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 2--State and Local Government
Volume 2--State and Local Government
Pages 98-155
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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response State and Local Government
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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response Volume 2: State and Local Government 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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, 2-30 Template 5.2. Core Functions for Implementing CSC Plans in States During CSC Incidents, 2-36 References, 2-43 VOLUME 3: EMS 6 Prehospital Care: Emergency Medical Services (EMS)
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VOLUME 4: HOSPITAL 7 Hospitals and Acute Care Facilities 4-1 VOLUME 5: ALTERNATE CARE SYSTEMS 8 Out-of-Hospital and Alternate Care Systemss 5-1 VOLUME 6: PUBLIC ENGAGEMENT 9 Public Engagement 6-1 VOLUME 7: APPENDIXES 7-1 Appendixes x CONTENTS
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Acronyms ASPR Assistant Secretary for Preparedness and Response ASTHO Association of State and Territorial Health Officials CDC Centers for Disease Control and Prevention CMS Centers for Medicare & Medicaid Services CONOPS concept of operations CSC crisis standards of care DHS Department of Homeland Security DMAT disaster medical assistance team DOD Department of Defense EMA emergency management agency EMAC Emergency Management Assistance Compact EMS emergency medical services EMTALA Emergency Medical Treatment and Active Labor Act EOC emergency operations center EOP emergency operations plan ESAR-VHP Emergency System for Advance Registration of Volunteer Health Professionals ESF Emergency Support Function FD&C Food, Drug, and Cosmetic (Act) FEMA Federal Emergency Management Agency FMS federal medical station HHS Department of Health and Human Services HPP Hospital Preparedness Program xi
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ICS incident command system LHD local health department MAC multiagency coordination MOU memorandum of understanding MRC Medical Reserve Corps MSCC Medical Surge Capacity and Capability NDMS National Disaster Medical System NIMS National Incident Management System PHEP Public Health Emergency Preparedness PHS Public Health Service RDMAC regional disaster medical advisory committee REC regional emergency coordinator RMCC regional medical coordinating center SDMAC state disaster medical advisory committee SNS Strategic National Stockpile VA Department of Veterans Affairs xii ACRONYMS
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It focuses on the unique role of the state health department2 in leading CSC efforts within states, and on the interplay of local health department, regional, state emergency management, and federal partners in state planning and implementation efforts for CSC incidents. Two templates provide core functions for state and local planners to help guide the development and, when needed, the activation and implementation of CSC plans.
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-8 lead and the fact that multiple state agencies and leaders will have pivotal CSC roles, the state health department is fundamentally the most appropriate agency to lead and coordinate CSC planning and implementation efforts at the state level and to advise state leadership on CSC issues. This section focuses on the attributes of state health departments that make them especially well suited to lead CSC planning and implementation efforts.
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However, the state health department is in a unique position to assume the lead role in CSC planning and implementation at the state level (including determining when to implement the state CSC plan) because of its expertise in population-based public health; relationship to the provision of health care; already established local, regional, state, and federal connections with a wide range of stakeholders that may be involved in or affected by a CSC response; legal powers to use public health emergency response authorities; and role in ensuring the representation of appropriate substate (e.g., regional, local)
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. Responsibilities Depending on the state and the structure of its public health system, the state health department typically has a range of public health, health care, and emergency response system responsibilities, such as • providing oversight of and/or support to local health departments, depending on whether the structure is centralized or decentralized; • overseeing EMS agencies; • regulating laboratories; • licensing health care practitioners (e.g., through professional licensing boards)
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. State health departments' linkages to and role in regulating public and private components of the health care system, as well as health care practitioners, also are critical for effective CSC planning and implementation.
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State health departments, with their links to local public health agencies and regional medical disaster planning groups, as well as their 5 For the purposes of this report, "EMA" is used throughout to refer to these offices and agencies.
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To support consistency and avoid duplication of effort, the committee encourages state EMAs and state health departments to collaborate closely in CSC planning and implementation efforts. Depending on these entities' response structures and roles, as previously described, the level and type of such collaboration may vary by state.
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. Consistency with State CSC Response The state health department also can play a central role in ensuring, to the extent feasible, that the actions of federal health care responders are consistent with the state CSC plan and its implementation during a CSC incident.
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For example, the HHS RECs are well positioned to support, facilitate, and encourage interstate CSC planning and implementation efforts and communication. Through its lead role in CSC coordination, the state health department can work with its partners to identify various regional medical and public health disaster planning efforts occurring within the state; to link them so they can form a statewide, interdependent system that supports health and medical responses; and to promote consistency in planning and response among such entities and, when needed, across state lines.
