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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
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu
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Building Hawaii’s Innovation Economy: Summary of a Symposium
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
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. 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 Sciences 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 Academy, 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
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* Resigned from the committee October 2011.
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical 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 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
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its release. The review of this report was overseen by Dr. Georges Benjamin, American Public Health Association. 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.
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Contents
VOLUME 1: INTRODUCTION AND CSC FRAMEWORK
Summary
1 Introduction
2 Catastrophic Disaster Response: Creating a Framework for Medical Care Delivery
3 Legal Issues in Emergencies
4 Cross-Cutting Themes: Ethics, Palliative Care, and Mental Health
VOLUME 2: STATE AND LOCAL GOVERNMENT
5 State and Local Government
VOLUME 3: EMS
6 Prehospital Care: Emergency Medical Services (EMS)
VOLUME 4: HOSPITAL
Acronyms
7 Hospitals and Acute Care Facilities
Roles and Responsibilities of Health Care Facilities
Operational Considerations
Template Description
Template 7.1. Core Functions of Hospital Facilities and Providers in the Implementation of CSC Plans
References
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VOLUME 5: ALTERNATE CARE SYSTEMS
8 Out-of-Hospital and Alternate Care Systems
VOLUME 6: PUBLIC ENGAGEMENT
9 Public Engagement
VOLUME 7: APPENDIXES
Appendixes
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Space/Structure
Need to use non-patient care locations for patient care (e.g., cot-based care, care in lobby areas) to accommodate demand; specific space resources overwhelmed (operating rooms), and delay poses a significant risk of morbidity or mortality; disrupted or unsafe facility infrastructure (damage, systems failure)
Staff
Specialty staff unavailable to provide or adequately supervise care (pediatric, burn, surgery, critical care) in timely manner, even after call-back procedures have been implemented
Supply
Supplies absent or cannot be substituted for (e.g., absence of available ventilators, lack of specific antibiotics), leading to risk to patient of morbidity
SOURCE: IOM, 2009, p. 64.
FIGURE 7-2
Usual location of technical specialist(s) and technical units within the incident command framework.
NOTE: PIO = public information officer.
Function 4. Control. Incident command training should be supplemented by facility- and department- specific training and exercises, as familiarity with incident management does not correlate with competency in initiating or supervising a departmental response. Staff at all levels should attain competency in facility protective actions (e.g., securing of entrances/exits, whom to contact to manage the ventilation system) and expansion or reassignment of their area’s resources to support the incident response. Some of these actions will be predetermined—such as central supply bringing a disaster cart to the emergency department in a mass casualty incident—while others will be implemented on an as-needed basis by the incident commander, often with input from the clinical care committee or technical experts. Job action sheets and response guides (Hick et al., 2008) should provide initial information to unit supervisors and command staff about how their units’ space and staffing will expand should there be a need to transition from conventional to contingency and even to crisis care.
Function 5. Communications. Internal communications to patients and staff, as well as to external staff and, optimally, patients’ families, are critical. Hotlines, the Internet, text messaging, e-mail, written letters, updates on social media (at a minimum Facebook and Twitter), and other means of communication may be used to provide incident information. It is helpful to provide updates both at scheduled times and when new information is available. The public information officer serves as the conduit for information to the internal and external stakeholders, including staff, visitors, families, and news media, as approved by the incident commander (California Emergency Medical Services Authority, 2006a). Following ICS principles, a process should be in place for rapidly vetting new information or status changes from general staff and other command or technical specialists via the public information officer, as approved by the incident commander.
Function 6. Coordination. A large part of incident management for a hospital is working with EMS and public health/emergency management to manage, to the extent possible, the flow of victims to the facility. If a hospital is overwhelmed and other facilities have capacity, EMS and public information can help avoid further burden on the affected hospital and organize the transfer of patients or resources as needed to restore the facility to contingency and eventually to conventional footing. Accomplishing this involves coordination among command staff, the liaison officer, and the public information officer to assess the situation and make appropriate requests to the jurisdictional EOC or EMS agencies/media consistent with the community plan. The EOC, in turn, will need a liaison to speak for area hospitals and help coordinate information and a common operating picture for health care that will drive resource requests and actions from the EOC. Without coordination mechanisms, a hospital can easily become an “island,” as happened at Charity Hospital in New Orleans after Hurricane Katrina (Deboisblanc, 2005). If a regional health care coordination center or multiagency coordination center (FEMA and Emergency Management Institute, 2008) is activated, the hospital should understand the authorities, resources to support coordination, and purpose of and how to interface with this entity.
If proactive triage of resources is necessary, command staff should understand how the hospital can provide input into the deliberations of the state and/or regional disaster medical advisory committee and receive guidance on implementing guidelines and triage mechanisms. This coordination helps promote regional consistency. A regional system for coordinating patient transfers, if in use, potentially can affect mortality by “gatekeeping,” or triaging the transportation of patients with key underlying needs to regional centers (Kanter, 2007; Kirby, 2010; Noah et al., 2011).
Function 7. Public Information. Providing the public with clear messages about when and where to seek care is a priority in a stressed health care system. The bigger the incident, the more important this issue becomes. To get effective messages out in a timely manner, the hospital will need to coordinate with its usual media sources via the public information officer (FEMA, 2007c), but also work closely with any joint information system (JIS) (FEMA and Emergency Management Institute, 2010), usually managed at the jurisdictional or state EOC level. The JIS ensures consistency of messages and provision of these messages to the media. If public health, health care, and EMS lack consistency in their recommendations for when and where to seek care, when to use 911, and so on, the public will quickly become confused, and trust will be lost.
Managing expectations during an incident is extremely important because a clear understanding of resource limitations gained from the major media at least facilitates a “frame shift” for patients seeking care and health care providers. Messages should include what the institution is doing, why, what the priorities are for the hospital and its patients, and what is being done at other levels to address the problems.
