator Help to coordinate administrative sup port to CSC, including integrating logis tics, Pharmacy, HR, Public Affairs, En gineering, Police and Quadrad; present CSC issues at appropriate committee meetings; participate in regional hospi tal coalition meetings Veterans Integrated Service Network (VISN)
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o Is there a provision for regional triage or appeals teams? o The incident commander and planning section chief at each health care facility are responsible for ensuring that liaison exists with local public health and other health care facilities and regional coalitions to provide for regional situational awareness and consistency.
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Roles of the Clinical Care Committee A group of technical experts (referred to as the clinical care committee) , drawn from numerous disciplines within and sometimes outside the facility (e.g., toxicologists)
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Appendixes C and D detail specific resource deficits and situations that hospitals may wish to assess and for which they may wish to exercise their responses. It is difficult to simulate an overwhelming number of casualties in exercises, but through scenario-based learning and the posing of "extension" questions during smaller exercises or debriefs, providers can gain experience with the building blocks of manag HOSPITALS AND ACUTE CARE FACILITIES 4-7
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ing a much larger incident. Triage teams can effectively gain experience through tabletop and other simulation experiences, as can incident command/hospital command center teams (DHS, 2007)
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This means providers are making resource allocation decisions individually and without structured guide HOSPITALS AND ACUTE CARE FACILITIES 4-9
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. Triage decisions are influenced by rapidly changing patient volumes and often reflect the prior experience of the provider (e.g., previous military or mass casualty training)
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) to o Medicine on-call beds required; consider these beds as soon as o Surgery on-call intensive care unit (ICU)
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* If no evacuation of patients is possible and the crisis care situation is prolonged, the incident commander should convene the clinical care committee to prioritize resources/service delivery.
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• Surge capacity is fully employed within health care facilities (and regionally) if capacity/space is the limited resource.
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The clinical care committee should, as part of its work, identify relevant incident-specific prognostic indicators and share or obtain incident-specific information from other entities (e.g., RDMAC, state, CDC)
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In all cases, the response and any strategies should be Analyzed at regular intervals as part of the disaster response planning cycle, and the elements repeated until the incident concludes. The terms in this figure can be further described as follows: Awareness • Incident commander recognizes current or anticipated resource shortfall(s)
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• Clinical care committee provides input to the planning section (or incident com mander, depending on assignment) as to the specific adaptations necessary to accommodate ongoing demands and any recommended decision tools or policies.
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. Decision tools that predict patient prognosis are extremely helpful in the triage process, as they provide 4-18 CRISIS STANDARDS OF CARE
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no longer be offered, as the resource commitment is unjustified compared with the HOSPITALS AND ACUTE CARE FACILITIES 4-19
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The clinical care committee should be prepared to examine this possibility, especially when highly intensive therapies are being provided. • Triage decisions in this setting may have to be made in the absence of any state declaration of emergency or activation of a full incident response by the facility.
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Even in an epidemic, available resources will vary among facili ties, and if a resource is available (e.g., a ventilator) , it should be provided to a patient in need unless the clinical care committee finds compelling reasons for not doing so -- for example, if the demand 4-22 CRISIS STANDARDS OF CARE
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. It is the responsibility of the clinical care committee and incident commander to ensure that transitions to crisis care are as graceful as possible, as more and more resources are committed to certain areas while other care activities (e.g., specialty clinics, outpatient and elective surgeries)
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Personnel expected to serve on a clinical care committee should be assigned to one of these groups if possible, with other technical experts being added according to the needs of the incident. All participating personnel, including any backup personnel, should clearly understand their responsibilities and exercise their roles prior to an incident.
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Generally, if specific or inter mittent input is required, the technical specialists directly inform the incident commander or operations section. When a technical unit (such as the clinical care committee)
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and expansion or reassignment of their area's resources to support the incident response. Some of these actions will be predetermined -- such as central supply bringing a disaster cart to the emergency department in a mass casualty incident -- while others will be implemented on an as-needed basis by the incident commander, often with input from the clinical care committee or technical experts.
