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 5--Alternate Care Systems
Volume 5--Alternate Care Systems
Pages 284-346
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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
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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 National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars 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 technical matters.
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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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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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Acronyms ACS Alternate Care System CDC Centers for Disease Control and Prevention CSC crisis standards of care DMAC disaster medical advisory committee EMS emergency medical services EOC emergency operations center ESAR-VHP Emergency System for Advance Registration of Volunteer Health Professionals ESF Emergency Support Function FEMA Federal Emergency Management Agency HHS Department of Health and Human Services HICS hospital incident command system ICS incident command system JIS joint information system MAC multiagency coordination MOU memorandum of understanding MRC Medical Reserve Corps NDMS National Disaster Medical System NIMS National Incident Management System xi
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PFA psychological first aid SDMAC state disaster medical advisory committee SNS Strategic National Stockpile VA Department of Veterans Affairs xii ACRONYMS
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. For this reason, efforts to improve the integration of outpatient care assets into disaster response are critical, not only to improve the provision of crisis care but also to avoid crisis care.
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Outpatient Care Resources Outpatient care resources include solo and group practices, surgical and procedure centers, long-term care facilities, group home and congregate environments, and home care/durable medical equipment vendors. All of these entities should have a disaster plan.
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staffing public health clinics inadequate; provide site and logistics support (and potential staffing from Medical Reserve Corps and other public sources) ; address prescribing and practice regulatory issues Nonambulatory alternate care sites Provide policy, medical direction, Provide site and logistical support (hospital overflow; may include staffing, and special medical materiel in conjunction with emergency medical shelter for nonambulatory support to site management; legal/regulatory patients)
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Hospitals and acute care facilities, in coordination with government emergency response entities (including public health agencies) , should educate out-of-hospital and alternate care providers on a variety of response topics prior to an incident to support an effective response.
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The vast majority of this infrastructure is private, although there are some publicly operated clinics. Additionally, urgent care facilities, clinics based in retail stores, and pharmacies that may provide some medical screening and care should be engaged in disaster response.
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. Home care and durable medical equipment vendors may play critical roles as well in providing equipment and services to shelters and alternate care sites (AHRQ, 2011; Rebmann et al., 2011)
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. One of the primary benefits of alternate care systems is their flexibility: both government emergency response entities and private health care institutions can establish them to maximize the efficiency of reaching an entire community.
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Requested by state health or emergency management agencies, they are designed to be moved into "structures of opportunity" in the community, such as schools or convention centers. Although multiple federal medical stations are available, the supply is clearly inadequate for a multistate or national event (e.g., a pandemic, a major earthquake)
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Plans for surge capacity mass mortuary sites should be planned in coordination with the jurisdiction's coroner and office of emergency management for possible logistical support. In addition, plans should include options for staffing (incorporating a National Disaster Medical System [NDMS]
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Hospitals and acute care facilities should work closely with local public health agencies to determine priorities for therapies and services. Emergency response entities should ensure that appropriate regulatory and logistical issues of care are addressed in coordination with other public and private agencies.
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requires close coordination with EMS, emergency management, and other response entities. • Provider engagement -- This includes education about disaster relief opportunities (e.g., MRC registration)
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• Outpatient surge capacity, • Early incident strategies • Outpatient surge capacity • Private alternate care sites including isolation plus • Private alternate care • Hotline and web-based o Public "flu centers" sites triage and prescribing for • Hotline and web-based o Augmented home care early illness/exposure o Nonambulatory • Mass fatality management triage and prescribing for early illness/exposure alternate care sites (for • Vaccination sites -- private hospital overflow) o Mass fatality and public management *
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TEMPLATE DESCRIPTION Many of the functions and tasks required of the various outpatient care entities to plan for and implement CSC are similar in nature. Thus, the following descriptions of the general functions of outpatient care facilities are meant to serve as a broad guide; specific functions and tasks for outpatient care facilities, long-term care facilities, home care/medical equipment vendors, and alternate care systems are enumerated in Template 8.1 at the end of this chapter.
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Increased funding and time need to be allocated to reaching these providers and practices to ensure that they have a voice in planning and implementing the response to emergencies that affect the outpatient sector. This may be accomplished through existing coalitions or the establishment of new mechanisms for coordination and collaboration among outpatient care entities.
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These effects include the need for changes to staff scopes of practice, increased repur posing of patient care space, and the reuse and reallocation of supplies. The societal impact of a disaster requiring the outpatient sector's response cannot be underesti mated.
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Logistics. Logistical requirements at alternate care sites are substantial.
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. Surge capacity often is limited in outpatient health care facilities because of the lack of classrooms and flat-space areas that often are available in hospitals.