Function 8. Operations. The operations section, including the triage team and clinical care providers under operations, is responsible for developing and implementing strategies and tactics needed to meet incident action plan objectives as approved by the incident commander (see Figure 7-2 above for operations’ position on the abbreviated ICS organizational chart) (California Emergency Medical Services Authority, 2006b).
Especially in a no-notice incident, the operations section chief may be responsible for a wide variety of tasks, such as facility assessment and evacuation, patient triage and treatment, and the expansion of clinical care areas. The section chief should be well versed in gaining situational awareness and promoting communication with the clinical units, as well as with the command staff. Delegation is critical to ensure that strategies and tactics are properly implemented. Job aids can facilitate the process of situational assessment and guide initial actions. These aids may include job action sheets, initial action prompts or assessment tools, tables reflecting expansion or evacuation needs, and other resources (Hick et al., 2008).
Based on the situational assessment, the incident commander or appropriate section chief should decide how much to expand or “surge” clinical care (California Department of Public Health, 2008). Default actions may be taken when a disaster alert is called. In a mass casualty incident, for example, surgeries may be held and postanesthesia care and preinduction areas cleared for patient care. Conventional capacity can easily be maximized by summoning additional staff. Expansion to contingency and, if necessary, crisis capacity should be template driven and may involve space and supply adaptations in addition to staffing changes. During the 2009 H1N1 pandemic, for example, facilities had success remaining in conventional operations by implementing their surge plans (Meites et al., 2011). Table 7-2 provides an example of a template expansion plan. These templates should be supported by policy and other documents, and, while they may take many forms, are useful as a quick reference. If it is clear to the operations section chief that crisis capacity should be utilized, the incident commander and planning section chief should be made aware so that external assistance can be sought or plans made to cope with the demand. It is fundamentally important that a decision to implement CSC not be made independently, but jointly with other health care institutions in the region. In the HICS, the operations section’s infrastructure branch is responsible for maintaining hospital infrastructure, including power, water, HVAC (heating, ventilation, air-conditioning), medical gases, and environmental and food services. It will be important for the operations section to coordinate infrastructure with the planning and logistics sections in developing surge capacity during conventional, contingency, and crisis conditions (California Emergency Medical Services Authority, 2006b).
The medical care branch director implements the incident action plan for clinical care. He/she may be the first to recognize an impending shortfall of resources and alert the incident commander and operations section chief. In a crisis, they should oversee and be accountable for the actions taken at the unit level (e.g., emergency department, intensive care) and any triage processes. Their input to the clinical care committee is crucial to the committee’s understanding of the existing challenges and needs, as well as how the strategies and tactics in use are working or failing. The clinical care committee should work with the medical care branch director to determine what services the hospital can provide and how and where to provide them, and to recommend to the incident commander courses of action for coping with the scarce resource situation.
The clinical care committee also should determine crisis clinical policies for the hospital, which can include the surgeries that may be performed, what triage criteria the emergency department will use based on volume, what patients may be seen in what clinics, and what adjunct spaces and equipment are to be used for critical care (Rubinson et al., 2008b). Recommendations on when and how to implement substitution, adaptation, conservation, or reuse/reallocation strategies for specific resources also may be required (Hanfling, 2006; IOM, 2009; Minnesota Department of Health, 2011; Peleg and Kellermann, 2009; Rubinson et al., 2008a,b). These recommendations should be developed in close collaboration with the clinical departments and the medical care branch director prior to adoption. The clinical care committee also should provide any required modifications to guidelines and triage tools that are available from other sources, including regional and state disaster medical advisory committees. Examples of how this process has been structured are available in the literature (Frolic et al., 2009; Kaposy et al., 2010).
BOX 7-8
Appeals
A process appeal is an appeal generated when an invested individual (family member or patient’s clinician) believes that a decision was arrived at unfairly or deviated substantially from guidelines without justification. This is a retrospective appeal, and requires that the clinical care committee examine documentation and discuss the case with the triage team members and additional technical experts. If there are findings of an unfair or unjust decision, a process should be in place for communicating this to the invested individual(s). Regionally, there may be an appeals committee that examines these cases if there is any initial finding of merit. Note that this is not a legal proceeding, but essentially an ethics opinion on whether triage personnel executed their duties in good faith.
A clinical appeal is an appeal generated when the patient’s clinician believes the clinical data used for the triage decision do not reflect recent improvements in the patient’s condition. This is an urgent appeal that, if the triage team reconsiders, may affect the clinical decision. Clinical staff should be aware of the mechanism and indications for initiating such an appeal.
Finally, the clinical care committee is responsible for quality assurance of allocation and triage decisions, including review of the decisions and related documentation and discussion with clinical staff and triage team members about pending process modifications that might aid their performance. The clinical care committee also should review any process appeals (that is, any challenge to a triage decision on the basis of faulty reasoning or malfeasance) and either address them or refer them to a regional appeals committee (if established) (Box 7-8). Process appeals are retrospective and do not change the allocation decision (Debruin et al., 2010).
A triage team is used when proactive triage decisions are made regarding the allocation of scarce, potentially life-saving interventions (for example, mechanical ventilation and ECMO). The team should comprise at least two physicians trained in critical care or with substantial expertise in critical care decision making (or in the specialty area within which the allocation decisions are being made) (Hick et al., 2007; IOM, 2009).6 These physicians may be supported by other technical or ethics personnel at the facility’s discretion. They should review objective evidence for the patients requiring the intervention and determine who should receive the resources available. These decisions are then communicated to the medical care branch director or designated unit leader (e.g., critical care unit leader) for action.
