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Crisis Standards
of Care
A Systems Framework for
Catastrophic Disaster Response
EMS
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Crisis Standards of Care
A Systems Framework for Catastrophic Disaster Response
Volume 3: EMS
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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Crisis standards of care : a systems framework for catastrophic disaster
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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]
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Copyright 2012 by the National Academy of Sciences. All rights reserved.
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Suggested citation: IOM (Institute of Medicine). 2012. Crisis Standards of Care: A Systems Framework for Cata-
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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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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
Summary 1-1
1 Introduction 1-15
2 Catastrophic Disaster Response: Creating a Framework for Medical Care Delivery 1-31
3 Legal Issues 1-55
4 Cross-Cutting Issues: Ethics, Palliative Care, and Mental Health 1-71
VOLUME 2: STATE AND LOCAL GOVERNMENT
5 State and Local Governments 2-1
VOLUME 3: EMS
Acronyms xi
6 Prehospital Care: Emergency Medical Services (EMS) 3-1
Roles and Responsibilities of Emergency Medical Services, 3-1
Operational Considerations, 3-8
Template Descriptions, 3-12
Template 6.1. Core Functions of EMS Systems in the Development of State Crisis Standards
of Care (CSC) Plans, 3-23
Template 6.2. Core Functions of EMS Systems and EMS Personnel in the
Implementation of CSC Plans, 3-29
References, 3-41
Additional Resources, 3-43
ix
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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 Systems 5-1
VOLUME 6: PUBLIC ENGAGEMENT
9 Public Engagement 6-1
VOLUME 7: APPENDIXES 7-1
Appendixes
x CONTENTS
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Mental Health
State Task 1
State EMS office participates in a rapid mental health triage/incident Refer to the mental
management system linking local, regional, and state disaster systems health section of
of care, including health care facilities and mental health resources, in Chapter 4 for a
ICS operations. more a detailed list
of functions and
State Task 2 discussion of examples.
State EMS office provides for access to a continuum of evidence-based
mental health interventions for adults and children.
Regional/Local Task 3
Regional infrastructure and local public and private EMS agencies
provide training in basic “neighbor-to-neighbor, family-to-family”
psychological first aid for the general public and health care workers
that includes triage.
Region/Local Task 4
Regional infrastructure and local public and private EMS agencies
provide CSC-specific behavioral coping components in risk
communications.
State and Regional/Local Task 5
All stakeholders complete a CSC gap analysis with plan to enhance
local disaster mental health and spiritual care capacities and
capabilities.
Regional/Local Task 6
Regional infrastructure and local public and private EMS agencies
develop a health care worker resilience system with integrated triage
and referral components.
Palliative Care
State Task 1
State EMS office, with medical direction, defines the role of EMS Refer to the palliative
personnel in providing symptomatic management for patients needing care section of Chapter
palliative care and provides the necessary training and resources. 4 for additional
information.
State Task 2
With palliative care experts, state EMS office provides just-in-time
training that may be appropriate for EMS personnel, especially in a
sustained CSC incident.
Regional/Local Task 3
State and local medical directors address palliative care, if appropriate,
in the emergency operations plan, including triage tools and any
agency-specific protocols or policies (which are approved by medical
directors at the state or agency level).
3-34 CRISIS STANDARDS OF CARE
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Function 9. Logistics
Notes and Resources
Staffing Resources
State and Regional/Local Task 1
State EMS office, regional infrastructure, and local EMS providers Refer to NDMS and
understand available staffing resources within jurisdictions and utilize EMAC websites.
established processes for requesting and allocating the workforce
(Medical Reserve Corps [MRC], Emergency System for Advance
Registration of Volunteer Health Professionals [ESAR-VHP], state strike
teams, NDMS teams, military/National Guard personnel, including
ambulances).
State and Regional/Local Task 2
State EMS office, regional infrastructure, and local EMS agencies
utilize a resource monitoring system to track staffing resources and
understand when to activate mutual-aid agreements or alternative
staffing patterns.
State and Regional/Local Task 3
All stakeholders ensure that call-back criteria and policies are in place,
including maintenance of current and accurate employee contact
information.
State and Regional/Local Task 4
State EMS office, regional infrastructure, and local EMS providers have
the capability to assess the number of staff available for large-scale
incidents.
