5: Toolkit Part 2: Public Health

INTRODUCTION

This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide public health decision making during a disaster or public health or medical emergency. This tool focuses specifically on the role of public health in supporting the public health and medical sector across the spectrum, from prehospital care through end-of-life care. Because integrated planning across the emergency response system is critical for a coordinated response, it is important to first read the introduction to the toolkit and materials relevant to the entire emergency response system in Chapter 3. Reviewing the toolkit chapters focused on other stakeholders would also be useful.

Roles and Responsibilities

Public health is a complex system focused on the health of the population residing within their jurisdiction. Activities focus on protecting people from unsafe or harmful conditions while providing methods to promote optimum health and prevent disease. Public health can be established as a local government function, sometimes called “home ruled,” in which the jurisdiction has the authority to set up their own governance and local ordinances. These cannot be counter to overall state authority. State public health has responsibility for the health of the population within the entire state, and may consist of locally run satellite state public health agencies. In either model, state public health has powers under the authority of the governor outlined in state statutes, which can be enacted in a public health, natural disaster, or catastrophic medical incident when usual mechanisms and powers are insufficient to meet the regulatory or response requirements of an incident.

Threats to human health are always present, whether caused by nature or humans. Without thorough preparation and coordinated planning between government and private-sector partners, communities and individuals will be unable to prevent, protect against, respond to, and mitigate incidents, and rapidly recover when an incident occurs. Public health and medical preparedness can only be achieved when component partners at the local, regional, and state/tribal level work in synergy through all-hazards preparedness. This becomes critical when resources are scarce. Local and state public health should lead the planning for crisis



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5: Toolkit Part 2: Public Health INTRODUCTION This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide public health decision making during a disaster or public health or medical emer- gency. This tool focuses specifically on the role of public health in supporting the public health and medical sector across the spectrum, from prehospital care through end-of-life care. Because integrated planning across the emergency response system is critical for a coordinated response, it is important to first read the introduction to the toolkit and materials relevant to the entire emergency response system in Chapter 3. Reviewing the toolkit chapters focused on other stakeholders would also be useful. Roles and Responsibilities Public health is a complex system focused on the health of the population residing within their jurisdiction. Activities focus on protecting people from unsafe or harmful conditions while providing methods to pro- mote optimum health and prevent disease. Public health can be established as a local government function, sometimes called “home ruled,” in which the jurisdiction has the authority to set up their own governance and local ordinances. These cannot be counter to overall state authority. State public health has responsibility for the health of the population within the entire state, and may consist of locally run satellite state public health agencies. In either model, state public health has powers under the authority of the governor outlined in state statutes, which can be enacted in a public health, natural disaster, or catastrophic medical incident when usual mechanisms and powers are insufficient to meet the regulatory or response requirements of an incident. Threats to human health are always present, whether caused by nature or humans. Without thorough preparation and coordinated planning between government and private-sector partners, communities and individuals will be unable to prevent, protect against, respond to, and mitigate incidents, and rapidly recover when an incident occurs. Public health and medical preparedness can only be achieved when component partners at the local, regional, and state/tribal level work in synergy through all-hazards preparedness. This becomes critical when resources are scarce. Local and state public health should lead the planning for crisis 105