Optimally, triage team members should understand their possible roles and have exercise experience in making such decisions prior to an incident to ensure their familiarity with the operational components involved (including, e.g., patient data, work flow, documentation). Note that it would be unusual for a facility triage team not to be available for other duties most of the time, as proactive triage decisions will be relatively infrequent; a mechanism for conference calls or other decision making should therefore be available. However, it is not ideal for the triage team members to be the clinical care providers for the patients they are considering, as it is difficult to remain a patient advocate and avoid bias due to knowledge of the full scope of the patient’s situation (Kirby, 2010).
The team should document its decisions in both the patient chart and a unit log. Clinical documentation for those not receiving resources should follow a template and reflect the current situation, the demands of the incident, and the data considered in the decision relative to those patient(s) who received the resources. Unit staff should document the transition of care and continued palliative or other ongoing care, as well as communications to the family and the patient if they are able to understand the situation. Reevaluation of these patients is important to ensure their continued consideration for resources as the incident and their conditions evolve (Klein et al., 2008). The legal and ethical implications of withdrawal of care are substantial, and should be examined with the assistance of legal counsel in advance of an incident in conjunction with analysis of applicable state laws (see Chapter 3) (Eastman et al., 2010).
Given the expertise involved, coalitions or health systems may elect to have centralized, regional, or even state-based triage teams to facilitate decision making at multiple sites, with the added benefit of maintaining situational awareness across multiple facilities. In these cases, a process for ensuring documentation of the decision process in the patient’s medical record is essential, whether in the form of a dictation, faxed or e-mailed template, or other mechanism.
If a resource is being assigned among persons not yet receiving it, it should be assigned to those patients with the better prognosis. An ethically fair triage process requires that physicians use the best available data and system to assess patient prognosis. Once this step is accomplished, some patients will have an essentially equal prognosis. When the medical prognosis is equal, any allocation scheme must ensure consistency in order to be fair. Community engagement strategies (see Chapter 9) may help solicit community values regarding prioritization of care schema, such as prioritizing patient age or using a first-come, first-served or lottery approach. If such engagement processes have not yet occurred, an allocation system should follow a consistent and fair approach, and the health care system should communicate that strategy broadly to the public. Close coordination among the health care institution and regional and state entities is thus required to prevent inconsistencies in triage when medical prognoses are equal, and the state ideally should define secondary processes to be followed, which should be understood by providers.
The threshold for withdrawal of a critical resource for reassignment to another patient should be much higher. The patient who is using the resource should, in the judgment of the triage team, have a substantially worse prognosis to justify withdrawal and reassignment of the resource. Therapies are not assigned in this setting, but offered as therapeutic trials; the triage team should weigh whether the patient with the resource has had an adequate trial of the therapy with respect to prognosis and benefit. Patient condition and clinical data should be reexamined at least every 24 hours (although, as noted above, failure to improve over this period of time may be expected rather than indicate failure of treatment).
More triage decisions are likely to be required early in an incident when, using influenza management as an example, patients already on ventilators are likely to have more organ system failures and poor predicted survival compared with healthier patients with more isolated respiratory failure. As this cohort of patients is ventilated, it will be less and less likely that arriving patients will have a substantially better chance of a good outcome, and thus few reallocations of ventilators will occur.
The triage team may occasionally receive clinical appeals and may need to reconsider its decisions if there has been a substantial improvement in parameters and/or prognosis. The institution should have a process in place for requesting these appeals and communicating any appeals holds or changes in decisions to unit staff, as well as mechanisms for ensuring that timely data are supplied to the triage team.
Triage situations will have a profound emotional impact on patients, families, and providers. Mental health issues should be addressed in a proactive fashion by the incident command team (see Chapter 4 for detail on these issues).
Mental health under CSC will require specific competencies of mental health, social services, and health care staff. Efforts also will be required to enhance community resilience through “neighbor-to-neighbor, family-to-family” support systems (such as certain psychological first aid models created specifically for use by community members as needed). The resilience of the health care workforce is paramount to the success of the CSC strategy.
One-shot, one-size-fits-all approaches, such as some once-common stress debriefing, are no longer recommended and may result in exacerbating the mental health problems of those most affected by a disaster (Bisson et al., 1997, 2007; IASC, 2007; McNally et al., 2003; NIMH, 2002). The replacement for those outmoded approaches is more integrated efforts to enhance the resilience of the workforce specifically with respect to mass casualty events, including CSC, as part of CSC preparedness (Schreiber and Shields, 2012).
Hospital incident command operations need to encompass integrated mental health operations as part of ICS/EOC and medical/health operations. Recent models developed for Los Angeles County, Seattle/King County, the American Red Cross’s National Operations Center/Disaster Mental Health, and a new national prototype specifically for children utilize real-time situational awareness of triage/ mental health risk in patients/disaster victims and responders (including health care workers and their families) across varied disaster systems of care (e.g., hospitals, schools, shelters, public health settings) to guide actual mental health operations within the ICS (see Schreiber et al., in press). Other recommended features include a common operating picture of
• population-level mental health risks (traumatic loss, multiple traumatic losses) using a common rapid mental health triage system across disaster systems of care;
• mental health risks among health care workers; and
• mental health resources, including emerging national models of Internet-based intervention (Ruggiero et al., 2006).
Addressing the social and psychological challenges of CSC requires a triage-driven mental health incident management system and community resilience efforts through community engagement (see Chapter 9). Also required are basic “neighbor-to-neighbor, family-to-family” psychological first aid competencies that leverage the community, responders, and family members as the first line of psychosocial support (see the American Red Cross’s “Coping in Times of Crises” and the “Listen, Protect and Connect” psychological first aid models).