State and Regional/Local Task 5
State EMS office, regional infrastructure, and local EMS providers
ensure that staff receive personal preparedness training to assist with
family needs and are prepared for on-site accommodation of staff and
family members, as appropriate.
Transportation and Equipment Resources
State and Regional/Local Task 1
State EMS office, regional infrastructure, and local EMS agencies
conduct an assessment of the types and location of EMS transportation
and equipment resources available within the state and know how to
request resources from other jurisdictions (through EMAC, the federal
ambulance contract, medication caches, equipment trailers).
State and Regional/Local Task 2
State EMS office, regional infrastructure, and local EMS agencies, with
medical direction, identify strategies for appropriate substitution,
conservation, adaptation, reuse, and reallocation of scarce equipment
and supplies.
State/Regional/Local Task 3
State EMS office, regional EMS infrastructure, and local EMS agencies
utilize a resource tracking or deployment system to monitor the
availability of ambulances and understand when to engage other
modes of patient transportation.
PREHOSPITAL CARE 3-35
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Space
State and Regional/Local Task 1
State EMS office, regional infrastructure, and local EMS providers Refer to Maryland
understand when to initiate plans to transport patients to alternate care emergency medical
sites and the processes for requesting and allocating such space. dispatch (EMD)
protocol.
State and Regional/Local Task 2
State EMS office, regional infrastructure, and local EMS providers are
able to recognize when to activate alternate call centers (such as 211 or
nurse triage centers) to provide information to the public.
Regional/Local Task 3
Regional infrastructure and local EMS providers understand when to
initiate treat-and-release protocols and processes approved by state
and agency medical directors.
Regional/Local Task 4
Regional infrastructure and local EMS providers identify regional
staging areas for use when major mutual aid will be required but
specific assignments are not yet available, and understand support
requirements for those sites.
PSAPs and Call Centers Task 5
PSAPs, regional call centers, and dispatch centers understand when to
utilize CSC dispatch protocols and alter resource assignments.
Special Populations
State and Regional/Local Task 1
State EMS office, regional infrastructure, local EMS providers, Refer to the Pediatric
and medical directors identify patient groups requiring special Emergency Mass
consideration with respect to transportation, treatment, equipment, and Critical Care Task Force
supplies. supplement (Task
Force for Pediatric
State and Regional/Local Task 2 Emergency Mass
Local EMS personnel are trained and exercised in managing special Critical Care, 2011). The
populations, including pediatric, burn, elderly, and non–English- full-text articles are
speaking patients, and purchase and stockpile tools, equipment, and available free of charge
supplies to address special-population needs. on the Pediatric Critical
Care Medicine website.
Function 10. Planning
Notes and Resources
Disaster Medical Advisory Committee
State Task 1
State EMS office understands how to interface with incident command, Refer to SDMAC
in particular the planning section and planning cycle, as well as how to charter and state CSC
interface with the SDMAC, its role in activating the CSC plan, and other plan.
strategies.
State and Regional/Local Task 2
Technical specialists and medical directors understand their interface
with command and planning sections.
3-36 CRISIS STANDARDS OF CARE
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Personnel Management
State and Regional/Local Task 1
In collaboration with existing regional structures, state and local Refer to information on
EMS agencies establish policies and procedures to integrate external the MRC, ESAR-VHP,
staffing resources (MRC, ESAR-VHP, state strike teams, disaster medical NDMS, and EMAC on
assistance team [DMAT]) during a disaster based on mutual-aid the ASPR and FEMA
agreements, EMAC, the NDMS plan, emergency operations plan, and websites.
appropriate annexes.
State and Regional/Local Task 2
In collaboration with existing regional structures, state and local EMS
agencies develop an educational program and materials to orient
external staffing resources on local, regional, and state triage and
treatment policies and applicable elements of the state CSC plan.
State and Regional/Local Task 3
State and local EMS providers develop policies for personnel
management, such as altered staffing configurations, shift lengths, and
staff roles, and address any collective bargaining issues that may arise
prior to an incident.
State and Regional/Local Task 4
Need for nonmedical assistance for families, volunteers, and external
staffing resources is addressed within the emergency operations plan.