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Thus, local CSC coordination, consistent with state planning and response actions, is critical to achieving the envisioned systems-based CSC response described in Chapter 2. Similarly, the local health department often is in the best position to coordinate CSC planning and implementation at the local level given its close linkages to the state, neighboring regional partners, the community, the health care system, and emergency management and response partners.
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Local health departments often have defined local public health emergency response roles (e.g., conducting biosurveillance activities, mass dispensing medical countermeasures directly to their constituents) and participate in established local and regional emergency preparedness partnerships (e.g., health care coalitions)
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, as described later, and to comment on the draft state CSC plan. Local health departments can, in turn, identify and engage appropriate local stakeholders as CSC planning proceeds.
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. In other states, individual health care facilities or public health departments in large cities have initiated CSC planning, including the development of CSC protocols or the conduct of community engagement activities (Public Health-Seattle and King County, 2009; Shah, 2012)
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Depending on the context of the crisis and the robustness of work already accomplished, the local role thus remains central to optimizing CSC planning. Once CSC efforts have transitioned from the planning to the implementation phase, local health departments (and their local government partners)
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Some local government agencies may be required to take a more active role in driving state efforts to initiate or to further CSC work. In these cases, local health departments -- especially those with sufficient capacity to do so -- may need to take the lead in advancing CSC planning in partnership with their other local and regional partners.
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variation in CSC planning also may be necessary to address jurisdictional realities. However, if regional efforts are disjointed and/or undertaken independently and outside of the context of state-level and other regional and local CSC planning efforts, public health outcomes and trust may be compromised or eroded.
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Thus the ideal way to maximize the consistency of service provision in a crisis situation is to engage in CSC planning in advance of a crisis and not when a crisis is already at hand. TEMPLATE DESCRIPTIONS Building on the five key elements of and milestones for developing state-level CSC plans, as described in Chapters 1 and 2, respectively, and as outlined in detail in the committee's letter report (IOM, 2009)
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Therefore, not all components of the CSC planning and implementation templates will apply directly to local government disaster efforts. To further support CSC planning and implementation efforts, other chapters of this report provide additional detail on critical planning components, including legal issues (Chapter 3)
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, the SDMAC can contract to a smaller, technical committee of CSC experts that assumes operational responsibility during CSC incidents or is otherwise available during routine times to inform and advise the state health department, state leadership, and other stakeholders on CSC plan development/improvement, implementation, and recovery issues. The technical committee of CSC experts can also assist regional disaster medical advisory committees and/or regional health care coalitions in engaging in CSC planning.
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The SDMAC should also consult with the state health department general counsel or attorney general's office, as applicable, to conduct a CSC legal assessment and ensure the development of a legal framework for CSC implementation in the state. The SDMAC should then begin drafting the CSC plan.
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. The state should ensure that findings resulting from state- and locally led public engagement activi ties are shared with local health departments and other state, regional, and local planning partners, as appropriate, and are used to help inform the state-level CSC planning process and any corresponding regional and local planning efforts.
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W hile the full SDMAC will have a pivotal role during the state CSC planning phase (Template 5.1) , the authorities and responsibilities of the state health department and other state (and local, as applicable)
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The state health department and state EMA should be able to receive and manage emergency alerts and requests from stakeholders (in particular, from local health department/local government, health care, and emergency management partners) that may trigger acti vation of the state CSC plan.
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The state EMA and state health department also ensure that command staff are trained in CSC plan components and response and understand their roles, as well as the roles of local, regional, state, and federal stakeholders, in the state's CSC response. States and local jurisdictions that have public health department EOCs should activate and ensure appropriate operation of such operations centers (including providing notification of EOC activation to response partners)
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, other local health departments (as applicable, based on the public health department structure within the state) , or local government agencies also should be responsible for public and risk communication messaging for their jurisdictions in coordination with state messaging (and vice versa)
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Figure 5-5.eps NOTE: EMA = emergency management agency; EOC = emergency operations center; LHD = local health department; SHD = state health department; SDMAC = state disaster medical advisory committee. response plans and intrastate and interstate mutual-aid agreements to substitute, conserve, and adapt staffing, transportation, patient triage, and destinations.
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. Addressing the social and psychological challenges of CSC requires the use of the triage-driven mental health incident management system, as well as community resilience efforts based on commu nity engagement during the CSC planning phase (see Chapter 9)
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, as well as how to donate resources to other jurisdictions. For highly at-risk supplies, government response partners can identify and share with applicable stakeholders strategies for their appropriate substitution, conservation, adaptation, reuse, and reallocation, and also utilize resource tracking methods to monitor the availability of applicable resources during the CSC response.
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With support of the SDMAC, the state health department and state EMA, as well as local government response partners, should understand when to deactivate or scale down the state CSC plan and what their roles in deactivation are. Through established communication systems, they will need to notify stakeholders, media, and the pub lic of the rationale for deactivating the state CSC plan and shifting back to contingency or conventional care, and what such deactivation means.
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Establishment of CSC Planning Committee Notes and Resources Task 1 State public health agency is identified as the lead state agency for CSC planning and implementation. Task 2 State health department establishes and staffs a state-level, An SDMAC or similar multidisciplinary, and transparent state disaster medical advisory committee may committee (SDMAC)
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State health department (and the SDMAC, as applicable) engages with local health departments on the importance of -- and their role in -- CSC planning and implementation.
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Task 5 State health department leadership reviews the state CSC plan and collaborates with the SDMAC on revising the plan, if needed, prior to 2-32 CRISIS STANDARDS OF CARE
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Plan Introduction and Review -- Stakeholder and Public Engagement Task 1 State health department, with the support of the SDMAC, continues to engage regularly with local health departments on CSC planning. Local health departments • nderstand their role in CSC planning and response; u • nderstand the role of local health care stakeholders in CSC u planning and response; • nderstand state CSC processes; u • nderstand applicable federal, state, and local legal authorities u and existing mutual aid agreements and processes; and • ave the opportunity to review and provide comments on the h draft state CSC plan.
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. Task 3 State and local health departments support health care facility and system surge capacity and planning efforts, including by developing protocols and plans for allocation of scarce resources so these plans can coalesce at the regional hospital coalition level.
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, developing a process for continuous assessment of routine and catastrophic disaster response capabilities based on existing information and knowledge management platforms, and creating a mechanism for ensuring that CSC milestones are being achieved; • onducting annual workshops, tabletop exercises, and functional c exercises involving the state CSC plan at the interstate, state, regional, and local levels in conjunction with state/local EMA, public health, hospital, and federal exercises and partners, when feasible; • eviewing and updating the plan on a regular basis or as needed r (using information gained through provider and community engagement and through exercises and actual emergencies) as elements of a disaster planning process improvement cycle; • oliciting input from stakeholders and the public about the plan, s including continuing to conduct public engagement activities, as needed; and • otifying stakeholders and the public, as necessary, of any n substantive plan updates.
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and local (e.g., mayor, local health department) leadership to assess the situation and make a determination on activation of the state CSC plan.
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. Task 2 State EMA and the state health department ensure that command staff • re trained in CSC plan components and response; a • nderstand their roles, as well as the roles of local, regional, u state, and federal stakeholders, in the state CSC response; • re well versed in incident action planning during longer-term a events; STATE AND LOCAL GOVERNMENT 2-37
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f Task 5 State EMA and the state health department ensure that communication systems account for redundancy and interoperability in the event the disaster affects usual means of contact. Coordination Task 6 State EMA and command staff, in collaboration with the state health department, are capable of serving as the interface for resource requests and managing the acquisition or donation process (as well as any existing plans for resource triage/allocation)
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pre-established risk communication plans for routine and catastrophic disaster response. Task 2 State health department and the state EMA leverage pre-existing relationships with applicable media partners to facilitate risk communication during the emergency.
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including health care facilities and mental health resources, in incident command operations; • rovides for access to a continuum of evidence-based p interventions for adults and children; • rovides training in basic "neighbor-to-neighbor, family-to p family" psychological first aid with triage for the general public and health care workers; • rovides CSC-specific behavioral coping components for risk p communications; • ompletes a CSC gap analysis with a plan for enhancing c local disaster mental health and spiritual care capacities and capabilities; and • evelops a health care worker resilience system with integrated d triage and referral components. Palliative Care Task 5 State CSC response addresses palliative care for all patients, including palliative care principles and triage tools, supply issues for patients (including those who will not receive other treatment modalities)
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Task 3 State health department and the state EMA, with support of the SDMAC, coordinate response evaluation, development of an after action report, and implementation of improvement plan items so there is a continuous feedback loop for strengthening the state CSC plan. Task 4 State health department and the state EMA, with support of the SDMAC, understand their roles in CSC recovery, including ongoing mental health operations.
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2010. National profile of local health departments.
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