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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response Alternate Care Systems

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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response Volume 5: Alternate Care Systems 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 1-13 2 Catastrophic Disaster Response: Creating a Framework for Medical Care Delivery 1-29 3 Legal Issues in Emergencies 1-53 4 Cross-Cutting Themes: Ethics, Palliative Care, and Mental Health 1-69 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 7 Hospitals and Acute Care Facilities 4-1 VOLUME 5: ALTERNATE CARE SYSTEMS Acronyms ix 8 Out-of-Hospital and Alternate Care Systems 5-1 Roles and Responsibilities of Out-of-Hospital and Alternate Care Systems, 5-2 Operational Considerations, 5-9 ix

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Template Description, 5-13 Template 8.1. Core Functions of the Out-of-Hospital and Alternate Care Systems in CSC Planning and Implementation, 5-22 References, 5-47 VOLUME 6: PUBLIC ENGAGEMENT 9 Public Engagement 6-1 VOLUME 7: APPENDIXES 7-1 Appendixes x CONTENTS

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(private sites are established by the health care facilities that operate them). Function 4. Control Task 1 MAC group and ACS site staff understand the interface for resource requests and the acquisition process (as well as any existing plans for resource triage/allocation) with local and state emergency management. Task 2 Emergency management agreements/plans reflect how public health and health care facilities support sheltered populations with medical needs. Task 3 ACS site staff understand the need for security/access controls and community law enforcement support options as appropriate. Task 4 ACS options reflect a phased expansion of surge capacity/capabilities for conventional, contingency, and crisis care situations (from electronic to augmented services at private and public sites). Task 5 MAC group has a process for ongoing incident analysis to maintain situational awareness and facilitate ACS decisions. Function 5. Communications Task 1 Public health agencies have policies and procedures for exchanging situational updates with hospitals/outpatient care facilities, EMS, and emergency management. Task 2 MAC group/center has a means of communicating with key stakeholders (including those listed under Function 2, Task 1) to maintain incident communications (including redundant communications mechanisms as required). Function 6. Coordination Task 1 MAC group understands the interfaces among local public health and emergency management agencies and local/regional hospital coalitions, including existing agreements. Task 2 MAC group understands the function of the state disaster medical 5-40 CRISIS STANDARDS OF CARE

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advisory committee and any regional medical coordination center or regional disaster medical advisory committees, and can activate/ facilitate regional groups according to local plans. Function 7. Public Information Notes and Resources Task 1 MAC group ensures that appropriate risk communications relevant to See http://www.fema. ACS are developed for the public regarding when and where to seek gov/emergency/nims/ care (e.g., traditional media, websites, calling programs, e-mail, social PublicInformation. media). This includes the ability to reach key cultural groups served by shtm. ACS. Task 2 MAC group or public health agencies coordinate information with other agencies and participate in JIS and JIC activities when implemented by the jurisdiction, state, or coalition. Function 8. Operations Task 1 Local/state public health agencies maintain an inventory of usual and surge medical resources. Task 2 Local/state public health agencies understand private/public ACS capacities to augment health system capacity, including • elephone hotlines and other “electronic care” (including t coordination with private and public safety answering points); • mbulatory care (“flu centers” or triage/casualty collection a points); and • onambulatory care (shelter-based care, hospital overflow, n federal medical station integration, limited emergency/surgical care). Task 3 For each of these public sites (or for similar sites that are incident specific) MAC group understands the activation process (and any authorities or agreements involved). Task 4 Plans are made for patient registration, tracking, and record keeping, including access to and storage of medical records. Task 5 Plans are made for laboratory and pharmacy services appropriate to the site, including clinical ordering and results systems. OUT-OF-HOSPITAL AND ALTERNATE CARE SYSTEMS 5-41

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Task 6 Scope of clinical operations is defined and modified according to the evolving needs of the incident and the supplies available. Task 7 ACS site has staff trained to provide psychological first aid to patients/ evacuees, can implement psychological triage processes (such as PsySTART) as required, and has a referral/management plan for those with acute mental health needs. Task 8 ACS policies and education address the provision of palliative care (either on site or facilitated in the home environment). Function 9. Logistics Staffing Task 1 Local public health agencies identify sources of potential staffing (e.g., health care systems/coalitions, Medical Reserve Corps, EMS) for the various types of public ACS sites. Task 2 ACS credentialing policies and procedures are congruent with applicable regulations and statutes. Task 3 Plans are made for staff orientation, education, and supervision. Task 4 Capacity of nontraditional resources (family members, volunteers) to provide nonmedical care is examined and addressed as needed within the ACS operations plan. Task 5 Legal liability, worker’s compensation, compensation, and other issues are addressed according to the source of the staff (e.g., hospital, volunteer, MAC group). Supplies Task 1 Supply lists for each type of ACS (shelter, ambulatory, nonambulatory) are developed, optimally, including the source of initial supply and resupply. Task 2 Emergency management and public health agencies, health care facilities, and medical supply vendors understand their role in the ACS setup, resupply, and delivery processes. 5-42 CRISIS STANDARDS OF CARE

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Task 3 For local or state cached supplies (such as a local pharmaceutical cache) or SNS supplies, MAC group/ACS facility understands the process for request, receipt, and distribution of these supplies. Space Task 1 Health care facilities identify privately owned spaces for ACS establishment on site or at other owned and modified sites. Task 2 Public health and emergency management agencies identify public spaces for major ACS facilities and establish any necessary agreements or authorities required to utilize them (recognizing that no-notice incidents may require ACS sites at ad hoc locations). Special Considerations Task 1 Patient groups requiring special consideration are identified, and, to the degree possible, equipment and supplies to address the needs of these groups are purchased and/or stockpiled in relation to the expected size of the alternate care site, potentially including • p ediatric patients, • p atients with behavioral and cognitive impairment, • t he need for isolation/infection control, and • t he need for contamination assessment (post-HAZMAT or radiological dispersal device with population-based exposure). Task 2 Facility understands any regional plans or resources for specific groups (e.g., pediatric-specific disaster supplies, regional pediatric or dialysis networks) and the ACS site’s role in these plans. Function 10. Planning Task 1 Technical specialists are available as needed to provide input on infection control, clinical care, and other issues arising at the ACS site. This may include input from the regional or state disaster medical advisory committee. Task 2 Planning section maintains situational awareness and modifies clinical care guidelines or supply/staffing requests to meet demand/anticipated demand. Task 3 Planning section addresses policy modifications and demobilization based on incident demands. OUT-OF-HOSPITAL AND ALTERNATE CARE SYSTEMS 5-43

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Function 11. Administration Notes and Resources Authority Task 1 Public health and emergency management examine their delegation of authority to public ACS site incident commanders during a disaster and make any changes necessary to ensure that CSC decisions to open an ACS site are supported (i.e., that the incident commander is acting with the authority of the agency and any necessary political entities). During a crisis, the administration may require additional communications and coordination with the incident commander. Task 2 Public health and emergency management agencies understand their authorities to open and provide ACS services, including the ability to facilitate private ACS sites through use of regulatory relief and emergency orders. Regulatory and Legal Issues Task 1 Health care facilities and emergency management agencies understand See Chapter 4 for relevant changes to agency/facility authorities and protections when a more detailed state declarations of emergency/public health emergency are made, discussion. including legal protections or obligations for medical providers (e.g., duty to serve). Task 2 Agency heads/political leaders are aware of surge capacity/CSC plans and implications for patient care, including ACS sites. Task 3 Legal counsel identify state and local laws and regulations that would constrain public and private ability to open ACS sites and potential relief mechanisms. Core Functions of the Outpatient Sector in CSC Planning and Implementation Out-of-Hospital Providers Function 1. Notification Task 1 Providers ensure that up-to-date contact information and acknowledgment of receipt of exercise and incident messaging are provided to employers (and any other relevant groups, such as the MRC). 5-44 CRISIS STANDARDS OF CARE

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Function 2. Command, Control, Communications, and Coordination Task 1 When a disaster occurs that affects the providers’ facility/agency, providers understand where they report, to whom they answer, and how to execute their roles. They also understand the range of their potential roles within the rest of the health care system and opportunities for volunteer assignment (for example, reassignment to an alternate care site or a hospital within the corporate system). Task 2 Providers know how to contact and provide situational updates to and/ or request resources from their administrator/emergency operations center/command center as applicable to the facility/agency plan. Task 3 Providers receive incident command training appropriate to their role in the command structure, including • nowledge of the location of plans and actions for the full k continuum of care in their area, including the use of crisis spaces and staffing; and • nderstanding of appropriate resources (job aids) to guide u capacity expansion decisions or other unit-based plans. Function 3. Public Information Task 1 Providers understand key sources of facility/community information in a disaster (e.g., web, social media, e-mail, hotline). Function 4. Operations Notes and Resources Task 1 Providers understand facility-based actions during expansion of care from conventional to crisis (e.g., expanded facility hours, scheduling changes, triage of appointments, use of ancillary spaces). Task 2 Providers are prepared to perform triage as it relates to their role (may involve triage of appointments, or may involve another triage role within their system, such as telephone triage). Task 3 Providers likely to perform triage (both reactive and proactive) See the ethics section understand the criteria they may consider (as well as what not to of Chapter 4. consider) when making triage decisions. OUT-OF-HOSPITAL AND ALTERNATE CARE SYSTEMS 5-45

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Task 4 Providers understand sources of employee mental health support. See the mental health and palliative care Task 5 sections of Chapter Providers understand normal stress reactions and coping mechanisms, 4 for a more detailed as well as danger signs, and receive training in psychological first aid discussion. and psychological triage appropriate for their roles. Task 6 Providers understand their potential role in providing/facilitating palliative care during a disaster. Function 5. Logistics Task 1 Providers understand the utilization of space in their facility and other expansion plans that involve their department/unit. Task 2 Providers understand how their unit staffing and hours may change during a disaster. Task 3 Providers understand how their role may be changed/expanded during a crisis, including incorporation of staff from outside the unit or facility, and any potential roles at other sites within their health system (if applicable). Task 4 Providers understand how record keeping and other duties may change in crisis situations (e.g., where to find and how to use paper forms). Task 5 Providers understand the process for requesting necessary clinical resources during an incident. Function 6. Legal Issues Notes and Resources Task 1 Providers understand legal obligations and liabilities for practice both Chapter 3 provides within and outside of their facility/agency when a more detailed discussion. • disaster or public health emergency has been declared, a • disaster or public health emergency has not been declared, a and • hen providing other disaster relief functions (for example, w if serving as a Medical Reserve Corps or disaster medical assistance team member). 5-46 CRISIS STANDARDS OF CARE

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