Function 11. Jurisdiction, Scope, Authority, and Legal/Regulatory Issues
Notes and Resources
State and Regional/Local Task 1
State EMS office and EMS providers examine the scope and delegation Refer to state and local
of authority to incident commanders during a disaster and make any legal counsel.
necessary changes to ensure that CSC decisions are supported (i.e.,
that the incident commander is acting with the authority of the agency/
jurisdiction). During a crisis, policy makers may require additional
communications and coordination with the incident commander.
State and Regional/Local Task 2
State EMS officials understand the impact of the CSC plan on the Refer to Chapter 2 for
provision of patient care within the appropriate jurisdiction, understand a detailed discussion of
state and local laws and regulations that would impact the response legal functions.
organizations’ ability to implement CSC, and identify possible solutions.
EMS Personnel Functions
Function 1. Notification
Task 1
EMS personnel understand call-back roles and responsibilities during an
incident, including potential roles that may vary from routine, such as
ICS positions.
PREHOSPITAL CARE 3-37
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Task 2
EMS personnel ensure up-to-date contact information. Exercises in
incident messaging are conducted.
Function 2. Command, Control, Communications, Coordination
Task 1
EMS personnel understand where they report and to whom they answer
during a disaster and how to execute their roles.
Task 2
EMS personnel understand how to contact and request resources from
dispatch and/or EMS command personnel.
Task 3
EMS personnel undergo training and exercising in their appropriate role
in the command structure, including
• nowledge of plans, resources, and actions for the full continuum
k
of care in their jurisdiction, such as use of triage protocols,
alternative resources, and staffing; and
• nderstanding and use of appropriate job action aids to
u
guide decisions and activities based on applicable emergency
operations plans.
Task 4
EMS personnel understand and are able to use interoperable
communications and backup systems.
Function 3. Public Information
Task 1
EMS personnel know of all potential sources of information in a disaster
and key contacts within each (web, Twitter, hotline, etc.).
Function 4. Operations
Task 1
EMS personnel understand how to utilize the resource management
system and assess the need to expand from conventional to crisis care
and activate the CSC plan.
Task 2
EMS personnel understand when and how to apply disaster triage
protocols, the EMS pandemic influenza plan, and mass casualty plans, if
available.
Task 3
EMS personnel understand when to activate mutual-aid agreements,
the emergency operations center, and the emergency operations plan.
3-38 CRISIS STANDARDS OF CARE
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Task 4
EMS personnel undergo training and exercising in their ICS role and are
able to function within the unified command or multiagency command
ICS structure.
Function 5. Logistics
Communications
Task 1
EMS personnel understand how to utilize interoperable communications
systems, backup communications systems, the patient tracking system,
and the incident/resource management system (web-based and/or
hard copy).
Staffing
Task 1
EMS personnel understand how staffing and hours may change during
a disaster.
Task 2
EMS personnel understand how role may be changed/expanded (scope
of practice) during crisis, including integration of staffing resources
from other jurisdictions.
Task 3
EMS personnel understand how changes in record keeping and other
duties may occur in crisis situations (e.g., where to find and how to use
paper forms).
Task 4
EMS personnel are aware of changes to treat-and-release protocols.
Transportation, Equipment, and Supplies
Task 1
EMS personnel understand how to access supply caches and trailers
from other jurisdictions.
Task 2
EMS personnel understand what to do in case of shortages when
crisis plans are in place (shelter in place, reuse supplies, use alternative
modes of transportation).
Function 6. Mental Health
Notes and Resources
Task 1
EMS personnel understand how to access local mental health and The mental health
employee support resources, including any incident-specific mental section of Chapter 4
health information or resources. provides a more
PREHOSPITAL CARE 3-39
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Task 2 detailed discussion of
EMS personnel are aware of the site-based mental health triage system functions.
in place for at-risk patients and coworkers and for self-triage.
Task 3
EMS personnel are trained in psychological first aid and integrated,
evidence based mental health triage techniques.
Function 7. Legal Issues
Notes and Resources
Task 1
EMS personnel understand their legal obligations and liabilities in Chapter 3 describes
providing crisis care in the ambulance and in alternate patient care legal issues in depth.
settings when
• disaster or public health emergency is declared;
a
• disaster or public health emergency has not been declared;
a
and
• hey have other disaster relief functions (for example, serving as
t
an MRC or DMAT member).
3-40 CRISIS STANDARDS OF CARE
OCR for page 209
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