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Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report
B
Glossary
Alternate care facility A temporary site that is not located on hospital property, established to provide patient care. It may provide either ambulatory or non-ambulatory care. It may serve to “decompress” hospitals that are maximally filled, or to bolster community-based triage capabilities. Has also been referred to as an “alternate care site.”
Clinical care committee Composed of clinical and administrative leaders at a healthcare institution, this committee is responsible for making prioritization decisions about the allocation of critical life-sustaining interventions. The clinical care committee may also be formed at the healthcare coalition level (e.g., hospital, primary care, emergency medical services agency, public health, emergency management. and others), playing the role of the disaster medical advisory committee at the regional level (see disaster medical advisory committee). May appoint a triage team (see triage team) to evaluate case-by-case decisions.
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Contingency surge The spaces, staff, and supplies used are not consistent with daily practices, but provide care that is functionally equivalent to usual patient care practices. These spaces or practices may be used temporarily during a major mass casualty incident or on a more sustained basis during a disaster (when the demands of the incident exceed community resources) (Hick et al., 2009).
Conventional capacity The spaces, staff, and supplies used are consistent with daily practices within the institution. These spaces and practices are used during a major mass casualty incident that triggers activation of the facility emergency operations plan (Hick et al., 2009).
Crisis standards of care The level of care possible during a crisis or disaster due to limitations in supplies, staff, environment, or other factors. These standards will usually incorporate the following principles: (1) prioritize population health rather than individual outcomes; (2) respect ethical principles of beneficence, stewardship, equity, and trust; (3) modify regulatory requirements to provide liability protection for healthcare providers making resource allocation decisions; and/or (4) designate a crisis triage officer and include provisions for palliative care in triage models for scarce resource allocation (e.g., ventilators) (Chang et al., 2008). Crisis standards of care will usually follow a formal declaration or recognition by state government during a pervasive (pandemic influenza) or catastrophic (earthquake, hurricane) disaster which
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recognizes that contingency surge response strategies (resource-sparing strategies) have been exhausted, and crisis medical care must be provided for a sustained period of time. Formal recognition of these austere operating conditions enables specific legal/regulatory powers and protections for healthcare provider allocation of scarce medical resources and for alternate care facility operations. Under these conditions, the goal is still to supply the best care possible to each patient.
Crisis surge Adaptive spaces, staff, and supplies are not consistent with usual standards of care, but provide sufficiency of care in the setting of a catastrophic disaster (i.e., provide the best possible care to patients given the circumstances and resources available). Crisis capacity activation constitutes a significant adjustment to standards of care (Hick et al., 2009).
Disaster medical advisory committee At the state or regional level, evaluates evidence-based, peer-reviewed critical care and other decision tools and recommends decision-making algorithms to be used when life-sustaining resources become scarce. May also be involved in providing broader recommendations regarding disaster planning and response efforts. When formed at the regional level, this group may take on the same functions as that of the clinical care committee. Those functions are focused in two distinct areas—medical advisory input and resource allocation decision approval.
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Emergency response system A formal or informal organization covering a specified geographic area minimally composed of healthcare institutions, public health agencies, emergency management agencies, and emergency medical service providers to facilitate regional preparedness planning and response.
EMS (emergency medical services/system) A system of healthcare professionals, facilities, and equipment providing out-of-hospital emergency care.
Healthcare coalition A group of individual healthcare assets (e.g., hospitals, clinics, long-term care facilities, etc.) in a specified geographic location that have partnered to respond to emergencies in a coordinated manner. The coalition has both a preparedness element and a response organization that possess appropriate structures, processes, and procedures. During response, the goals of the coalition are to facilitate situational awareness, resource support, and coordination of incident management among the participating organizations (ICDRM, 2009).
Healthcare institution Any facility providing patient care. This includes acute care hospitals, community health centers, long-term care institutions, private practices, and skilled nursing facilities.
Healthcare practitioners Includes “healthcare professionals” and other non-licensed individuals who are involved in the delivery of healthcare services.
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Healthcare professionals Individuals who are licensed to provide healthcare services under state law.
Indicator Measurement or predictor that is used to recognize surge capacity and capability problems within the healthcare system, suggesting that crisis standards of care may become necessary and requiring further analysis or system actions to prevent overload.
Legal standard of care The minimum amount of care and skill that a healthcare practitioner must exercise in particular circumstances based on what a reasonable and prudent healthcare practitioner would do in similar circumstances; during non-emergencies and disasters, they are based on the specific situation.
Medical standard of care The type and level of medical care required by professional norms, professional requirements, and institutional objectives; these standards vary as circumstances change, including during emergencies or crisis events.
Memorandums of Understanding (MOUs) A voluntary agreement among agencies cies and/or jurisdictions for the purpose of providing mutual aid at the time of a disaster.
Mutual aid agreements Written instrument between agencies (MAAs) and/or jurisdictions in which they agree to assist one another on request by furnishing personnel and equipment. An “agreement” is generally more legally binding than an “understanding” (Barbera and Macintyre, 2007).
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Palliative care Medical care provided by an interdisciplinary team to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Palliative care affirms life by supporting the patient and family’s goals for the future, including their hopes for cure or life prolongation, as well as their hopes for peace and dignity throughout the course of illness, the dying process, and death.
Protocol A written procedural approach to a specific problem or condition.
Public health system A complex network of individuals, organizations, and relevant critical infrastructures that have the potential to act individually and together to create conditions of health, including communities, healthcare delivery systems (e.g., home care, ambulatory care, private practice, hospitals, skilled nursing facilities, and others), employers and business, the media, homeland security and public safety, academia, and the governmental public health infrastructure (IOM, 2008).
Resource sparing The process of maximizing the utility of supplies and material through conservation, substitution, reuse, adaptation, and reallocation.
Scope of practice The extent of a professional’s ability to provide health services pursuant to their competence and license, certification,
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privileges, or other lawful authority to practice.
SOFA score The Sequential Organ Failure Assessment (SOFA) score is a scoring system to determine the extent of a person’s organ function or rate of failure. The score is based on six different body systems: respiratory, cardiovascular, hepatic, hematopoietic, renal, and neurologic.
Triage The process of sorting patients and allocating aid on the basis of need for or likely benefit from medical treatment. Several types of triage are referenced in this letter:
• Primary triage: The first triage of patients into the medical system (it may occur out of hospital), at which point patients are assigned an acuity level based on the severity of their illness/disease.
• Secondary triage: Reevaluation of the patient’s condition after initial medical care. This may occur at the hospital following EMS interventions or after initial interventions in the emergency department. This often involves the decision to admit the patient to the hospital.
• Tertiary triage: Further reevaluation of the patients’ response to treatment after further interventions; this is ongoing during their hospital stay. This is the least practiced and least well-defined type of triage.
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Triage team Appointed by the clinical care committee, uses decision tools appropriate to the event and resource being triaged, making tertiary triage using scarce resource allocation decisions. This is similar in concept to triage teams established to evaluate incoming patients to the emergency department requiring primary or secondary triage, usually in a sudden-onset, no-notice disaster event (e.g., explosive detonation).
Trigger Evidence that austere conditions prevail so that crisis standard of care practices will be required. This may occur at an institutional, and often regional, level of response. It suggests the need for the immediate implementation of response pathways that are required to manage a crisis surge response emanating from the disaster situation.