Palliative care focuses on the relief of suffering and distress (e.g., pain, nausea) during serious, lifethreatening illness to help patients and families have the best possible quality of life. The emphasis is on coping, comfort, and well-being. One goal of disaster response is to provide comfort to the most people possible. Therefore, efforts to plan for appropriate palliative care for all victims are a high priority, along with caching and adequate use of medications to provide comfort (Bogucki and Jubanyik, 2009; Matzo et al., 2009). During triage situations, planning for thoughtful care transitions if support and interventions are unavailable is critical to maintaining comfort and dignity. Multidisciplinary planning is helpful to identify processes and interventions that can be implemented at the hospital and support that can be offered to patients and their families. Planning in advance for these activities is as critical as planning for the triage process, yet often is overlooked; the result may be greatly increased suffering and emotional distress for all during an incident (Downar and Seccareccia, 2010). More in-depth discussion of palliative care planning and the needs of patients can be found in Chapter 4.
Function 9. Logistics. Logistical planning for scarce resource incidents begins with anticipating possible deficits (see Appendix C) based on
• hospital location (geographic risks of facility impact and isolation by natural, terrorist, or other incidents);
• hospital role in the community (e.g., trauma center, children’s hospital);
• fragility of vendor supplies and anticipated supply lines; and
• facility goals and resources.
Often, hospitals in a geographic area rely on the same vendors for supplies of medical equipment (such as hospital beds and ventilators), which can lead to rapid depletion of these items during an incident. Also, vendors may not be able to deliver items because of access problems. Hospitals should determine minimum amounts of equipment to be kept on hand. Durable medical equipment is expensive, but retaining monitors, ventilators, and hospital beds that have been removed from service may be a good strategy. Increasing par levels of medications and supplies can be difficult in times ofjust-in-time inventory management, but often there are no good substitutes for inexpensive caches of medications (e.g., narcotic analgesias) that are rotated through stock. Forecasting demand can reveal staggering supply needs, especially during a prolonged incident (Hota et al., 2010).
The logistics section provides for maintenance of the physical environment, providing human resources, materiel, and services to support the incident response activities. The logistics section should coordinate with the operations and planning sections to expand alternate care locations (California Emergency Medical Services Authority, 2006c). Space expansion plans should include planning for both inpatient and outpatient surge, and may require preincident or just-in-time modification of spaces, including creation of temporary walls, changes in room configurations, ventilation modifications, or other changes. Predictive and historical demand forecasting can yield helpful information about the likely impact on the institution (Sills et al., 2011). In addition to a surge of patients, accommodations may have to be made for the family members or pets of staff during an incident that severely damages community infrastructure.
The logistics section also is responsible for the labor pool and credentialing unit, a collection point for available hospital staff and volunteers that may be a resource for addressing staffing shortages (California Emergency Medical Services Authority, 2006d). Staffing patterns and shift lengths may be changed during an incident, although such changes should be balanced against the detrimental effects of fewer staff per patient, less experienced staff, and fatigue (Cheung et al., 2008; Clarke et al., 2002; Gershengorn et al., 2011; Needleman et al., 2002). Consistent with the Assistant Secretary for Preparedness and Response’s (ASPR’s) Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), an adequate staff must be held in reserve, especially in no-notice incidents, when many staff may self-report and then be unable to supplement shifts later that day or night. Agreements for obtaining and integrating additional staff from the Medical Reserve Corps, federal teams, and local sources should be in place prior to an incident (ASPR, 2011; HHS, 2012). The logistics unit should make requests to the EOC or partner facilities and ensure adequate credentialing, check-in, privileging, orientation, and supervision. Use of supplemental personnel should conform to the hospital’s staffing bylaws and policies.
Special challenges during an incident may include the need for patient isolation, decontamination, or special equipment. Managing contaminated belongings and washwater, creating negative airflow or isolation areas, and ensuring that adequate equipment is available for pediatric or burn patients in advance of an incident, as well as identifying multiple vendors and sources for resupply, can greatly reduce the potential for scarce resource situations and prevent staff exposure to harmful agents.
Another challenge is providing for the nearly one-third of the U.S. population that qualifies in some manner as at-risk, whether by virtue of functional limitations, age, medical conditions, pregnancy, or mental health problems (among other factors). Hospital planning should focus on those factors that require specialized planning, training, or equipment, such as the following:
• Maternal health: Pregnant patients represent two lives to be saved, and they may be at higher risk of complications from influenza or other disease processes or trauma. Considerations for planning for a crisis with respect to maternal health include (Beigi, 2007; Rasmussen et al., 2008)
Triage: Discussion should encompass whether pregnancy results in triage priority when other factors are relatively equal. A model for triage of pregnant patients has been proposed, but it does not address how such decisions are integrated with decisions about other patients being triaged (Beigi et al., 2010). The committee believes triage processes should be inclusive of all patients requiring the same resource, although the prognostic predictors may vary depending on the underlying disease.
Prioritization of maternal care: What is required and what may become optional for prenatal care and evaluation of symptoms (e.g., abdominal pain)?
Infection: Is a separate area or process for pregnant patients required to prevent them from acquiring an illness in the health care environment (CDC, 2009b)? Do pregnant women access vaccine in the same way as the general population?
Delivery: What deliveries may be accomplished more safely at home, particularly during an epidemic? Few providers are knowledgeable about the process of labor and delivery or management of common complications.
Information and consultation: Hotlines and other resources that do not require an actual provider visit are strongly preferred during an epidemic, and may reduce workload during other incidents (University of Minnesota, 2007).
• Pediatrics: Children represent 24.3 percent of the U.S. population, and 6.9 percent of the U.S. population is under age 5 (U.S. Census Bureau, 2012). Children evoke emotional responses in most health care providers, which can complicate their care and lead to additional psychological stressors for providers, particularly if they are not accustomed to caring for children who are severely injured or ill. Community emergency departments see 90 percent of pediatric emergency cases (American Academy of Pediatrics et al., 2009), few of which involve critical injury or illness. The following are a few key tenets of pediatric care planning (see also Box 7-9):
Age-appropriate equipment and sufficient volumes and types of supplies should be stocked for pediatric emergency use.
Providers should have at least basic skills in pediatric resuscitation, including quick reference materials.
The facility should plan for unaccompanied minors and their physical and emotional support.
