7: Toolkit Part 2: Emergency Medical Services

INTRODUCTION

This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide emergency medical services (EMS) decision making during a disaster. 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 also would be helpful.

Roles and Responsibilities

The role and expanse of responsibilities of the EMS professional go far beyond prehospital patient care delivery and transport. Emergency medical dispatch (EMD) plays the critical role as the “gatekeeper” of the resources and assets that must be appropriately dispatched and distributed for a successful emergency response. Once on the scene, the EMS provider is the direct observant of the scene of the incident, if an accident, or of the patient’s residence. It is often the EMS provider who notes that a patient may not have any or insufficient resources within his or her residence to maintain independence or personal safety. Therefore, an important message to include in any crisis planning is that all personnel, regardless of years of experience or expertise, should be (and feel) empowered to report any unusual events, observations on the scene, or surge in patient complaints or threats to an administrative avenue that is operational and responsive at all times.

The role of the EMS medical director is very important. This individual is a physician with a solid foundation of knowledge and expertise in emergency medical dispatch, EMS, emergency medicine, public health, triage, and appropriate allocation of resources who can serve in a leading role during an emergency or catastrophic incident. The continuous partnership of the EMS medical director with the EMS agency supervisor as a unified team during all aspects of the response cannot be understated.

Each state has the statutory authority and responsibility to regulate EMS within its borders. In addition, each state has the authority over the certification or licensure of their EMS providers, EMS scope of practice, and EMS provider titles. For the delivery of EMS services, some states have mandatory statewide protocols while others permit the use of variable regional or local protocols. During the creation of crisis standards of care (CSC) plans, the state EMS offices and the National Association of State EMS Officials



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7: Toolkit Part 2: Emergency Medical Services INTRODUCTION This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide emergency medical services (EMS) decision making during a disaster. Because inte- grated 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 also would be helpful. Roles and Responsibilities The role and expanse of responsibilities of the EMS professional go far beyond prehospital patient care delivery and transport. Emergency medical dispatch (EMD) plays the critical role as the “gatekeeper” of the resources and assets that must be appropriately dispatched and distributed for a successful emergency response. Once on the scene, the EMS provider is the direct observant of the scene of the incident, if an acci- dent, or of the patient’s residence. It is often the EMS provider who notes that a patient may not have any or insufficient resources within his or her residence to maintain independence or personal safety. Therefore, an important message to include in any crisis planning is that all personnel, regardless of years of experience or expertise, should be (and feel) empowered to report any unusual events, observations on the scene, or surge in patient complaints or threats to an administrative avenue that is operational and responsive at all times. The role of the EMS medical director is very important. This individual is a physician with a solid foundation of knowledge and expertise in emergency medical dispatch, EMS, emergency medicine, public health, triage, and appropriate allocation of resources who can serve in a leading role during an emergency or catastrophic incident. The continuous partnership of the EMS medical director with the EMS agency supervisor as a unified team during all aspects of the response cannot be understated. Each state has the statutory authority and responsibility to regulate EMS within its borders. In addi- tion, each state has the authority over the certification or licensure of their EMS providers, EMS scope of practice, and EMS provider titles. For the delivery of EMS services, some states have mandatory statewide protocols while others permit the use of variable regional or local protocols. During the creation of crisis standards of care (CSC) plans, the state EMS offices and the National Association of State EMS Officials 145