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Operations. The operations section, including the triage team and clinical care providers under operations, is responsible for developing and implementing strategies and tactics needed to meet 4-28 CRISIS STANDARDS OF CARE
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The clinical care committee should work with the medical care branch director to determine what services the hospital can provide and how and where to provide them, and to recommend to the incident commander courses of action for coping with the scarce resource situation. The clinical care committee also should determine crisis clinical policies for the hospital, which can include the surgeries that may be performed, what triage criteria the emergency department will use HOSPITALS AND ACUTE CARE FACILITIES 4-29
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This is a retrospective appeal, and requires that the clinical care committee examine documentation and discuss the case with the triage team members and additional technical experts. If there are findings of an unfair or unjust decision, a process should be in place for communicating this to the invested individual(s)
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The patient who is using the resource should, in the judgment of the triage team, have a substantially worse prognosis to justify withdrawal and reassignment of the resource. Therapies are HOSPITALS AND ACUTE CARE FACILITIES 4-31
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using a common rapid mental health triage system across disaster systems of care; • mental health risks among health care workers; and 4-32 CRISIS STANDARDS OF CARE
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The logistics section also is responsible for the labor pool and credentialing unit, a collection point for available hospital staff and volunteers that may be a resource for addressing staffing shortages (California Emergency Medical Services Authority, 2006d)
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It also provides awareness through mate riel and personnel tracking, and situational awareness through patient and bed tracking (California Emergency Medical Services Authority, 2006d)
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Notification. Providers that have agreed to act as technical specialists or members of the clinical care committee or triage team should understand their responsibilities to those groups during a disaster.
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Task 2 Expectations of staff, including technical experts and those staffing the clinical care team, are understood prior to an incident, and appropriate activation/notification policies are in place.
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clinical care committee and potential triage team members; • ommand staff being trained and exercised (at least table-top) c in activation of the full continuum of care, including use of crisis spaces and staffing; • ommand staff understanding incident action planning and use c of the planning section during longer-term events; and • ppropriate resources (job aids)
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Function 6. Coordination Task 1 Command staff understand the interface between the institution and local public health, emergency management, and local/regional hospital coalitions, as well as any multiagency coordination constructs.
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to identify specific risks to the facility and specific resources at risk. Task 2 Facility emergency operations plan includes a crisis care annex that details the use of the clinical care committee and triage team, including • m embership, • a ctivation, • r oles and responsibilities, • c onsiderations prior to implementing triage strategies, • d ocumentation of decisions (medical records as well as incident documentation)
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Function 9. Logistics Notes and Resources Supplies Task 1 In conjunction with the clinical care committee, emergency For an example, management committee identifies key potential scarce resources based see the Minnesota on different types of incidents and, to the extent possible, stockpiles or Department of Health's identifies alternative sources for these supplies.
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Function 10. Planning Technical Specialists and Clinical Care Committee Task 1 Clinical care committee understands its interface with incident command, and in particular the medical care branch director, planning section chief, and planning cycle, including its role in developing strategies for the next operational period.
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. Task 2 Emergency operations plan includes anticipating orientation, mentoring, education, and clinical care policies for outside staff.
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Notification Task 1 Providers understand their call-back responsibilities during an incident, including potential roles as technical specialists or clinical care committee/triage team members. Task 2 Providers ensure up-to-date contact information and acknowledge receipt of exercise and incident messaging.
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2006a. Incident commander: Job action sheet.
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2008. Surge capacity concepts for health care facilities: The CO-S-TR model for initial incident assessment.
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Results of a prospective, multicentre study. Intensive Care Medicine 25(7)
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Working group on "Sepsis-related problems" of the European Society of Intensive Care Medicine. Critical Care Medicine 26(11)
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