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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response State and Local Government

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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response Volume 2: State and Local Government Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations Board on Health Sciences Policy Dan Hanfling, Bruce M. Altevogt, Kristin Viswanathan, and Lawrence O. Gostin, Editors

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. HHSP23320042509XI between the National Academy of Sciences and the Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Crisis standards of care : a systems framework for catastrophic disaster response / Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations, Board on Health Sciences Policy ; Dan Hanfling ... [et al.], editors. p. ; cm. Includes bibliographical references. ISBN 978-0-309-25346-8 (hardcover) — ISBN 978-0-309-25347-5 (pdf ) I. Hanfling, Dan. II. Institute of Medicine (U.S.). Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations. [DNLM: 1. Disaster Medicine—standards—United States. 2. Emergency Medical Services—standards—United States. 3. Emergency Treatment— standards—United States. WA 295] 363.34—dc23 2012016602 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carv- ing from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. Crisis Standards of Care: A Systems Framework for Cata- strophic Disaster Response. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished schol- ars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and techni- cal matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sci- ences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Acad- emy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON GUIDANCE FOR ESTABLISHING STANDARDS OF CARE FOR USE IN DISASTER SITUATIONS LAWRENCE O. GOSTIN (Chair), O’Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC DAN HANFLING (Vice-Chair), Inova Health System, Falls Church, VA DAMON T. ARNOLD, Illinois Department of Public Health, Chicago (retired) STEPHEN V. CANTRILL, Denver Health Medical Center, CO BROOKE COURTNEY, Food and Drug Administration, Bethesda, MD ASHA DEVEREAUX, California Thoracic Society, San Francisco, CA EDWARD J. GABRIEL,* The Walt Disney Company, Burbank, CA JOHN L. HICK, Hennepin County Medical Center, Minneapolis, MN JAMES G. HODGE, JR., Center for the Study of Law, Science, and Technology, Arizona State University, Tempe DONNA E. LEVIN, Massachusetts Department of Public Health, Boston MARIANNE MATZO, University of Oklahoma Health Sciences Center, Oklahoma City CHERYL A. PETERSON, American Nurses Association, Silver Spring, MD TIA POWELL, Montefiore-Einstein Center for Bioethics, Albert Einstein College of Medicine, New York, NY MERRITT SCHREIBER, University of California, Irvine, School of Medicine UMAIR A. SHAH, Harris County Public Health and Environmental Services, Houston, TX JOLENE R. WHITNEY, Bureau of Emergency Medical Services (EMS) and Preparedness, Utah Department of Health, Salt Lake City Study Staff BRUCE M. ALTEVOGT, Study Director ANDREW M. POPE, Director, Board on Health Sciences Policy CLARE STROUD, Program Officer LORA TAYLOR, Senior Project Assistant (until January 2012) ELIZABETH THOMAS, Senior Project Assistant (since February 2012) KRISTIN VISWANATHAN, Research Associate RONA BRIER, Editor BARBARA FAIN, Consultant for Public Engagement * Resigned from the committee October 2011. v

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and techni- cal expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review com- ments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Richard Alcorta, Maryland Institute for Emergency Medical Services Systems Knox Andress, Louisiana Poison Center Connie Boatright-Royster, MESH Coalition Susan Cooper, Tennessee Department of Health Lance Gable, Wayne State University Center for Law and the Public’s Health Carol Jacobson, Ohio Hospital Association Amy Kaji, Harbor-UCLA Medical Center Jon Krohmer, Department of Homeland Security Onora Lien, King County Healthcare Coalition Suzet McKinney, The Tauri Group Peter Pons, Denver Health Medical Center Clifford Rees, University of New Mexico School of Law Linda Scott, Michigan Department of Community Health Robert Ursano, Uniformed Services University School of Medicine Lann Wilder, San Francisco General Hospital and Trauma Center Matthew Wynia, American Medical Association Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before vii

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its release. The review of this report was overseen by Dr. Georges Benjamin, American Public Health Asso- ciation. Appointed by the Institute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. viii REVIEWERS

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Contents VOLUME 1: INTRODUCTION AND CSC FRAMEWORK Summary 1-1 1 Introduction 1-15 2 Catastrophic Disaster Response: Creating a Framework for Medical Care Delivery 1-31 3 Legal Issues in Emergencies 1-55 4 Cross-Cutting Themes: Ethics, Palliative Care, and Mental Health 1-71 VOLUME 2: STATE AND LOCAL GOVERNMENT Acronyms ix 5 State and Local Governments 2-1 Roles and Responsibilities of State Government, 2-2 Roles and Responsibilities of Local Government, 2-10 Operational Considerations, 2-12 Template Descriptions, 2-17 Template 5.1. Core Functions for CSC Plan Development (Within States), 2-30 Template 5.2. Core Functions for Implementing CSC Plans in States During CSC Incidents, 2-36 References, 2-43 VOLUME 3: EMS 6 Prehospital Care: Emergency Medical Services (EMS) 3-1 ix

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VOLUME 4: HOSPITAL 7 Hospitals and Acute Care Facilities 4-1 VOLUME 5: ALTERNATE CARE SYSTEMS 8 Out-of-Hospital and Alternate Care Systemss 5-1 VOLUME 6: PUBLIC ENGAGEMENT 9 Public Engagement 6-1 VOLUME 7: APPENDIXES 7-1 Appendixes x CONTENTS

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Function 6. Plan Maintenance Task 1 State health department and the SDMAC ensure that the state CSC plan is operational and ready for activation by • onducting ongoing education with stakeholders, public officials, c and the public about the plan and its implementation; • racking developments in CSC planning and guidance (within t and external to the state), developing a process for continuous assessment of routine and catastrophic disaster response capabilities based on existing information and knowledge management platforms, and creating a mechanism for ensuring that CSC milestones are being achieved; • onducting annual workshops, tabletop exercises, and functional c exercises involving the state CSC plan at the interstate, state, regional, and local levels in conjunction with state/local EMA, public health, hospital, and federal exercises and partners, when feasible; • eviewing and updating the plan on a regular basis or as needed r (using information gained through provider and community engagement and through exercises and actual emergencies) as elements of a disaster planning process improvement cycle; • oliciting input from stakeholders and the public about the plan, s including continuing to conduct public engagement activities, as needed; and • otifying stakeholders and the public, as necessary, of any n substantive plan updates. Task 2 State health department general counsel (or others at the state level) work to revise state legal and regulatory authorities to address CSC needs if necessary (see Chapter 3). STATE AND LOCAL GOVERNMENT 2-35

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Template 5.2. Core Functions for Implementing CSC Plans in States During CSC Incidents Function 1. Alerting and Activation Task 1 State health department and the state emergency management agency (EMA) are able to receive and manage emergency alerts that may trigger activation of the state CSC plan from stakeholders, including local public health, health care, and emergency management partners. Task 2 Upon receiving emergency information suggesting the need for activation of the state CSC plan, state health department (as the lead state agency for CSC) activates and consults with the state disaster medical advisory committee (SDMAC), and also consults with applicable state (e.g., governor, EMA) and local (e.g., mayor, local health department) leadership to assess the situation and make a determination on activation of the state CSC plan. Routine and crisis monitoring and reporting mechanisms are developed to establish local, regional, and state normative levels of seasonal/incident-based demand, resources, capacity (beds), and staffing. Task 3 Before or concurrently with health department activation of the state CSC plan, state health department ensures that applicable state and local emergency declarations (e.g., public health emergency, catastrophic health emergency, state of emergency, or civil defense emergency, depending on the jurisdiction) are made or requested; the state also understands applicable federal, state, and local legal authorities and regulations (see Chapter 3). Task 4 State health department activates components of the state CSC plan based on indicators and triggers outlined in the plan and on the assessment performed under Task 2 above; the state health department and state EMA also work with state, regional, and local partners to activate local and/or regional CSC or other emergency plans and mutual aid agreements, as applicable. Task 5 Throughout the emergency, SDMAC members are available to the state for consultation, and the state health department and SDMAC are able to continually assess the situation, including whether the state CSC plan should remain activated. Function 2. Notification Task 1 State health department and the state EMA provide immediate notification through pre-established communication systems 2-36 CRISIS STANDARDS OF CARE

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of activation of the state CSC plan (and any related emergency declarations). They also provide access to the plan (e.g., via the state health department website) to applicable local, regional, state, federal, and private-sector stakeholders, including • p ublic officials; • s tate health department staff; • s tate EMA staff; • l ocal health departments and other local government agencies; • l ocal EMAs; • h ealth care entities (e.g., regional medical coordination centers or regional DMACs, local clinical care committee[s] and triage team[s], health care coalitions, private practitioners, hospitals, health care systems, specialty hospitals, mental health agencies, professional boards and associations, and emergency medical services [EMS]); • nterstate partners (e.g., neighboring states); and i • ederal partners (e.g., Department of Health and Human Services f [HHS] regional emergency coordinators [RECs]). Task 2 State health department (or other state agency, as appropriate) notifies media and the public of the emergency situation and CSC plan activation, including what the problem is; what is being done; what is the expected duration/solution; what emergency declarations have been issued; and how public safety, health services, and public health will be affected. Task 3 State EMA and the state health department ensure that notification mechanisms account for redundancy and interoperability in the event the disaster affects usual means of contact. Function 3. Command and Control, Communications, and Coordination Command and Control Task 1 State EMA (with, as applicable, support of the state health department as the lead state agency for CSC) implements/expands the incident command system (ICS) consistent with event-driven demands and activates the state emergency operations center (EOC) at a level appropriate to the situation. The state EMA makes recommendations, as needed, to local EMAs on activation of local EOCs and response plans (see Chapter 6). Task 2 State EMA and the state health department ensure that command staff • re trained in CSC plan components and response; a • nderstand their roles, as well as the roles of local, regional, u state, and federal stakeholders, in the state CSC response; • re well versed in incident action planning during longer-term a events; STATE AND LOCAL GOVERNMENT 2-37

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• ave access to appropriate resources (e.g., job aids) to guide h decision making; and • nderstand the role of the SDMAC and any regional medical u coordination centers or regional DMACs, as well as the means by which information is received by or communicated to these bodies. Communications Task 3 State has policies and procedures in place for providing, receiving, and maintaining information that enables situational awareness throughout the response and for communicating information to stakeholders through a range of communication systems (e.g., Internet, radio, social media). Task 4 State should have the ability to maintain proactive and transparent communications throughout the CSC incident with the public, media, and stakeholders, including • s tate agencies and leadership; • l ocal health departments; • l ocal EMAs; • t he health care system (e.g., regional medical coordination centers or regional DMACs, local clinical care committees and triage teams, health care coalitions, private practitioners, hospitals, health care systems, specialty hospitals, professional boards and associations, and EMS); • nterstate partners (e.g., neighboring states); and i • ederal partners (e.g., HHS RECs) f Task 5 State EMA and the state health department ensure that communication systems account for redundancy and interoperability in the event the disaster affects usual means of contact. Coordination Task 6 State EMA and command staff, in collaboration with the state health department, are capable of serving as the interface for resource requests and managing the acquisition or donation process (as well as any existing plans for resource triage/allocation) (e.g., through the Emergency Management Assistance Compact [EMAC]) with • ocal health departments and local EMAs; l • ocal/regional health care coalitions; l • ther intrastate and regional partners, as well as interstate o partners; and • ederal partners (e.g., HHS). f Task 7 State health department, the state EMA, and other state agencies, as applicable, are capable of documenting response actions, including tracking of resources and expenses. 2-38 CRISIS STANDARDS OF CARE

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Function 4. Public Information Task 1 State health department and the state EMA implement (and adapt as needed for the emergency) pre-established risk communication plans for routine and catastrophic disaster response. Task 2 State health department and the state EMA leverage pre-existing relationships with applicable media partners to facilitate risk communication during the emergency. Task 3 State health department and the state EMA have processes and mechanisms in place to ensure appropriate and timely risk communication and consistent messaging to the public via the media (e.g., websites, calling programs, e-mail, social media). Task 4 State health department coordinates the development of messaging for public information/risk communication efforts (including where to direct those interested in volunteering for the response). Task 5 State EMA and/or the state health department (depending on pre- established risk communication roles in the state) coordinate risk communication and participate in joint information system and joint information center activities. Function 5. Operations Notes and Resources Conventional Operations Task 1 For conventional care situations, state understands the roles and See Chapter 2 of authorities of health care sector partners in augmenting emergency this report and the medical care through medically approved triage, treatment, and committee’s 2009 transport protocols and in using normal modes of transportation, letter report for staffing, and equipment, including mutual aid agreements. The state additional detail also coordinates and provides guidance on the delivery of care for on conventional, health care providers, as applicable. Sharing of resources through contingency, and crisis mutual aid agreements and mechanisms is encouraged/promoted. care. Contingency Operations Task 2 For contingency care situations, state understands how to implement various applicable emergency response plans and intrastate and interstate mutual aid agreements to substitute, conserve, and adapt staffing, transportation, patient triage, and destinations. The state also coordinates and provides guidance on the delivery of care for health care providers, as applicable. Sharing of resources through mutual aid agreements and mechanisms is encouraged/promoted. STATE AND LOCAL GOVERNMENT 2-39

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Crisis Operations Task 3 For crisis care situations, state understands how to execute mass casualty, surge capacity, and CSC plans to maximize resources for meeting broad public health needs (including the institution and authorization of alternate care systems). The state also coordinates and provides guidance on the delivery of care under CSC for health care providers. To the extent feasible, sharing of resources through mutual aid agreements and mechanisms is encouraged/promoted. Mental Health Task 4 State utilizes a disaster mental health concept of operations, including Mental Health section the following features: of Chapter 4 of the report provides a more • rovides a rapid mental health triage/incident management p detailed discussion and system linking local, regional, and state disaster systems of care, examples. including health care facilities and mental health resources, in incident command operations; • rovides for access to a continuum of evidence-based p interventions for adults and children; • rovides training in basic “neighbor-to-neighbor, family-to- p family” psychological first aid with triage for the general public and health care workers; • rovides CSC-specific behavioral coping components for risk p communications; • ompletes a CSC gap analysis with a plan for enhancing c local disaster mental health and spiritual care capacities and capabilities; and • evelops a health care worker resilience system with integrated d triage and referral components. Palliative Care Task 5 State CSC response addresses palliative care for all patients, including palliative care principles and triage tools, supply issues for patients (including those who will not receive other treatment modalities), and planning for management of in-home deaths as part of the state mass fatality plan. Task 6 State provides information on palliative care training (including just-in- time training) to stakeholders during the response. Task 7 State provides public information on palliative care, including management of at-home deaths, during the response. At-Risk Populations Task 8 State CSC response identifies and addresses patient groups (e.g., pediatric, maternal, burn, elderly, non-English-speaking) requiring 2-40 CRISIS STANDARDS OF CARE

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special consideration for risk communication, transportation, treatment, equipment, and supplies. Task 9 State conducts a preliminary assessment of needs of at-risk populations at the outset of the CSC incident, and continually monitors, assesses, and provides support for these populations’ needs throughout the response in conjunction with local resources. Function 6. Logistics Notes and Resources Staffing Task 1 State understands available staffing resources and needs within the state (including for alternate care sites) and utilizes resource monitoring system(s), as available, to track staffing resources. Task 2 State understands when to activate mutual-aid agreements and utilizes Task 2 examples established legal processes for supplementing and allocating the include the Medical workforce, including for appropriate use in alternate care sites. Reserve Corps (MRC), the Emergency Task 3 System for Advance State ensures that agency call-back criteria and policies are in place Registration of and maintains current and accurate employee contact information. Volunteer Health Professionals (ESAR- Task 4 VHP), state strike State ensures that staff receive personal preparedness training to assist teams, National with family needs and are prepared for on-site accommodation of staff Disaster Medical and family members, as appropriate. System (NDMS) teams, and scope of practice expansions. Supplies Task 5 State understands the types and locations of applicable resources (e.g., medication caches, equipment trailers) available within the state (and whether such resources fall under mutual-aid agreements). The state also understands how to appropriately request, accept, and utilize resources from other jurisdictions (e.g., through EMAC) and from federal partners (e.g., Strategic National Stockpile [SNS] assets). Task 6 State assesses and identifies, in collaboration with its local and regional partners, key potential scarce resources based on the type of event and the availability of stockpiled or identified alternative sources for these supplies. Task 7 State identifies and shares with applicable stakeholders strategies for appropriate substitution, conservation, adaptation, reuse, and reallocation of highly at-risk supplies. STATE AND LOCAL GOVERNMENT 2-41

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Task 8 State utilizes a resource tracking method to monitor the availability of applicable resources for the CSC response. Space Task 9 State understands the types and locations of applicable space resources related to CSC/alternate care sites in the state, including sites that may be established on the premises of a health care facility (see Chapter 8). Task 10 State and local health departments track available beds and alternate patient care space (e.g., beds in storage, cots, space for lease, and other potential sources); accept requests for such space; and develop plans to maximize available space in patient care locations and convert non-patient care areas to patient care, as necessary (see Chapter 8). Task 11 State makes appropriate legal and regulatory changes, as needed, to authorize use of alternate care sites during the CSC incident (see Chapter 3). Function 7. Termination, Demobilization, Recovery, and Evaluation Task 1 State health department and the state EMA, with support of the SDMAC, understand when to deactivate the state CSC plan and what their roles in deactivation are. Task 2 State health department and the state EMA, with support of the SDMAC, notify stakeholders, media, and the public of reasons for deactivation of the state CSC plan and what such deactivation means through established communication systems. Task 3 State health department and the state EMA, with support of the SDMAC, coordinate response evaluation, development of an after- action report, and implementation of improvement plan items so there is a continuous feedback loop for strengthening the state CSC plan. Task 4 State health department and the state EMA, with support of the SDMAC, understand their roles in CSC recovery, including ongoing mental health operations. 2-42 CRISIS STANDARDS OF CARE

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