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(NASEMSO), the lead national organization for state EMS offices, are invaluable assets. They are the best sources of EMS-specific information regarding individual state EMS system structure and state EMS administrative, legislative, and operational requirements and practices. During routine and evolving crises that will not require a federal response or gubernatorial declaration of emergency, the state EMS offices and NASEMSO are assets of knowledge and support. Special attention to neighboring state EMS systems must be consistently included at all levels of CSC because emergency dispatch and response, prehospital care delivery, and patient transport occur routinely across state lines on a daily basis during conventional levels of care in many jurisdictions. Additional discussion about EMS roles and responsibilities in planning for and implementing 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 templates that outline core functions and tasks. Key Considerations for EMS Disaster planning has been a core component for the EMS community for many years. As a result, EMS providers tend to have integrated adaptation skills in their routine practice. The concept of CSC, with the three stages of conventional, contingency, and crisis levels, is a relatively new concept for many in the health care community, including EMS providers. In the past, the focus has been on crisis planning rather than maximizing crucial tactics at the conventional and contingency phases to avoid entering a state of crisis. This toolkit is designed to serve as a facilitator of creative, flexible, and expansive thought during the development of processes and protocols for the EMS disaster planning team. CSC require a shift from the former culture and mindset of disaster planning of a binary response (disaster or not) to a continuum of services that can be provided based on demand, with adaptations at each step to allow the system to bend, but not break. The EMS agency should craft its plan in a manner that best incorporates and coordinates the available local, regional, state, and federal resources into a framework that serves the jurisdiction. A disaster response team should have and be able to execute a plan to manage a response to victims without an adequate supply of medical resources. Such a team should have and be able to execute a plan to retain, secure, and maintain the EMS workforce instead of writing a plan where the primary focus is on managing a disaster without staffing. Significant alterations in response procedures and allocation of resources may be required at the contin- gency level, with the primary goal of avoiding a transition into the crisis level. Important elements that must accompany these procedures include training and disaster exercises that actively include emergency medical dispatch, EMS, and EMS medical direction; community engagement and education; repeated and frequent dissemination of timely and accurate information to the community and the Joint Information Center; and appropriate regulatory relief and liability protection for the parameters included in both contingency and CSC. Ideally, these groups should be included in all disaster training exercises along with organizations in the private and public sectors and any out-of-state agencies that may be dispatched for mutual aid. The true test of the fortitude of the EMD and EMS response system is to stress it beyond its capacity. The most valuable disaster exercises will tax this system beyond its limits and demonstrate how well the participants identify indicators, recognize critical triggers, and develop and implement adaptive and effec- 146 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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tive tactics. In the creation of disaster exercises as well as in conventional operations, it is beneficial for an EMS system to break down the barriers between public and private EMS agencies and cultivate symbiotic partnerships between these organizations. As a disaster transitions through the conventional, contingency, and crisis plans, there must also be triggers and indicators that signal the incident commander that the crisis is deescalating and potentially approaching resolution (though in long-term events, a return to conventional status may be only temporary). In partnership and close liaison with the emergency management system and other key emergency response system stakeholders, those with nimble minds who can create a path less trodden and use reduced resources effectively will be successful. DISCUSSION AND DECISION-SUPPORT TOOL Building on the scenarios and overarching key questions presented in Chapter 3, this tool contains addi- tional questions to help participants drill down on the key issues and details for EMS. It also contains a chart that provides example EMS 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 agency.1 Participants may choose to complete a single, general blank chart, or one each for various scenarios from their Hazard Vulnerability Analysis. Discussion Participants Suggested participants for a discussion focused on EMS are listed below. • EMS agencies; • EMS medical directors; • Emergency medical dispatch centers; • Call centers and medical resource control centers; • Public and private prehospital transport agencies (including first response agencies); • Local hospitals and long-term care facilities; • Local public health agencies;2 • Local emergency management agencies; • Mutual aid network participants; • Local emergency planning committees; • Public and private evacuation transportation partners; • Local and regional medical supply agencies; • Law enforcement agencies; • Local or regional legal representative; and • State EMS office liaison. 1  Theblank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards. 2  EMS frequently works with people with serious and persistent mental illness and substance abuse, even outside of disaster situations. Depending on local and state structures, behavioral health officials may be located in different agencies: for example, public health or health and human services. It will be important to engage them in the deliberative process, and to include consideration of behavioral health issues (see Chapter 6 for more details). TOOLKIT PART 2: EMERGENCY MEDICAL SERVICES 147