• Functional limitations: The institution’s usual resources (for example, wheelchairs or sign language interpreters) may be unavailable during a disaster, and contingency plans for those needing these resources should be developed.
• Medically dependent patients: Those on home oxygen and electrical devices may arrive at the hospital during blackouts and other community infrastructure losses for assistance. Outpatient dialysis systems usually have robust disaster plans, but local transportation and infrastructure may be too damaged to meet dialysis needs initially.
• Mental health: Disasters are extremely destabilizing for patients with mental health issues. Additionally, patients may run out of or become separated from their medications or be unable to fill prescriptions. Planning should account for the potential for disaster stocking of psychotropic and anxiolytic medication for both maintenance and acute use.
BOX 7-9
Pediatric Issues in the Tuscaloosa Tornado
On April 27, 2011, an EF-4 tornado struck Tuscaloosa, Alabama. DCH Regional Medical Center in Tuscaloosa treated 600-800 patients in the first 24 hours after the tornado, the vast majority in the first 14 hours. One hundred patients were admitted. DCH is not a usual receiving facility for pediatric trauma but received at least 50 pediatric victims, including three pediatric fatalities (all of whom were apparently dead on arrival and one of whom was unclaimed for days after the storm). After initial assessment, stabilization, and management, 30 patients were transferred to Children’s Hospital of Alabama for admission and further care, representing a high percentage of transferred and admitted patients. Although the area hospitals have outstanding referral criteria for pediatric patients and participate in the Southeastern Regional Pediatric Disaster Response Network (a multistate pediatrics preparedness network) to improve surge response, no just-in-time training, network support, or follow-on resources could substitute for the availability of pediatric-specific supplies and the response of emergency and pediatric providers to the local hospital. Additional supplies were brought to DCH Regional as the evening wore on, but initial stabilization efforts relied on supplies that were present at the institution. Many children presented without family members, and families often were separated as a result of transfers or admission to other facilities. These children required significant staff support. One staff member recalled being moved at the sight of a 6-year-old crying in the hospital hallway, injured, and knowing his parents were dead.
Key points:
• R egional plans for specialty patients (e.g., burn, pediatrics) are critical for ongoing care and referral. In overwhelming situations, concentrating those less than 5 years of age at children’s hospitals may offer the best outcomes when all patients cannot be admitted to specialty facilities. This requires regional coordination.
• Rtabilization care often will occur at the institution closest to the incident, requiring a commitment to stocking basic supplies and providing basic training and immediate reference materials.
• R lanning for unaccompanied minors and their support (including their safe disposition once medical care has been completed) often is underemphasized.
SOURCES: AAP, 2011; Branson, 2011; EMSC National Resource Center, 2010; Kanter and Cooper, 2009; National Commission on Children and Disasters, 2009; NYCDHMH, 2007.
Function 10. Planning. The planning section is responsible for gathering incident-related data, which encompass up-to-date incident information, analyses, and forecasts regarding operations and assigned resources, including the development of alternatives for tactical operations. The planning section conducts planning meetings and prepares the incident action plan. It also provides awareness through materiel and personnel tracking, and situational awareness through patient and bed tracking (California Emergency Medical Services Authority, 2006d). The planning section is responsible as well for working with command staff, technical specialists, and the operations section to identify objectives for the next operational period (usually 12-24 hours) (Plourde and Moats, 2006). In addition, the planning section may be asked to activate, support, and facilitate interactions with technical specialists and the clinical care committee to obtain input on clinical care strategies for meeting excess demand or specialty consultation.
Personnel management includes ensuring that current staff can be contacted easily (with up-to-date information and processes) and that modifications to shift durations and other staffing changes are checked against current personnel policies and any union or other agreements. A range of options may be implemented, including changing staffing patterns and responsibilities, using administrative staff to provide basic patient care and feeding, adding supplemental staff if possible, and changing staffing ratios. Those changes that result in the least impact on patient care should be implemented first (AHRQ, 2007).
Additional training and orientation materials may need to be developed and provided to current staff either as a refresher or to introduce new concepts. The emphasis should be on reassigning personnel so that those with technical expertise can focus on those areas, and others can perform less technical (and less consequential) tasks. For example, respiratory therapists may concentrate on supervising ventilator use while other staff are delegated to administer inhaled medications (nebulizers and metered dose inhalers).
Function 11. Administration. The administrator of the facility should work with legal counsel and any corporate administrators to determine the institution’s authority and liability in crisis settings, and how declarations of emergency may change those rights and responsibilities. These issues should be understood before an incident occurs.
Regulations affecting patient care and information exchange (such as the Emergency Medical Treatment and Active Labor Act [EMTALA] and the Health Insurance Portability and Accountability Act [HIPAA]) (California Hospital Association, 2009; HHS, 2011) should be examined in advance of an incident; certain actions, such as suspension of selected federal requirements, may be requested and granted during disaster situations. Usually, exceptions to the regulations are made for emergencies, including permitting information sharing to allow family reunification and the exchange of public health and safety information. A crisis is not the time to scramble to research these issues. Administration and counsel should have a good understanding of applicable state laws and federal regulations (see also the detailed discussion of legal issues in Chapter 3).
It is important for hospitals and providers to understand their regulatory and legal protections and liabilities. Both can be held liable for their clinical and administrative decisions (Hodge and Brown, 2011).7 Clear documentation of actions and use of standard or community guidelines can mitigate that liability. Activation of emergency health powers may confer additional protections, depending on the state. Having a preplanned, systematic approach consistent with that of other facilities in the community contributes to protecting institutions and providers. Triage decisions may have to be made in the absence of a declaration of emergency (e.g., an isolated ECMO triage decision during a seasonal influenza epidemic, no other regional/community resources available). Thus, it is important to consider the process within or between institutions when there is no disaster situation. In most states, when an incident is large enough to warrant a declaration, early actions may be protected by dating the emergency orders to cover the entire incident timeline regardless of when the declaration was issued.