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standards of care (CSC) and ensure both an implementation plan and incorporation into the culture of the health spectrum. Additional discussion about public health roles and responsibilities in planning for and implement- ing CSC is available in the Institute of Medicine’s (IOM’s) 2012 report Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. This report also includes planning and implementation tem- plates that outline core functions and tasks. DISCUSSION AND DECISION-SUPPORT TOOL Suggested participants for a discussion focused on public health are listed below. Building on the scenarios and overarching key questions presented in Chapter 3, this tool contains additional questions to help par- ticipants drill down on the key issues and details for public health. It also contains two charts (one for slow- onset and one for no-notice) that provide example public health indicators, triggers, and tactics, and a blank chart for participants to complete. The scenarios, questions, and example chart are intended to provoke discussion that will help participants fill in the blank chart for their own situation.1 Participants may choose to complete a single, general blank chart, or one each for various scenarios from their Hazard Vulnerability Analysis. The questions below and associated table of sample indicators and triggers are broken out by the two scenarios because the role of public health will vary significantly based on the incident. Nearly all incidents or planned events will need public health and medical assistance and possible response. The first scenario demonstrates a slow-onset incident in which local and state public health would monitor the activity of influenza worldwide. This would provide an opportunity for planning and anticipating response activities. The second scenario demonstrates the issues associated with a no-notice event and describes potential points of consideration to respond and support response activities. In this scenario, there will be an immediate role of medical response, supported by public health, and intermediate- and long-term responsibilities for local and state public health offices. Discussion Participants From a public health perspective, any agency or organization that will be impacted in their service delivery by public health decisions should be discussion participants at some point in the deliberation process.2 Public health impacts all sectors and thus the need for integrated planning and long-term follow-up should be a key component in planning for and implementing CSC and will have a critical supporting role throughout an incident. Local public health discussions should include their agency emergency management/preparedness coor- dinator, health officer, and medical director at a minimum. Agency subject matter experts (SMEs) should be engaged based on incident type, with consideration of potential clinical services impacted: communi- 1  The blank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards. 2  As discussed above, the structure and organization of public health and health varies across states and localities. The discussion par- ticipants listed here are provided as a suggestion; discussion organizers should develop a participant list that would be appropriate for the structures and organization of the particular jurisdiction. 106 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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cable disease, epidemiology, environmental health, legal, and any departments that serve vulnerable popula- tions potentially impacted. Other governmental entities, such as emergency management, behavioral health, county commissioners, coroner or medical examiner, and other key stakeholders, should also be included. Local external discussion participants would include executive leadership of the impacted medical orga- nizations, such as hospital chief executive officers (or chief medical officer and/or emergency department medical director or nurse manager), medical director or executive of emergency medical services (EMS) agency(s), Federally Qualified Health Centers, long-term care facilities, community mental health, dialysis center(s), home care, impacted primary care providers, funeral directors, etc., for SME input as the incident expands. State public health entities involved may be a chief medical executive, state health officer, state epide- miologist, director of public health preparedness, an EMS and trauma system medical director or executive, a behavioral/mental health executive, health emergency management coordinator (EMC)3 and Emergency Support Function- (ESF-) 8 leads/state health operation center chiefs, and a legal advisor, including attor- ney general, if appropriate. State external discussion participants would be the State Disaster Medical Advisory Committee (SDMAC) or designee, impacted local health agencies, regional health care coalition leadership or similar group (e.g., state EMS/trauma advisory committees), executive leadership of impacted medical health orga- nizations (e.g., hospital association, state medical society, behavioral/mental health, state pediatric associa- tion) and other stakeholders or SMEs based on incident or event. Key Questions: Slow-Onset Scenario The questions below are focused on the slow-onset influenza pandemic scenario presented in Chapter 34: 1. What routine medical and public health surveillance systems are in place? Who or what agency submits the data, and who routinely monitors? Are these systems integrated to ensure multiple data feeds such as electronic communicable disease and laboratory results, influenza-like illness, sentinel physician reports, and pharmacy and over-the-counter medication sales, etc.? In reviewing these systems, are there thresholds already established that trigger actions or the need for further public health review? 2. Is an emergency department syndromic surveillance system in place? What are the components, thresholds, triggers, etc.? Is a protocol in place for further investigation once a threshold is identi- fied? How would trending data indicate or contribute to the local/state potential impact on delivery of services and standards of care? 3  Astate health emergency management coordinator (EMC) serves as the liaison from state health to the state emergency operations center (EOC). In this role, the state health EMC or similar role would identify collaboration or resources needed through other state agencies. Depending on the state, the entity coordinating on public health and health may be referred to in different ways, including, for example, state (public) health emergency coordination center, department of (public) health operations center, or state (public) health operations center. 4  These questions are provided to help start discussion; additional important questions may arise during the course of discussion. The questions are aimed at raising issues related to indicators and triggers, and are not comprehensive of all important questions related to disaster preparedness and response. TOOLKIT PART 2: PUBLIC HEALTH 107