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. The operation of such sites requires partnership among public health agencies, emergency man agement agencies, and private health care entities to ensure that staffing and supply needs are met.
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, o use of an action planning process for ongoing assessment and adjustment of strategies and tactics, and o exercise and evaluation plans; • facility resources and redundancy of logistical elements, such as supply chains and critical ser vices (e.g., electricity, water) ; • the interface mechanism/process between the facility and partner facilities, coalitions, and local government emergency response entities (such as public health)
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These issues include what level of records is to be kept, who will be responsible for their storage, and what will be done about access and data privacy, as well as the public versus private nature of the records and the data they contain. Emergency management and public health agencies should understand their powers during a disas ter, including during a public health versus a general emergency, and any regulatory or other relief that can facilitate the use of alternate care systems.
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, be able to rec ognize psychological issues that may arise, and be aware of their potential role as palliative care providers. Function 5.
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Task 2 Emergency response plan provides triggers and process for incident command to activate the CSC plan and indicators (if applicable) to prompt consideration of activation.
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Task 4 Command staff understand options for security/access controls and community law enforcement support during a disaster. Task 5 Facility plan reflects a phased expansion of surge capacity/capabilities for conventional, contingency, and crisis care situations.
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o Function 6. Coordination Task 1 Command staff understand the interface between the institution and local public health and emergency management agencies and any local/regional health care coalitions during a disaster.
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Operations Notes and Resources Conventional, Contingency, and Crisis Care Conditions Task 1 Under conventional care conditions, command/supervisory staff know how to maximize capacity, including postponing elective appointments, adjusting staffing and hours, and other changes. Task 2 Under contingency care conditions, command/supervisory staff can implement plans for repurposing patient care areas (e.g., changes to waiting areas to segregate infectious patients, space expansion)
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Space Task 1 Facility has examined available patient care space and conversion of non-patient care areas to patient care, as possible. 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 5-26 CRISIS STANDARDS OF CARE
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Task 5 Facility understands the process and supporting agreements (e.g., related to worker's compensation, liability) for sharing staff with other facilities in need, including staffing of alternate care sites.
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, and the National Weather Service. Task 2 Emergency response plan provides triggers and the process for incident command activation.
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Task 3 Command staff understand the processes for sheltering, relocation, and evacuation in response to threats to the facility. Task 4 Command staff understand options for security/access controls and community law enforcement support at their facility during a disaster.
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Coordination Task 1 Command staff understand how they are expected to interface with local public health and emergency management agencies and/or existing health care coalitions during an incident. Task 2 Institution understands the function of the state disaster medical advisory committee and any regional medical coordination center or regional disaster medical advisory committees, as well as the means by which information is received from or shared with these bodies.
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Task 2 Palliative care is addressed in the emergency operations plan, including palliative care principles and resources, incorporation of incidentspecific triage criteria when applicable, and patient/family support resources. Task 3 Palliative care awareness training is provided to staff, and just-in-time training can be made available.
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Task 4 Facility understands the process and supporting agreements (e.g., related to worker's compensation, liability) for sharing staff with other facilities in need, including staffing of alternate care sites.
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Function 1. Alerting Task 1 Home care agencies are able to receive and manage alerts from public safety, corporate administration, public health agencies (health alert network)
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with local public health/emergency management agencies and/or local health coalitions as applicable. Task 2 Command staff understand the processes for sheltering, relocation, and evacuation in response to threats to the agency, including facility assessment (includes suspension of services because of unsafe delivery conditions)
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o Function 6. Coordination Task 1 Command staff understand the policy interface between the agency and local public health and emergency management agencies and local/regional hospital coalitions.
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Task 2 Palliative care is addressed in the emergency operations plan, including palliative care resources, the physician decision-making process, education, and any agency-specific procedures. Task 3 Palliative care training (including just-in-time training)
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Task 4 Use of nontraditional assistance (family members, volunteers, Medical Reserve Corps providers) to provide care is addressed as needed within the emergency operations plan.
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. Task 3 Agency and/or corporate legal counsel are aware of surge capacity/ CSC plans and implications for patient care (e.g., plans to triage the provision of home care or of medical resources)
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alternate care sites. Task 2 A NIMS-compliant ICS is utilized to coordinate ESF-8 assets.
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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.
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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)
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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.
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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)
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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.
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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)
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and psychological triage appropriate for their roles. Task 6 Providers understand their potential role in providing/facilitating palliative care during a disaster.
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2004. Rocky Mountain regional care model for bioterrorist events: Locate alternate care sites during an emergency.
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2009. Hospital alternative care sites during H1N1 public health emergency.
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2006. The prospect of using alternative medical care facilities in an influenza pandemic.
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2012a. Development of standards and guidelines for healthcare surge during emergencies -- alternate care sites [draft text]
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