Providers should be familiar with their protections in daily operations, during disasters (when some state laws provide additional protections for clinical decisions), and during declared health emergencies. There often are significant differences in liability when care is provided in nonhospital versus hospital settings and in situations where reimbursement is not expected. Furthermore, there is significant state-to-state variability in protections, so providers responding to assist in other states who are not protected as federal or state employees should understand their obligations and liabilities.
Hospital Providers
It is important for providers to take an active interest in their facility’s disaster preparedness and response plan, with specific attention to its CSC indicators, triggers, and implementation protocols. This section of the template enumerates the functions and associated tasks of those providing health care during a disaster.
Function 1. Notification. Providers that have agreed to act as technical specialists or members of the clinical care committee or triage team should understand their responsibilities to those groups during a disaster. These duties may need to be reconciled with their other clinical responsibilities, especially if the duration of the response is lengthy. All providers should regularly update and ensure the accuracy of their contact information, as the facility will need to get in touch with staff to meet rapidly changing demand. It is important for all providers to participate actively in tests and exercises of the facility’s notification systems so they can gain insight into those systems prior to an incident, and so the facility has an opportunity to identify and rectify any issues.
Function 2. Command, Control, Communications, and Coordination. All providers should receive role-appropriate incident command training, including knowledge of how to access available resources to guide their actions as the standard of care progresses from conventional to crisis. In the reactive phase of triage, providers may not have an understanding of the scope and scale of the incident, so it is important that they know how to contact their facility’s command center to determine resource availability. Beyond their commitment to a particular facility, providers may have obligations that involve public-sector disaster response roles, including serving as a part of the Medical Reserve Corps or ESAR-VHP. For each of their roles, providers should be clear about whom to contact, where to report, and how to execute their responsibilities.
Function 3. Public Information. While facilities will be responsible for managing internal and external communications systems, individual providers should familiarize themselves with processes for inputting information into and extracting information from facility and public sources (likely electronic or telephone based).
Function 4. Operations. Providers should know their unit’s protocols for expanding care as demand overwhelms available resources. To operate effectively under CSC conditions, providers should thoroughly understand their triage roles (if any), as well as acceptable and unacceptable bases for triage decisions.
Function 5. Logistics (space, staff, supplies). While local and state governments and facilities bear responsibility for managing resources to avoid or mitigate scarcity on a regional level, individual providers will have to adapt to any deficits that occur in their unit. It is important that providers be well versed in how to expand their patient care space to accommodate a significant increase in patient volume. Providers themselves may become a scarce resource as patient volume increases; familiarity, through education and exercises, with the ways in which their own roles will change with shifts in the care continuum will enable maximal use of their time and energy. These changes can include an expansion or contraction of their traditional scope of practice, changes in documentation duties, and incorporation of external staff into the unit. Finally, providers should know where to access additional supplies and how guidance is to be received on substituting, conserving, adapting, and reusing those supplies.
Function 6. Operations (mental health). Changes to the clinical care environment during disaster response can take a toll on providers’ emotional health. For this reason, it is important that providers be able to recognize the signs and symptoms of abnormal (as opposed to normal) responses to stress and be clear on how to access employee mental health services. Greater detail on mental health care can be found in the mental health section of Chapter 4.
Function 7. Legal Issues. The legal implications of providing care during a disaster, especially one that requires the use of CSC, can be daunting. Providers should not wait until an incident has occurred to learn about their legal protections and liabilities in different disaster scenarios (e.g., in a declared versus a nondeclared emergency, as a public versus private care provider). Chapter 3 provides a detailed discussion of the legal issues associated with disaster response.
Template 7.1. Core Functions of Hospital Facilities and Providers in the Implementation of CSC Plans
Hospital Facilities
Function 1. Alerting
Notes and Resources
Triggers and indicators are consistent with regional and state plans as applicable.
Task 1
Health care facility is able to receive and manage alerts from emergency medical services (EMS), public safety, hospital partners, the department of public health (Health Alert Network), and the National Weather Service.
Task 2
Health care facility emergency response plan provides the triggers and process for incident command to activate the CSC plan and indicators (if applicable) to prompt consideration of activation.
Function 2. Notification
Notes and Resources
Institution tests notification systems at least annually and ensures that up-to-date contact information is available.
Task 1
Institution is able to alert staff within and external to the facility, including
• EMS and coalition/partner health care facilities;
• medical, administrative, and support staff;
• clinical care committee members; and
• technical experts, including those in toxicology, radiation safety, infectious disease, critical care, emergency medicine, trauma surgery, blood banking, dialysis, pediatrics, burn surgery, and mental health (those institutions without in-house expertise should identify other sources for consultation).
Notification mechanisms account for redundancy in case a disaster affects usual means of contact/consultation.
Task 2
Expectations of staff, including technical experts and those staffing the clinical care team, are understood prior to an incident, and appropriate activation/notification policies are in place.
Function 3. Command
Notes and Resources
See Appendix B for a sample hospital CSC plan.
See Table 7-2 in Chapter 7 for a sample surge capacity template.
Task 1
Hospital incident command system (HICS) (or other national incident management system [NIMS]) and community-compliant system is in place. Includes
• understanding where technical specialists, the clinical care committee, and the triage team fit into the incident management structure;
• training and exercising with key staff, including those on the clinical care committee and potential triage team members;
• command staff being trained and exercised (at least table-top) in activation of the full continuum of care, including use of crisis spaces and staffing;
• command staff understanding incident action planning and use of the planning section during longer-term events; and Notes and ResourcesSee Appendixes B, C, and D.
• appropriate resources (job aids) being available to guide capacity expansion.
Function 4. Control
Notes and Resources
See Appendixes B, C, and D.