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3. What information would be communicated to the local or state emergency management that would trigger an EOC activation for a public health/medical event? How do incidents that have ESF-8 as the lead agency impact operations in the EOC? 4. Has the local or state health department identified triggers to impact or restrict public gatherings to minimize exposures and thus decrease demand for medical resources? 5. Because this is a slow-onset incident, is there a local trigger for request of Strategic National Stockpile (SNS) medical materiel through the state-identified process? 6. What is needed to initiate points of dispensing (PODs)? How does the health department identify the sequence of POD placement and staff resources? Are the hospitals closed PODs and are there any anticipated variations in planning and response during CSC activities? Will there be separate POD(s) for first responders and their families, and will this include off-duty as well as on-duty workers? 7. How does the risk communication/public information officer modify messaging to address evolving conditions and coordinate messages with other agencies? When and by what mechanism does the state or an interjurisdictional information system become necessary? 8. What is the status of the public health workforce? Does the individual agency have plans in place to identify and meet essential public health functions while supporting medical care delivery dur- ing CSC? How does the agency Continuity of Operations Planning impact delivery of services, especially if clinical services are offered within the public health agency? 9. How is the impacted workforce and a need to solicit and use volunteer health care providers addressed? For example, volunteers may be accessed through the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), Medical Reserve Corps (MRC), etc. 10. What data or information are/is needed by public health executive leadership to consider a dec- laration or regulatory relief to facilitate contingency or crisis care within the medical health com- munity? What lead time is needed to educate and communicate with senior policy leaders? 11. What activity would follow a declaration of emergency by the governor (health or general depend- ing on legal environment of jurisdiction) or executive orders by the local or state public health authority? Does the local depend on the state to generate? What is needed for the agency? 12. State public health—what is the threshold for activation of the SDMAC or engagement of other SMEs? What communications need to occur internally with state government? 13. A slow-onset incident with high mortality rate will impact ESF-8 activities specific to fatality management. What resources are needed to assist the local coroner/medical examiner? Are there local or state plans for surge of decedents that may include surge storage, temporary interment, etc.? Key Questions: No-Notice Scenario The questions below are focused on the no-notice earthquake scenario presented in Chapter 3: 108 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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1. What is the status of infrastructure within the impacted area and has public health identified what is needed to support response? This will vary dramatically with available health care resources at the local level and the degree to which they are impacted. 2. Do any governmental regulations or rules need modification to facilitate incident response? If so, what information is needed and which agency serves as the lead to modify (e.g., state vs. federal regulations)? An example would be an “1135 waiver”5 (state request approved federally), modifica- tions to regulations on spacing between patient beds, cribs, dialysis chairs (state), staffing ratios, etc. 3. What are the applicable public health authorities, and if actions are needed how and when are these initiated and by whom? These are often outlined in a state public health code, licensing regulations, or applicable legislation. 4. What unique information should be collected by local and state public health and provided to local and state EOCs to support the spectrum of health care response? What is the most efficient method to collect the information, which may include the health care coalition medical coordina- tion center? This could include bed availability, patient tracking strategies, and anticipated short- falls of equipment or supplies, etc. 5. What support is needed for impacted person tracking and/or family reunification? 6. What critical health-related services to the community have been impacted? Are resources available outside the immediately impacted area? 7. Can any of the impacted services be assisted by local or state public health agencies, such as public health laboratories? 8. Is there a secondary environmental impact to the health of the public in the impacted area (pres- ence of nuclear power plant and hazardous materials production or storage sites, including “SARA Title III” sites6) for which local and state public health should initiate assessment and mitigation strategies? 9. How quickly and by what means can the risk communication and public information officer implement communication strategies in circumstances when usual means of communication are compromised? What additional resources may be needed to facilitate messaging in these situations? 10. What is the status of the public health workforce? What essential functions should be maintained and what resources should be mobilized to support medical care during CSC? How is the impacted workforce identified and paid, or volunteer health care workforce solicited and used (ESAR-VHP, MRC, etc.)? 11. What other governmental agency resources are needed to support response (priority contract access, transportation, vulnerable children/population services, vaccines, laboratory, etc.)? 5  Waiver or modification of requirements under section 1135 of the Social Security Act. See http://www.ssa.gov/OP_Home/ssact/ title11/1135.htm (accessed May 31, 2013). 6  The Superfund Amendments and Reauthorization Act (SARA) of 1986 created the Emergency Planning and Community Right-to- Know Act (known as “SARA Title III” or EPCRA), which is aimed at enhancing emergency planning and “community right-to-know” regarding hazardous and toxic chemicals. For additional information, see http://www.epa.gov/agriculture/lcra.html (accessed May 31, 2013). TOOLKIT PART 2: PUBLIC HEALTH 109

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Decision-Support Tool: Example Tables The indicators, triggers, and tactics shown in Tables 5-1 and 5-2 are examples to help promote discussion and provide a sense of the level of detail and concreteness that is needed to develop useful indicators and triggers for a specific organization/agency/jurisdiction; they are not intended to be exhaustive or universally applicable. Prompted by discussion of the key questions above, discussion participants should fill out a blank table (or a table per scenario), focusing on key system indicators and triggers that will drive actions in their own organizations, agencies, and jurisdictions. As a reminder, indicators are measures or predictors of changes in demand and/or resource availability; triggers are decision points (refer back to the toolkit intro- duction [Chapter 3] for key definitions and concepts). The example triggers shown in the tables mainly are ones in which a “bright line” distinguishes func- tionally different levels of care (conventional, contingency, crisis). Because of the nature of this type of t ­rigger, they can be described more concretely and can be included in a bulleted list. It is important to recognize, however, that expert analysis of one or more indicators may also trigger implementation of key response plans, actions, and tactics. This may be particularly true in a slow-onset scenario. In all cases, but particularly in the absence of “bright lines,” decisions may need to be made to anticipate upcoming problems and the implementation of tactics, and to lean forward by implementing certain tactics in advance of reach- ing the bright line or when no such line exists. These decision points vary according to the situation and are based on analysis of multiple inputs, recommendations, and, in certain circumstances, previous experience. Discussions about these tables should cover how such decisions would be made, even if the specifics cannot be included in a bulleted list in advance. 110 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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TABLE 5-1 Example Public Health Indicators, Triggers, and Tactics for Transitions Along the Continuum of Care in a Slow-Onset Scenario Indicator Category Contingency Crisis Return Toward Conventional Surveillance data Indicators: Indicators: Indicators: • Epidemiologic data identify • Epidemiologic data indicate • Epidemiologic data indicate sustained significantly increased or novel activity benchmarks and thresholds for critical decrease in “new” incident-related reports • Epidemiologic data identify unusual resources and maximum critical care • Electronic reporting mechanisms indicate population affected capacity will be exceeded return to normal reporting processes by • Trends over time indicate escalation • (Fatality) Communications from local health care organizations and/or significant impact medical examiner or coroner that Triggers: Triggers: morgue/storage capacity has been • Event-specific data collection is no longer • Health care organizations unable to exceeded required submit data due to impact of medical Crisis Triggers: Tactics: surge volumes • Epidemic curves continue to rise with • Public health initiates “catch-up” work to Tactics: unclear peak of cases capture health data from the prolonged • Investigate indicators further with • Surveillance has to be modified to incident; this is a critical role for public additional data, case finding, etc., to highest priority or impact-only with health for future incident response and attain improved situational awareness minimal set of identifiers for future demand forecasting • Work closely with health care coalition follow-up and medical health partners to target Tactics: data collection to key elements only • Event-specific data collection to • Develop additional data elements provide common operating picture based on incident and potential and potential treatment/outcome workload impact information • Consider what is already collected • Surveillance data collection narrowed electronically and modify to minimize to only automated data streams health care organization stressors related to incident • Governmental entities waive communicable disease reporting rules to only that which is directly related to the incident and key health issues Community and Indicators: Indicators: Indicators: communications • Communications systems (Health • Continued need to communicate • Decreased requests for messaging infrastructure Alert Network [HAN], telephone, with public about high risk, evolving • Decreased activity on established hotlines etc.) disrupted within and external to situation Triggers: jurisdiction • Water supply contamination • Media and health care requests returning to Triggers: Crisis Triggers: “normal” • Multiple requests for assistance from • Reports of disturbances at health care Tactics: multiple agencies or jurisdictions organizations or public shelters, etc. • Continue to provide appropriate levels of • Interruption or contamination of water • Prolonged and widespread utilities communication to the media, community, supply or utilities (power, natural gas) outages and impacted health care organizations • Identified need to establish Tactics: communication hotlines • Use all established resources to • Requests for specialized services coordinate and communicate health and needs for broad public messages communications continued 111

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TABLE 5-1 112 Continued Indicator Category Contingency Crisis Return Toward Conventional Community and Tactics: • Increase availability of coordinated communications • Work with established media and communications for gaps identified infrastructure professional organizations to ensure • Focused review of communications (continued) consistent messaging strategies to identify gaps in targeted • Implement statewide hotlines through populations vulnerable or causing established mechanisms such as disturbances poison control center, 211, etc. • Coordinate risk communication strategies with governmental public information officials Staff Indicators: Indicators: Indicators: • Increasing absenteeism among • Increasing absenteeism and inability • Impact of incident decreasing (Refer also to the public health staff; increased demand to fulfill critical missions to community • Personnel absenteeism is decreasing worker functional for staffing for community-based • Increased demand for resources • Personnel communicating need to initiate capacity table in interventions, etc. Crisis Triggers: activities to “return to normal operations” Toolkit Part 1 [Table Triggers: • Unable to fulfill critical missions (e.g., Triggers: 3-1]) • Community-based interventions support alternate care sites) with • Missions able to be completed with required (e.g., vaccine, appropriate staff adequate staffing countermeasure distribution, “flu Tactics: Tactics: centers”) • Eliminate all nonessential functions to • Review and prioritize key services for Tactics: support local and state response to reimplementation at the local and state • Eliminate routine or non-life safety the incident levels laboratory testing, surveillance of • Reallocate any health professionals • Initiate data analysis of impact of crisis community organizations, etc. whose training allows them a more standards of care (CSC) implementation on • Initiate Continuity of Operations active role to support health care personnel Planning to ensure that essential organizations • Revert to normal staffing patterns/hours/ functions for local and state public • Assist if needed in coordination of duties health are implemented to support health volunteers to support public health care organization response health and medical functions identified • Identify services to put on “pause” • Triage personnel resources to as personnel resources continue to services of most benefit (community decline vaccination, etc.) • Activate mutual aid/support plans • Use just-in-time recruiting and training from other agencies, disciplines, as required to fulfill missions predesignated volunteer sources as • Obtain regulatory relief as required to required facilitate facility crisis responses (e.g., • Off-load tasks onto technology as who may administer vaccinations) possible (e.g., hotlines rather than face-to-face assessments) • Change staffing patterns and hours

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Space/infrastructure Indicators: Indicators: Indicators: • Health care organizations are unable • Health care organizations have • Surveillance indicates declining new to meet demands with traditional narrowed admission criteria to infections bed capacity with all surge strategies maximize available resources • Health care organizations are able to implemented Crisis Triggers: broaden admission based on available • Local and state public health initiated • Health care organizations have resources strategies to authorize alternate care implemented all medical surge Triggers: site initiation; this includes assurances strategies and should seek alternate • Decreasing census in alternate care sites related to governmental waivers care site locations for inpatient care within jurisdiction Triggers: overflow • State observes multiple health care • Space expansion is required for Tactics: coalitions readying for demobilization of community-based interventions • Supply or support mobilization of alternate care sites (vaccination campaign, etc.) deployment of volunteer health Tactics: • Recognition of the need to open professionals • Support health care alternate care site alternate care sites for screening • Implementation of governmental demobilization strategies clinics/early treatment waivers to establish alternate care • Patient records, resources, and supplies Tactics: sites should be accounted for and returned • Requests are made for waivers to • State emergency operation centers as required; local and state public health authorize alternate care sites for care and health emergency coordination departments mobilize resources to assist as delivery centers work with state and federal available • Local public health departments agencies to establish declarations and • State public health works with local partners work with their local health care emergency order rules specific to the and nongovernental organizations to organizations and regional health care necessary tactics to respond to the communicate plans to return to conventional coalitions to ensure that inpatient sites, incident care including skilled nursing facilities, are • State public health to communicate prioritized for support with state disaster medical advisory • Public health provides risk committee to review status of CSC communication and coordination guidelines and distribute to impacted assistance for medical care system— health care organizations when to seek care, etc. • Local health departments work with their primary care providers to identify mechanisms to expand services and protect personnel • Emergency Support Function-8 lead to keep each local emergency operations center aware of impact and contingency care implemented • State health implement statewide plans for nurse triage lines, 211, poison control support for callers related to event • State public health works with all health care coalitions to support implementation of statewide medical surge strategies • State health emergency coordination center to keep each local health department aware of impact and contingency care implemented continued 113

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TABLE 5-1 114 Continued Indicator Category Contingency Crisis Return Toward Conventional Space/infrastructure • State health to initiate process for (continued) implementing executive orders for public health emergency; may or may not implement at this time • Local and state public health begin planning strategies for CSC if anticipated event expansion Supplies Indicators: Indicators: Indicators: • Local and state monitoring of supplies • Demand forecasting/projections • Vaccine manufacturers have increased and inventory data indicate shortage/ exceed available critical resources supply chain so targeted groups for potential shortage • No national source of specific supplies vaccination is expanded based on disease • Benchmark supply availability to available trends and ethical guidelines disease reporting and mortality data Crisis Triggers: • Additional resources are obtained • Anticipate challenges with medical • Shortages of critical equipment, drugs, • Demand for resources (e.g., ventilators) is supply chain based on expanding or vaccine present significant risk to declining as event wanes incident; review communications persons who cannot receive them Triggers: from each health care coalition • National guidance on rationing • Critical medical supplies are sufficient to for the impact to their health care distributed meet the needs of the patients requiring organizations Tactics: them Triggers: • Focus allocation of scarce resources Tactics: • Decreased availability of critical to maintaining critical social/ • Continued, coordinated risk communication medical resources anticipated public safety function (civil order • Assessment if transition is temporary or • Requests to health care coalition maintenance) likely to be permanent medical coordination center for • Coordinated risk communication • Local public health should augment Points allocation of regional cache supplies strategies are critical of Dispensing plans to meet demands Tactics: • Use government purchasing powers to when vaccination is expanded as vaccine is • Prioritize resource allocation by support critical medical supplies available urgency of need and risk • Maintain communications with federal • Demobilization of SNS • Determine time frame and availability SNS program • State public health to review CSC guidelines from other vendors/sources • State and regional disaster medical for possible revision based on resource • Review and update risk advisory committees review triage availability communication strategies specific guidance available and propose to users of critical resources and recommendations community • State public health circulates • State health emergency coordination guidelines on allocation of resources center work with each health care • Legal, regulatory, and emergency coalition to allocate regional cache powers invoked as required to contents and other resources facilitate fair, planned allocation • State health emergency coordination process center initiates internal mechanisms to move anticipated Strategic National Stockpile (SNS) materiel requests to the state emergency operations center