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Key Emergency Response System Stakeholders Suggested stakeholders for the EMS-focused discussion are listed below. These entities should be involved at some point in the deliberation process, although they may not participate in initial discussions because of the need to keep the group at a manageable size. • State EMS offices; • State emergency management agencies; • State medical disaster committee; • State EMS/trauma committees; • State public health agencies; • State hospital and long-term care associations; • State trauma offices; • State health and human services agencies; • State law enforcement agencies; • Regional and local EMS advisory councils; • Regional and local health care coalitions; • Regional and local trauma advisory councils; • State and local disaster response network members; and • Regional and local law enforcement agencies. Key Questions: Slow-Onset Scenario The questions below are focused on the slow-onset influenza pandemic scenario presented in Chapter 3:3 1. What information from dispatch centers would drive actions on this event? How is that informa- tion shared? 2. What information/trigger would alert EMS to take specific actions such as donning a higher level of personal protective equipment (PPE)? 3. What information from EMS agencies would be shared with local public health and when? How is that information conveyed? 4. What information from the hospitals or skilled nursing facilities regarding this type of event would determine the EMS system’s actions? How is that information communicated to EMS? 5. What information is needed from public health regarding this type of event? How is that informa- tion obtained? 6. What guidelines and measures are in place to protect EMS personnel from becoming ill? 7. What actions can be taken if EMS agencies are unable to staff ambulances appropriately according to their usual model? 3  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. 148 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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8. What precautions would be initiated to provide protection (physical [including PPE], mental, behavioral, etc.) to EMS personnel during this event? 9. What just-in-time training could be implemented when medications or equipment become scarce? How will these programs, along with the associated protocols, be disseminated and implemented? 10. What criteria would be used in the treatment of patients in this type of event? 11. What process should be implemented to change response and transport protocols within the orga- nization and with state licensing agencies? What measures can be implemented if EMS agencies cannot transport patients to a health care organization? 12. How will EMS agencies respond to or triage calls if they have limited or no ambulances to trans- port patients? 13. What information needs to be known in order to return to contingency or conventional care? 14. What expanded role can EMS personnel provide in this type of event (EMS role at alternate care sites, vaccination sites, etc.)? Are protections in place for this expanded role? Are providers prepared to take on these responsibilities? 15. What should an EMS agency do if they have more patients to treat than they can manage? 16. At what point should an EMS agency go back to medical direction for additional medical oversight or changes to standard operating procedures (SOPs)? For example, at what point should ambulance staffing patterns be altered and normal scopes of practice expanded? Key Questions: No-Notice Scenario The questions below are focused on the no-notice earthquake scenario presented in Chapter 3: 1. What information does dispatch need to know to request mutual aid? 2. What information does EMS need to know from hospitals or other health care organizations? How will this information be communicated to EMS? 3. What information is needed from public health or emergency management that would drive actions on this event? 4. What information is needed to activate the EMS agency’s mass casualty plan and request additional medical resources? 5. What information is needed and how does EMS incident command identify a potential need for a declaration of emergency for a mass casualty incident? 6. What should the EMS agency do if they have more patients than they can transport? 7. What should the EMS agency do if they have no more personnel to assist with triage and treatment? 8. When/how will existing trauma field triage criteria and associated destination protocols be modi- fied or abandoned? 9. What just-in-time training could be implemented when medications or equipment become scarce? How will these programs, along with the associated protocols, be disseminated and implemented? 10. How will the EMS agency manage specialty care patients (e.g., burn, contaminated, pediatrics), particularly when usual referral centers are unavailable or unreachable? TOOLKIT PART 2: EMERGENCY MEDICAL SERVICES 149

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11. What information (or permission) is needed to activate CSC plans? 12. How are incoming staff, equipment, and patient transport resources coordinated between jurisdictions? 13. What system status management information is available to determine indicators and triggers and how are they communicated to leadership and other emergency response systems organizations? 14. What triggers at the state level exist to provide regulatory and liability protection as well as addi- tional resources? How does the EMS agency communicate needs and request these resources? Decision-Support Tool: Example Table The indicators, triggers, and tactics shown in Table 7-1 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, 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 introduction [Chapter 3] for key definitions and concepts). The example triggers shown in Table 7-1 below mainly are ones in which a “bright line” distinguishes functionally different levels of care (conventional, contingency, crisis). Because of the nature of this type of trigger, they can be described more concretely and can be included in a bulleted list. It is important to recog- nize, 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 before reaching 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. 150 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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TABLE 7-1 Example Emergency Medical Services (EMS) Indicators, Triggers, and Tactics for Transitions Along the Continuum of Care Indicator Category Contingency Crisis Return Toward Conventional Scope of the event Minor or major disaster Catastrophic Approaching resolution Surveillance data Indicators: Indicators: Indicators: • Increased patient encounters by EMS • Patient care demands exceed the • Stabilization or decrease in patient • Increased emergency department and/or available EMS resources, including mutual encounters by EMS hospital census aid • Stabilization or decrease in emergency • Reports of increased cases of influenza • Patient care demands exceed the department and/or hospital census • Reports of an earthquake with potential available hospital resources • Stabilization or decrease in the reports of additional aftershocks • Confirmation of increased virulence of of cases of influenza Triggers: the strain of influenza • Decreasing frequency of earthquake • Significantly elevated number of dispatch • Surveillance data are impacted due to aftershocks requests overwhelmed health care providers, Triggers: • Significantly increased patient care public health, or collapse of data entry • Stabilization or decrease in the number encounters with similar signs and systems of dispatch requests symptoms or high patient acuity • The incidence of illness and injury • Stabilization or decrease in calls with • Significantly increased data registry continues to escalate despite mitigation similar signs and symptoms or high entries from state or regional electronic measures patient acuity calls prehospital patient care record systems Crisis Triggers: Tactics: Tactics: • Multiple hospitals closed to EMS • Monitor the surveillance data for • Advise local health officials (or, as • Mutual aid partners not able to answer resurgence or continued mitigation applicable, base station or online medical calls involving potential life threats • Continue to advise local health officials direction) of the observed increase in Tactics: (or, as applicable, base station or online activity or increased incidence of patients • Maximize alternative avenues of data medical direction) of the observed with similar signs and symptoms collection and submission (verbal, paper, increase in activity or increased • Establish incident command for EMS or estimated reports) incidence of patients with similar signs and advise the emergency care system • Continue to advise local health officials and symptoms stakeholders of this action command (or, as applicable, base station or online • Provide incident command with frequent medical direction) of the observed reports and ongoing trends using increase in activity or increased incidence surveillance data of patients with similar signs and • Engage regional and state surveillance symptoms systems to follow trends and expanse of • Work with mutual aid agencies to revise the mass casualty incident or pandemic and/or implement call triage • Engage mutual aid partners as required continued 151

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TABLE 7-1 152 Continued Indicator Category Contingency Crisis Return Toward Conventional Community and Indicators: Indicators: Indicators: communications • Compromised communications (911, • Emergency medical dispatch • Stabilization or decrease in calls to infrastructure public safety) systems overwhelmed by call volumes and unable emergency medical dispatch • Reports of widespread road or structural to answer all calls • Stabilization or decrease in calls to damage • 911 system compromised medical advice hotlines • Increased calls or ambulatory • Media reports that incite increased • Communication systems, networks, presentation of patients to EMS agencies anxiety and physical infrastructure returning to seeking medical advice or treatment • Operational or structural collapse of the baseline functional state • Inaccurate information from unreliable communication centers Triggers: sources circulating within the community • Inaccurate information is in the forefront • The number of requests to emergency Triggers: Crisis Triggers: medical dispatch and for EMS are • >20% increase in emergency medical • Inability of high-acuity patients to access returning to baseline levels dispatch or medical advice hotlines the emergency response system Tactics: • An increase in rumors and inaccurate • Patient tracking mechanisms and systems • Continue to provide the community information within the lay population, are overwhelmed with information regarding the status media, and social networking sites Tactics: of the event Tactics: • Use prerecorded messaging to filter calls • Continue to educate and encourage • Initiate community education regarding that require direct emergency medical the community to engage in mitigation selective emergency medical dispatch dispatch staff contact measures (EMD) and EMS triage and transport • Maximize frequent use of emergency • Revise dispatch and transport measures broadcast system and media outlets protocols to normalize operations • Engage with media outlets to disseminate • Implement call triage models to target information on mitigation measures highest priority calls for response • Work with emergency management and crews in the field to obtain situational awareness regarding access and damage reports • Consider partnering to establish nurse call triage lines to mitigate requests for EMS transport Staff Indicators: Indicators: Indicators: • Members of the EMD and EMS workforce • Overwhelming number of patient with • Approaching normal baseline levels of (Refer also to the worker unable to report for duty due to insufficient staff to meet the demand for staffing. functional capacity table impassable roads, incapacitated personal triage, treatment, and transport • Return to normal shift level and staffing in Toolkit Part 1 [Table vehicles, or other direct effects • Significant portion of the emergency • Some emergency medical dispatch and 3-1]) • Members of the EMD and EMS workforce medical dispatch and EMS workforce EMS personnel may elect to remain off within the at-risk population for influenza is sustaining physical fatigue due to duty due to family obligations • Members of the EMD and EMS workforce extended work shifts and incident stress Triggers: unable to report for duty due to illness, • Significant number of the EMD and EMS • The number of emergency medical injury, or physical entrapment in workforce are affected as disaster victims dispatch and EMS personnel reporting residences or incapacitated by the disaster and are for duty is starting to stabilize unavailable to respond • Recovery of EMS personnel from illness and/or injury

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Triggers: • EMS and medical personnel are becoming Tactics: • EMS crews are at or approaching minimal victims of criminal activity by individuals • Direct emergency medical dispatch staffing seeking medications, medical supplies, to use initial automated answering • Loss of 10% or more of the workforce vaccinations, and expedited treatment or systems during spikes of high call Tactics: transport volume for medical emergencies, but • Use mutual aid staffing resources Crisis Triggers: revert to answering all calls when able • Prioritize dispatch calls according to • Unable to maintain staffing for EMS units • Initiate a gradual return to normal potential threat to life, placing non–life • Staff overwhelmed by number of patients triage, patient treatment, and transport threatening calls on a pending status who need care guidelines (requires medically trained emergency • Mutual aid staffing resources have been • Initiate a gradual transition to normal medical dispatch) exhausted staffing levels, work shifts, and sleep • Reduce staffing requirement from two Tactics: cycles advanced life support (ALS) providers to • Direct emergency medical dispatch • Initiate plan for reduction and relief of one ALS and one basic life support (BLS) to decline response to calls without mutual aid resources provider evidence of threat to life (requires • Continue to encourage or require • Change ambulance assignments medically trained EMD) mitigation measures (personal according to closest available units • Mandatory use of disaster triage protective equipment [PPE], hand instead of BLS/ALS capability guidelines washing, vaccination, etc.) • Activate non-EMS dispatch protocols • Direct EMS to decline transport of • Encourage timely engagement in stress in emergency medical dispatch centers assessed patients without significant management and personal resilience and advise patients with minor injuries or injury or illness (upon guidance from EMS resources illnesses to use their own transportation medical direction) • Activate non-transport protocols and • Limit resuscitation attempts to witnessed disaster triage guidelines for EMS cardiac arrests agencies • Reduce staffing for ambulances to one • Use 211 nurse call centers for triage EMS provider (upon guidance from EMS • Respond to critical or urgent calls medical direction) followed by batched transport of stable • Request additional EMS units through the patients to health care facilities local emergency operations center (EOC) • Encourage mitigation measures, e.g., • Use public and private mass mass vaccination, within EMD and EMS transportation resources for patients with workforce minor injuries or illnesses • Transport essential EMS and emergency • Integrate transportation resources from medical dispatch workers to the out of state and through the Emergency workplace via National Guard or other Management Assistance Compact or agency National Disaster Medical System • Provide support to families of EMS and • Secure federal, state, regional, and local emergency medical dispatch personnel EMS staffing resources and non-EMS to facilitate the maintenance of the staffing resources (e.g., National Guard) workforce • Provide appropriate security for EMS • Change shift length crews continued 153