Task 1
Command staff understand interfaces for resource requests and acquisition (as well as any existing plans for resource triage/allocation) with
• Local public health and emergency management,
• Local/regional hospital coalitions, and
• State resources (usually via local emergency management and/ or state public health).
Task 2
Command and other appropriate staff understand transfer and diversion policies in the area and their function during a disaster.
Task 3
Command staff understand the process 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 during a disaster.
Task 5
Facility plan reflects a phased expansion of surge capacity/capabilities for conventional, contingency, and crisis situations.
Task 6
Command staff understand the process for rapid facility and incident assessment in the immediate aftermath of an incident to gain situational awareness.
Task 7
Command staff understand the state public health department authorities and resource allocation/policy/plans for an epidemic or other public health crisis, including how the health care facility interfaces with local and state public health (this affects facility isolation, personal protective equipment, quarantine, vaccination, countermeasures, and other actions taken to contain an outbreak).
Function 5. Communications
Task 1
Facility has policies and procedures in place for sharing situational information with staff, patients, and other facilities and agencies within the region.
Task 2
Facility has redundant ability to communicate with
• local EMS,
• the local emergency operations center,
• the local/regional health and medical multiagency coordination center (as applicable), and
• other hospitals/facilities in the area.
Task 3
Facility has around-the-clock capability to receive health alerts and other local, state, and federal health communications and a process for rapidly analyzing those communications, and developing or modifying policy accordingly.
Function 6. Coordination
Task 1
Command staff understand the interface between the institution and local public health, emergency management, and local/regional hospital coalitions, as well as any multiagency coordination constructs.
Task 2
Facility 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 communicated to these bodies.
Task 3
If the facility is part of a health care system, plans document the responsibilities of the facility vs. the corporate response structure and the process by which corporate policy and other region- or communitydeveloped policies and processes are integrated.
Task 4
If facility has a limited patient population (Department of Veterans Affairs [VA] hospital, children’s hospital, military hospital, rehabilitation hospital), there is guidance/a plan for how that facility will contribute to the response when an incident affects either its usual target population or other groups disproportionately.
Function 7. Public Information
Task 1
Facility has a process in place to ensure the development of appropriate risk communications in conjunction with coalitions and/ or public agencies, as well as facility-specific means of dissemination (website, calling programs, e-mail, social media).
Task 2
Facility coordinates information with other agencies and facilities and participates in joint information system (JIS) and joint information center (JIC) activities when implemented by the jurisdiction, state, or coalition. This includes the ability to reach key cultural groups served by the facility.
Function 8. Operations
Notes and Resources
See Appendix B.
See Appendix C.
See Appendix B.
The mental health section of Chapter 4 provides more detailed discussion and examples.
Palliative care may be addressed in the CSC/scarce resources annex or elsewhere in the facility emergency operations plan.
The palliative care section of Chapter 4 provides a more detailed discussion.
Conventional Care
Task 1
Command and unit staff are aware of actions to be taken to maximize the availability of staffed beds, including canceling elective admissions/ surgeries and invoking early patient discharge ("surge discharge") or movement.
Contingency Care
Task 1
Command and unit staff are aware of how to implement institutional plans for supply substitution, conservation, and adaption; staff responsibility extension; and patient care area repurposing (e.g., opening pre- and postanesthesia care units for general patient care).
Crisis Care
Task 1
This task is the same as Task 1 for contingency care, but options are expanded to include
• reuse and reallocation of supplies,
• changes in staff roles,
• use of cot-based care, and
• resource allocation and triage decisions and interface with the triage team (if activated).
Standards for patient care are adjusted according to circumstances (e.g., changed thresholds for intensive care unit or floor admission).
Medical Care Branch, Clinical Care Committee, and Triage Team
Task 1
Facility has planned for crisis care by convening potential members of an institutional clinical care committee and triage team (for tertiary triage of inpatients, not for no-notice incidents) to identify specific risks to the facility and specific resources at risk.
Task 2
Facility emergency operations plan includes a crisis care annex that details the use of the clinical care committee and triage team, including
• membership,
• activation,
• roles and responsibilities,
• considerations prior to implementing triage strategies,
• documentation of decisions (medical records as well as incident documentation),
• the triage process and possible decision tools to be used (including the ability to incorporate incidents or community-specific modifications),
• an appeals process for triage decisions, and
• anticipated clinical and administrative strategies.
Mental Health
Task 1
Facility has non-mental health personnel trained in basic psychological first aid and psychological triage and assigns a role to mental health operations within its incident command system.
Task 2
CSC-specific coping information/resources are provided to patients, family members, and staff, including CSC-specific “neighbor-to-neighbor, family-to-family” psychological first aid.
Task 3
Facility has a plan for triage-driven management of psychological casualties, including participation in local/regional plans for mental health incident management.
Task 4
Facility participates in the development of risk communications that include a behavioral component related to “coping with CSC” for patients, their families, and health care workers.
Task 5
Facility has a personal resilience plan for health care workers that includes triage and referral to a continuum of evidence-based care.
Task 6
Facility participates in a local gap analysis and develops an action plan to build key local disaster mental health and spiritual care capacities.
Task 7
Facility has a plan to engage community faith-based and other support providers, as well as key cultural groups within the community, during crisis care operations to expand mental health care capacity, particularly in times of resource triage.
Palliative Care
Task 1
Facility has planned for adequate symptomatic management (analgesia, antiemetics, anxiolytics) for all patients (including those that will not receive other treatment modalities).
Task 2
Palliative care, including palliative care principles, triage tools, and any facility-specific procedures, is addressed in the emergency operations plan.
Task 3
Palliative care training (including just-in-time training) is developed and provided according to the facility plan.
Function 9. Logistics
Notes and Resources
For an example, see the Minnesota Department of Health’s Strategies for Scarce Resource Situations.
All institutions should prepare to initially stabilize and treat all types of victims during a disaster.