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Fatality management Indicators: Indicators: Indicators: • Rising death toll • Funeral homes communicating limited • Number of deaths from influenza are • Rate of deaths projected to exceed resources to conduct funeral services stabilizing or sustained decline local capabilities • Rate of deaths projected to exceed Triggers: Triggers: regional/surge capabilities • Decedent processing is able to be • Health care organizations are Crisis Triggers: accommodated within surge or conventional reporting an inability to manage the • With disaster plans implemented, systems number of decedents within facilities fatality processing demand exceeds Tactics: • Local medical examiners/coroners are available resources and threat of civil • Risk communication on decedent unable to meet the demands of their unrest or decomposition is real management jurisdiction with usual processing Tactics: • Local and state public health, in conjunction Tactics: • Risk communication strategies with medical examiners/coroners, resume • Local public health works with medical coordinated at local and state levels normal processes, which include funerals examiners/coroners to determine • Activation of all available mortuary and traditional burials if the bottleneck is processing resources, including response • Alterations that had occurred should be (medical examiner caseload) or body teams and expanded cremation and addressed to return to “normal state,” management processing operations recognizing the complexity associated • Local public health contacts funeral • Governor declaration for expedited with variation in cultural and societal death home, mortuaries, morgues, or burials and/or temporary routines crematoriums to assess current impact interment upon state public health on capacity and expansion capacity recommendation. (NOTE: Requires • Local governmental agencies should extensive planning with multiple identify potential cultural barriers to state agencies to identify a location, modifications in death processes and tracking, and personnel support to prepare strategies to address these implement such a response to manage • Initiate strategies to expedite the mass fatality incident.) completion of death certificates/ • Consider transfer of decedents to investigations other locations for processing if • State public health investigates required modifications to laws, regulations, etc., for dealing with decedents • Governmental authorities initiate planning for possible alternate storage strategies • Consider federal or state disaster mortuary team resources • Consider temporary storage facilities implementation plan continued 115

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TABLE 5-1 116 Continued Indicator Category Contingency Crisis Return Toward Conventional Congregate Indicators: Indicators: Indicators: gatherings • Epidemiologic models indicate • Statewide indication of high • Decrease in evidence for person-to-person person-to-person spread is prevalent transmission in gathering settings trends • Multiple jurisdictions reporting Crisis Triggers: • Criteria for identifying “superspreaders” as that large gatherings implicated in • Forced quarantine is required individuals allows targeted interventions outbreak investigations to prevent spread of dangerous Triggers: • Outbreaks linked to funeral services pathogen • Sustained decrease in disease transmission Triggers: • Public gatherings prohibited trends • Epidemiologic data indicate increasing Tactics: Tactics: outbreaks directly related to known • Executive order or governor’s • Governor rescinds gathering orders congregate gatherings in more than declaration to eliminate congregate • Initiate public gatherings one jurisdiction gatherings • Local and state continue close monitoring Tactics: • Quarantine orders implemented as of epidemiologic data to ensure continued • Local and state review immediate indicated decline and are prepared to reinstate bans if and future large-scale venues for • Governmental agencies collaborate to cases increase anticipated cancellation enforce congregate-gathering bans • Local and state recommendations on school closures • State public health readies quarantine guidelines working with governor’s office

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TABLE 5-2 Example Public Health Indicators, Triggers, and Tactics for Transitions Along the Continuum of Care in a No-Notice (Earthquake) Scenario Indicator Category Contingency Crisis Return Toward Conventional Surveillance data Indicators: Indicators: Indicators: • Collection of Essential Elements of • Scope of incident indicates need to focus • Focused surveillance indicates Information indicates disruption of surveillance on key elements to support diminishing impact of incident services that impact local public health medical and public health operations Triggers: and health care organizations within • Communications indicate emergency • No additional victims being jurisdiction management and/or American Red Cross entered into system • Local health department identifies or other nongovernmental organization • Decreasing numbers in shelters specific population health surveillance establishing multiple sheltering and consolidation of sheltering data impacted by incident operations services • Impacted persons are being taken • Incident-related injuries necessitate Tactics: to multiple health care organizations modification of surveillance strategies • Return to routine surveillance through traditional and nontraditional • Shelters established, need for augmented activities methods surveillance to protect shelter population • Extensive review of incident- • Forecast temperature extremes Crisis Triggers: specific surveillance data to Triggers: • Health care organization capacity is determine long-term follow-up or • Communications from health care overwhelmed based on casualty counts further focused surveillance organizations to their health care and impact on health care infrastructure • Archiving of patient tracking from coalitions that many facilities have Tactics: event infrastructure damage • Collection of key information only to • Communications from local emergency maximize/distribute resources or reunite operations centers (EOCs) to state families EOC (SEOC) that medical and public • Continue established patient tracking health have significant impact to service system and allow access by non- delivery governmental and other organizations as • Incident disrupts medical supply chain; required to facilitate reunification anticipate shortages • Unable to locate or track all patients impacted by incident Tactics: • Data collection to local EOC • State health emergency coordination center queries all health care coalitions to identify statewide impact to service delivery and plan response strategies (patient and resource movement) • Local health department implements focused assessments and modification specific to impact of incident for jurisdictional population • Implement patient tracking system statewide continued 117

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TABLE 5-2 118 Continued Indicator Category Contingency Crisis Return Toward Conventional Community and Indicators: Indicators: Indicators: communications • Initial and subsequent damage reports • Local EOCs and state emergency • Public safety communications back infrastructure indicate substantial loss of 911 or other operation center are fully activated online communications statewide to respond to catastrophic • Repairs to health care • Initial and subsequent damage reports incident organizations provide the ability indicate substantial loss of health care or • Widespread loss of utilities to repopulate or resume previous residential infrastructure • Widespread loss of critical level of service • Numbers of persons are missing and the communications (cellular, Internet, public Triggers: pressure families are putting on 911 and safety radio, etc.) • Emergency communications other systems to find them Crisis triggers: systems reestablished • Disruption of roads impact ability to • Incident unfolding with health care Tactics: meet the needs of patient movement coalitions communicating more than X% • Communicate deescalation of Triggers: of facilities with significant infrastructure incident to community through • Requests from multiple health care damage (the level of care provided established methods and using risk organizations and health care coalitions by health care organizations and their communication strategies for governmental assistance due to roles in the community will impact the • Local and state public health infrastructure damage number of damaged facilities that cause assist with assessments or surveys • Significant reports of safety issues a transition to crisis response) to clear impacted health care that could impact community, thus • Inability for multiple hospitals to organizations for repopulation or indicating a need for coordinated risk remain in their current building without resume suspended services communication strategies significant support • Local EOCs getting queries from • Multiple health care facilities require health care organizations about utility evacuation and inadequate transport restoration resources to accomplish this Tactics: • Local emergency management indicates • Support requests from health care a need to establish multiple shelters, organizations through health care including functional needs coalition Tactics: • Prioritize key public health activities to • Continued need for risk communications support critical jurisdictional needs and to community health care organization service delivery • Identify needs of health care • Local public information officials work organizations in collaboration with health with media on health-related risk care coalitions communication strategies • Local health departments should identify • State public information officials working staff, including volunteers, to assist with with other state agency and local public public health issues in shelters, including information officials for coordinated risk those targeted to functional needs communications • State public information officials working • Local EOCs establishing mechanisms to with other state agency and local public implement family reunification systems information officials for coordinated risk communications • State working with locals to ensure that family reunification systems can meet demands

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Staff Indicators: Indicators: Indicators: • Personnel availability impacted by access, • Personnel availability impacted widely by • Decreasing use of alternate care family obligations, injury/direct effects access, family obligations, injury/direct sites Triggers: effects • Decreasing requests for staff • Request for additional medical or public • Local infrastructure damage will prevent support health personnel to support operations mutual aid in a timely manner Triggers: Tactics: • Alternate care sites and shelters initiated • Health care organizations releasing • Identify cross-trained personnel to Crisis triggers: volunteer and other supplemental support services linked to incident • Multiple organizations requesting medical staff • Modifications to services will be based on staff support and inadequate availability • Alternate care sites demobilizing staff available of staff via usual programs (ESAR-VHP, Tactics: • Plan to support response with volunteer etc.) • Initiate processes to return staff to health professionals (Emergency System • Specialty consultation unavailable to routine positions for Advance Registration of Volunteer hospitals boarding burn, pediatric, • Implement demobilizations Health Professionals [ESAR-VHP], or other patients due to demands or strategies if volunteers were used Medical Reserve Corps [MRC], coalition, communication issues at referral centers etc.) Tactics: • Use available staff and provide support for nonspecialized tasks to maximize response • Limit services to those related to life/ safety issues only • Facilitate out-of-area specialty consultation as applicable • Use volunteer health professional if available • State to seek additional personnel resources through federal programs (Department of Health and Human Services, Department of Defense, etc.) continued 119

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120 TABLE 5-2 Continued Indicator Category Contingency Crisis Return Toward Conventional Space/infrastructure Indicators: Indicators: Indicators: • Emergency management has initiated • Communications indicate demand • EMS indicates return to normal shelters exceeds patient transport supply dispatch and transport protocols • Emergency medical services (EMS) • Hospitals have inadequate space for • Alternate care sites no longer reporting evacuations of long-term care victims required/use diminishing (LTC) and similar facilities Crisis triggers: Triggers: • Hospital data indicate capacity exceeded • Requests to modify EMS transport • System data indicate returning to at multiple facilities despite surge protocols baseline transport status capacity plan activation • Requests for alternate care sites for Tactics: Triggers: inpatient overflow • Support efforts to return EMS to • Local requests for assistance with patient Tactics: normal operations and regulations movement • State ESF-8 works to implement protocol • Support demobilization of • Inadequate EMS resources to waivers to support modified transport alternate care sites and shelter accommodate demands plans medical support Tactics: • State public information official • Local and state public health staff • Need anticipated to modify EMS communicates efforts to all medical gather all after-action reports, transport protocols statewide and health entities meet with key stakeholders to suspend specific staffing and other • State coordination of field hospital and identify challenges, and plan to response requirements patient transportation assets from state, support future operations • Local EOCs work with regional health EMAC, and federal sources care coalitions to identify and prioritize transport resources • State health emergency coordination center to work on statewide available resources through health care coalition structure • State public health and SEOC identify additional resources through Mutual Aid Agreements (MAAs) or Emergency Management Assistance Compact (EMAC)

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Supplies Indicators: Indicators: Indicators: • Interruption in supply chain impacts • Critical medical supplies are unavailable • Mobilization of equipment, resource availability Crisis triggers: supplies, and resources to meet • Local use of resources exceeds supply • Unable to locate additional medical demand (e.g., blood products, surgical supplies) supplies to support medical care, Triggers: Triggers: presenting a life/safety risk • Decreasing requests for additional • Resource shortages reported, including Tactics: supplies to support response medical material and pharmaceuticals • Local and state public health should Tactics: • Local request for Strategic National continue to identify resources to support • Data collection and financial Stockpile (SNS) or cache materiel organizational response; this would accountability to assess impact of Tactics: include implementing MAA and EMAC incident and plan for remediation • Local health care organizations work with requests for services and supplies needed of gaps their health care coalition to distribute to deliver care • Continue situational monitoring regional resources, including obtaining • Executive orders or public health/ —is this a temporary or sustained resources from health care coalitions that emergency declaration if needed to improvement? are not impacted by the incident support altering the use of equipment, • State Emergency Support Function- supplies, or human resources (ESF-) 8 should identify possible waivers, • Public health guidance on allocation including the reuse of equipment and of specific scarce resources may be supplies within health care organizations required, with input from state disaster • Initiate process to request SNS or other medical advisory committee materiel through state EOC 121

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Decision-Support Tool: Blank Table to Be Completed Prompted by discussion of the key questions above, participants should fill out this blank table (or multiple tables for different scenarios) with key system indicators and triggers that will drive actions in their own organizations, agencies, and jurisdictions.7 Reminders: • Indicators are measures or predictors of changes in demand and/or resource availability; triggers are decision points. • The key questions were designed to facilitate discussion—customized for public health—about the following four steps to consider when developing indicators and triggers for a specific organiza- tion/agency/jurisdiction: (1) identify key response strategies and actions, (2) identify and examine potential indicators, (3) determine trigger points, (4) determine tactics. • Discussions about triggers should include (a) triggers for which a “bright line” can be described, and (b) how expert decisions to implement tactics would be made using one or more indicators for which no bright line exists. Discussions should consider the benefits of anticipating the implemen- tation of tactics, and of leaning forward to implement certain tactics in advance of a bright line or when no such line exists. • The example table may be consulted to promote discussion and to provide a sense of the level of detail and concreteness that is needed to develop useful indicators and triggers for a specific organization/agency/jurisdiction. • This table is intended to frame discussions and create awareness of information, policy sources, and issues at the agency level to share with other stakeholders. Areas of uncertainty should be noted and clarified with partners. • Refer back to the toolkit introduction (Chapter 3) for key definitions and concepts.  7  The blank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards. 122 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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Scope and Event Type: __________________________________ Indicator Category Contingency Crisis Return Toward Conventional Surveillance data Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Communications and Indicators: Indicators: Indicators: community infrastructure Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Staff Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Space/infrastructure Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Supplies Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Other categories Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: 123

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REFERENCE IOM (Institute of Medicine). 2012. Crisis standards of care: A systems framework for catastrophic disaster response. Washington, DC: The National Academies Press. http://www.nap.edu/openbook.php?record_id=13351 (accessed April 3, 2013). 124 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS