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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. Gostin, Editors

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. HHSP23320042509XI between the National Academy of Sciences and the Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. 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 ... [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] 363.34—dc23 2012016602 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carv- ing from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. Crisis Standards of Care: A Systems Framework for Cata- strophic Disaster Response. Washington, DC: The National Academies Press.

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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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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished schol- ars 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 techni- cal matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sci- ences 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. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Acad- emy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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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 in Emergencies 1-55 4 Cross-Cutting Themes: Ethics, Palliative Care, and Mental Health 1-71 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 Acronyms xi 7 Hospitals and Acute Care Facilities 4-1 Roles and Responsibilities of Health Care Facilities, 4-2 Operational Considerations, 4-8 Template Description, 4-25 Template 7.1. 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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Task 2 Legal department identifies state and local laws and regulations that would impact the institution’s ability to implement CSC plans and possible solutions (see Chapter 3 for a full list of functions). Core Functions of Hospital Facilities and Providers in the Implementation of CSC Plans Hospital Provider Functions Function 1. 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. Function 2. Command, Control, Communications, and Coordination Notes and Resources Task 1 Providers receive information on community disaster roles, including If provider is a member the Medical Reserve Corps (MRC) and Emergency System for the of command staff, Advance Registration of Volunteer Health Professionals (ESAR-VHP). additional training is required; see Task 2 Function 3 in “Hospital Providers understand where they report, to whom they answer during Facilities” section of a disaster, and how to execute their roles. (This may include private as this template. well as public roles, e.g., MRC member.) Task 3 Providers know how to contact hospital command center and request resources. Task 4 Providers receive incident command training appropriate to their role in the command structure, including • ocation of plans and actions taken to implement the continuum l of care in their area, including use of conventional/crisis spaces and • esources (job aids) or unit-based plans to guide capacity r expansion. 4-48 CRISIS STANDARDS OF CARE

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Function 3. Public Information Task 1 Providers understand key sources of facility/community information in disaster (web, Twitter, hospital hotline, etc.). Function 4. Operations Task 1 Providers understand unit-based actions during expansion of care from conventional to crisis (surge discharge, adapted care on unit, cot-based care, etc.). Task 2 Providers are prepared to perform triage as it relates to their roles (may involve, e.g., triage for early discharge, triage for resources in emergency department/surgery/other units, participation in triage team). Task 3 Providers likely to perform triage (both reactive and proactive) understand the criteria they may consider (as well as what not to consider) when making triage decisions. Function 5. Logistics Space Task 1 Providers understand disaster space utilization on their units, including contingency/crisis expansion as applicable. Staffing Task 1 Providers understand how their unit staffing and hours may change during a disaster. Task 2 Providers understand through education and other communications how their roles may be changed/expanded during a crisis (e.g., burn nurses may have responsibility only for burn/wound care as other nurses assume responsibility for overall patient care), including incorporation process for staff from outside the unit or facility as applicable. Task 3 Providers 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). HOSPITALS AND ACUTE CARE FACILITIES 4-49

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Supplies Task 1 Providers can access supplies from pharmacy/central/sterile supply and understands any existing contingency plans in case of shortage. Function 6. Operations Notes and Resources Mental Health Task 1 Providers understand employee resilience plan, including sources of See mental health employee mental health support. section of Chapter 4 for a more detailed Task 2 discussion. Providers are trained in anticipating normal stress reactions, developing a personalized “resilience plan” and identifying coping resources, as well as self-triage indicators of traumatic stress. Function 7. Legal Issues Notes and Resources Task 1 Providers understand legal obligations and liabilities for practice both Chapter 3 provides within and outside of their hospitals when more detailed discussion. * a disaster or public health emergency has been declared; * a disaster or public health emergency has not been declared; and * when providing other disaster relief functions (for example, if serving as MRC or disaster medical assistance team member). 4-50 CRISIS STANDARDS OF CARE

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