Supplies
Task 1
In conjunction with the clinical care committee, emergency management committee identifies key potential scarce resources based on different types of incidents and, to the extent possible, stockpiles or identifies alternative sources for these supplies.
Task 2
For highly vulnerable supplies, facility identifies strategies for appropriate substitution, conservation, adaptation, reuse, and reallocation.
Task 3
For local or state cached supplies (such as a local pharmaceutical cache) or Strategic National Stockpile (SNS) supplies, facility understands the process for requesting, receiving, and distributing these supplies.
Space
Task 1
Facility examines available beds, beds in storage, cots, beds for lease, and other potential sources and develops a plan for maximizing available patient care space and converting non-patient care areas to patient care as necessary.
Staffing
Task 1
Call-back criteria and policies are in place and include maintenance of current and accurate employee contact information.
Task 2
Facility assesses number of staff available for selected large-scale events, including those that limit access to the facility or result in provider illness. Consideration is given to the need for extended staffing requirements or for holding back adequate staff for future operational periods.
Task 3
Facility plans for on-site accommodation of staff and family members as appropriate.
Special Challenges
Task 1
Patient groups requiring special consideration are identified, and to the extent possible, equipment and supplies to address their needs are purchased and/or stockpiled in relation to the facility’s size and role in the community. These groups include (but are not limited to)
• pediatric patients,
• burn patients,
• patients requiring airborne isolation,
• patients requiring decontamination,
• patients with functional limitations (e.g., hearing or visually impaired), and
• patients requiring dialysis/renal replacement therapy.
Task 2
Facility understands regional/state plans or resources for specific groups (e.g., pediatric-specific disaster supplies, regional pediatric or dialysis networks) and how to access/activate them.
Function 10. Planning
Technical Specialists and Clinical Care Committee
Task 1
Clinical care committee understands its interface with incident command, and in particular the medical care branch director, planning section chief, and planning cycle, including its role in developing strategies for the next operational period.
Task 2
Technical specialists understand their interface with the command and planning sections.
Task 3
Clinical care committee reviews current response strategies, including any triage decisions made, and modifies strategies, tools, or processes based on evolving incident information as part of the incident planning cycle.
Personnel Management
Task 1
Hospital bylaws, credentialing policies and procedures account for disaster use of nonhospital staff (including use of local/regional staff in accordance with coalition agreements).
Task 2
Emergency operations plan includes anticipating orientation, mentoring, education, and clinical care policies for outside staff.
Task 3
Policies for altered staffing ratios, shift lengths, and staff roles are examined, and any collective bargaining issues are identified, if not addressed.
Task 4
As needed, emergency operations plan addresses the use of nontraditional assistance (family members, volunteers, Medical Reserve Corps [MRC] providers) to provide non-medical patient care.
Task 5
Hospital understands the process and supporting agreements (e.g., worker’s compensation, liability) for sharing staff with outside facilities in need, including staffing of alternate care systems.
Task 6
Hospital understands the need to attend to staff resilience and mental health risk to maintain the hospital’s continuity of operations.
Function 11. Administration
Notes and Resources
See Chapter 3 for a more detailed discussion.
Authority
Task 1
Administration (including corporate administration) has examined its disaster delegation of authority to incident commanders and made any changes necessary to ensure that crisis care decisions are supported (i.e., that the incident commander is acting with the authority of the institution). During a crisis, the administration may require additional communications and coordination with the incident commander.
Task 2
Administration understands relevant changes to agency/facility authorities and protections when the state declares an emergency/ public health emergency, including legal protections or obligations for medical providers (e.g., duty to serve).
Regulatory/Legal Issues
Task 1
Facility and/or corporate legal counsel are aware of CSC plans and implications for patient care.
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
If provider is a member of command staff, additional training is required; see Function 3 in “Hospital Facilities” section of this template.
Task 1
Providers receive information on community disaster roles, including the Medical Reserve Corps (MRC) and Emergency System for the Advance Registration of Volunteer Health Professionals (ESAR-VHP).
Task 2
Providers understand where they report, to whom they answer during a disaster, and how to execute their roles. (This may include private as 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
• location of plans and actions taken to implement the continuum of care in their area, including use of conventional/crisis spaces and
• resources (job aids) or unit-based plans to guide capacity expansion.
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).
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
See mental health section of Chapter 4 for a more detailed discussion.
Mental Health
Task 1
Providers understand employee resilience plan, including sources of employee mental health support.
Task 2
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
Chapter 3 provides more detailed discussion.
Task 1
Providers understand legal obligations and liabilities for practice both within and outside of their hospitals when
* 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).
1 Preston v. Tenet Healthsystem Memorial Medical Center Inc., no. 05-11709-B-15 (La. Civ. Dist. Ct. settled March 23, 2011).
2 This report addresses resource deficits in the setting of disasters, although it should be acknowledged that daily capacity challenges in emergency departments and hospitals may risk patient complications due to capacity issues (Bernstein et al., 2009; IOM, 2006; Maa, 2011).
3 Department of Veterans Affairs Emergency Preparedness Act of 2002, Public Law 107-287, 107th Cong., 2d sess. (November 7, 2002), 38 U.S.C. § 1785.
4 After initial distribution of the report, Boxes 7-1 and 7-2 were added to provide more specific information regarding the responsibilities of the VAMC and the VISN.
5 Hennepin County. Minnesota data used in the CDC FluSurge predictive model, available at: CDC (Centers for Disease Control and Prevention). 2009. FluSurge special edition. Atlanta, GA: CDC, http://www.cdc.gov/h1n1flu/tools/flusurge/ (accessed March 5, 2012).
6 It may be advantageous to have an odd number of individuals serve on the triage team.
7 Preston v. Tenet Healthsystem Memorial Medical Center Inc., No. 05-11709-B-15 (La. Civ. Dist. Ct. settled Mar. 23, 2011).
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