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TABLE 7-1 154 Continued Indicator Category Contingency Crisis Return Toward Conventional Space/infrastructure Indicators: Indicators: Indicators: • Evacuation routes are becoming crowded • Overwhelming number of patients • The demand for available ambulances • The general public is unable to access exceeds the ambulances available with patient need is better aligned timely care in clinics or emergency • Transport destinations are overwhelmed • Roadways are beginning to have department and do not have the capacity to accept reduced volume • Multiple emergency department and additional patients • Emergency departments and emergency care centers are going on • Law enforcement resources are emergency care centers are beginning diversion due to overwhelmed capacity overwhelmed or limited to accept patients • Roads and bridges have collapsed or • Evacuation routes are no longer passable • Structural damage to transport become structurally unstable • The virulence of a biologic agent has destinations is no longer affecting Triggers: increased compared to prior projections operational status • More than 20-30% of the emergency • Structural damage to the physical plant Triggers: departments, emergency care centers, of emergency medical dispatch, EMS, or • A reduction in health care facilities that and public health clinics have requested EOC that hampers or incapacitates their are on diversion additional medical staff or are on operational status • Reliable routes of transport have been diversion • Structural damage to the physical plant established for emergency and public • There is a trend within the general public of health care facilities that hampers or safety vehicles electing not to comply with emergency incapacitates their operational status Tactics: declaration mitigation directives (e.g., • Air ambulances are grounded due to • Continue operational support shelter in place, evacuation, driving weather of alternate transport sites until restrictions) Crisis Triggers: emergency department and Tactics: • No available ground ambulances for emergency care center report • Activate and open all alternative care transport improved flow of inpatients and sites, and support these with EMS • Mutual aid for additional vehicles is outpatients resources as possible exhausted • Initiate a gradual transition to • Activate alternate transport destination Tactics: conventional transport destinations and non-transport protocols for • Establish casualty collection points emergency medical dispatch and EMS • Use treat and release protocols personnel • Universal use of non-EMS dispatch and • Encourage the general public to comply non-transport protocols with emergency declaration directives, • Use mass transport vehicles (e.g., buses) engaging law enforcement assistance if to transport patients with minor injuries necessary • Use disaster triage guidelines • Designate ambulance transport solely for moderately/seriously ill or injured patients • Use alternative vehicles (e.g., aircraft if weather conditions permit, all terrain vehicles, motorcycles, bicycles, watercraft) to access moderately or severely ill or injured patients when routes of travel that are conducive to ambulances are no longer passable

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Supplies Indicators: Indicators: Indicators: • EMS agencies report increased use of • EMS reports inadequate or depleted • Demand for PPE for EMS personnel is PPE, medical supplies, medications, or supply of PPE, medical supplies, subsiding airway management equipment medications, or airway management • Demand for medical supplies or airway • Manufacturers of PPE, medical supplies, equipment management equipment is reduced vaccines, medications, or ventilators • Manufacturers of PPE, medical supplies, • Manufacturers of PPE, medical report decreased stock available vaccines, medications, or ventilators supplies, medications, or airway • Fuel shortages reported report insufficient or depleted stock management equipment report Triggers: • Manufacturers of disaster supplies and improving product availability • The available PPE is less than what is recovery equipment report factory Triggers: needed for the EMS workforce closures and/or halted production due to • Incident command is receiving reduced • The use of medical supplies, medications, loss of workforce requests for additional PPE and vaccines, and antidotes begins to exceed Crisis Triggers: medical supplies from EMS personnel their replacement • PPE is no longer available • Emergency departments, emergency Tactics: • Vaccinations, medications, or antidotes care facilities, and hospitals have • Conservation of PPE are depleted to the point that equivalent reduced requests for medications, • Conservation of supplies treatment cannot be provided antidotes, vaccinations, and ventilators • Provide medications and vaccinations to • Hospitals can no longer provide supplies • Manufacturers of disaster supplies and designated at-risk populations or medications to restock ambulances recovery equipment report a return to • Determine alternate vendors and sources Tactics: production of supplies • Activate crisis standards of care Tactics: prehospital patient care protocols • Assess the current status of the • Secure federal, state, regional, and local supplies of medications, medical emergency response assets equipment, and PPE • Request a limited volume of PPE and supplies to prepare for a potential resurgence and to begin replenishing the normal stock of supplies • Adjust supply allocation guidance toward normal 155

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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.4 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 EMS—about the fol- lowing four steps to consider when developing indicators and triggers for a specific organization/ agency/jurisdiction: (1) identify key response strategies and actions, (2) identify and examine potential indicators, (3) determine trigger points, and (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. 4  The blank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards.  156 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: 157

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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). 158 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS