8: Toolkit Part 2: Hospital and Acute Care

INTRODUCTION

This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide hospital and acute care 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. It would be helpful to also review the toolkit chapters focused on other stakeholders.

Roles and Responsibilities

Hospitals should ensure they are able to fulfill their mission to provide emergency care and inpatient/outpatient care to all members of the community, including specialty populations they may not normally serve (e.g., burn, trauma, pediatric) through development of response plans to include:

• Incident management systems such as the Hospital Incident Command System (HICS) that are compatible with the National Incident Management System (NIMS);

• Response communication and coordination capabilities with key stakeholders, including other health care organizations in the area, established health care coalitions, emergency management, emergency medical services (EMS), and public health;

• Appropriate space, staff, and supply planning to ensure the ability to meet the needs of a disaster relative to their Hazard Vulnerability Analysis (HVA) and role in the community; and

• Specific planning for scarce resource situations, including the role of incident management, how subject matter experts and/or a clinical care committee1 are used, triage processes, and the integration with scarce resource management processes at the coalition and jurisdictional levels.

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1 “Composed of clinical and administrative leaders at a health care institution, this committee is responsible for prioritizing the allocation of critical life-sustaining interventions. The clinical care committee may also be formed at the health care coalition level (e.g., hospital, primary care, emergency medical services agency, public health, emergency management, and others), playing the role of the disaster medical advisory committee at the regional level. . . . May appoint a triage team . . . to evaluate case-by-case decisions” (IOM, 2012, p. 7-1). See IOM (2012) for additional information about the roles and composition of the clinical care committee and other entities involved in planning and implementing crisis standards of care.



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8: Toolkit Part 2: Hospital and Acute Care INTRODUCTION This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide hospital and acute care decision making during a disaster. Because integrated plan- ning 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. It would be helpful to also review the toolkit chapters focused on other stakeholders. Roles and Responsibilities Hospitals should ensure they are able to fulfill their mission to provide emergency care and inpatient/out- patient care to all members of the community, including specialty populations they may not normally serve (e.g., burn, trauma, pediatric) through development of response plans to include: • Incident management systems such as the Hospital Incident Command System (HICS) that are compatible with the National Incident Management System (NIMS); • Response communication and coordination capabilities with key stakeholders, including other health care organizations in the area, established health care coalitions, emergency management, emergency medical services (EMS), and public health; • Appropriate space, staff, and supply planning to ensure the ability to meet the needs of a disaster relative to their Hazard Vulnerability Analysis (HVA) and role in the community; and • Specific planning for scarce resource situations, including the role of incident management, how subject matter experts and/or a clinical care committee1 are used, triage processes, and the integra- tion with scarce resource management processes at the coalition and jurisdictional levels. 1  “Composed of clinical and administrative leaders at a health care institution, this committee is responsible for prioritizing the alloca- tion of critical life-sustaining interventions. The clinical care committee may also be formed at the health care coalition level (e.g., hospital, primary care, emergency medical services agency, public health, emergency management, and others), playing the role of the disaster medical advisory committee at the regional level. . . . May appoint a triage team . . . to evaluate case-by-case decisions” (IOM, 2012, p. 7-1). See IOM (2012) for additional information about the roles and composition of the clinical care committee and other entities involved in plan- ning and implementing crisis standards of care. 159

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Additional discussion about the roles and responsibilities of hospital and acute care facilities in plan- ning for and implementing crisis standards of care (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 Issues for Hospitals This brief overview is supported by a more robust discussion of indicators and triggers in the overview chap- ters as well as by discussion of crisis care planning, strategies, and tactics in the IOM 2012 report and other publications (see Chapter 1). Hospitals should ensure that they have accounted for the following in their planning for disaster response, and for scarce resource situations in particular: 1. Situational awareness, including information availability and analysis 2. Disaster plan trigger(s) 3. Crisis care trigger(s) Situational awareness, including information availability and analysis, requires that the hospital can receive, verify when possible, and communicate the information available. This includes understanding sources, formats, availability, and processes for information access, assessment, and action within the facility (e.g., who receives health alerts and what they do with them). The hospital should determine whether it has daily management goals (prediction of discharge date, bed management) where information that may be critical to successful disaster response can be captured to improve efficiency and preparedness concurrently. It may be helpful to brainstorm a list of information and data that would be helpful in making decisions and determine how easy it is to obtain those data, how accurate and useful they will be, and whether or not they are actionable: that is, can the facility take actions to change the variable or not?—an example is bed a ­ vailability—and what are the likely actions to be taken? Considering information in the facility and regional HVA may be helpful. This will naturally lead to discussions about thresholds and decision making, and potentially to defining facility triggers. Disaster plan triggers cause activation of the facility emergency operations plan, marking the transition to contingency care. The roles authorized to activate the plan should be able to analyze situational informa- tion in order to make this decision. There is often uncertainty, and full plan activation involves significant time and financial impact for the facility. The larger the event, the less uncertainty there may be. Suggested triggers (number of victims by time of day, types of victims) should be available to the decision makers, who should also have the experience to consider the current facility status, the likely impact, and other factors when deciding whether or not to activate. Emergency actions at the unit level can be based on more certain triggers (in case of fire on a unit, perform the following actions), but at the institutional level, many triggers require at least a degree of interpretation of the situation (e.g., complete vs. partial hospital evacuation, des- tination of evacuated psychiatric inpatients) that is not amenable to binary criteria. Crisis care triggers should shift the incident management perspective to consideration of the overall, rather than individual patient demand and should prompt 160 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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• Use of adaptive strategies to reduce impact—extension of substitute, conserve, adapt, and reuse strategies, and introduction of reallocation if required; • Creation of a clinical care committee (or at minimum, involvement of subject matter experts) to provide recommendations; • Analysis of impact (using specific indicators for the resources in shortage) and development of recommended strategies and tactics to cope with the deficit; • Proactive strategies to acquire additional resources from coalition or emergency management part- ners, or manage those available in a congruent fashion; • Communication to staff, patients, and families about the situation and what is being done in con- cert with hospital and community ( Joint Information System) incident management; and • Determination if legal or regulatory actions are required to support crisis care strategies (e.g., from emergency management, public health). Crisis situations may begin with a discrete indicator of excess demand (e.g., inadequate numbers of ventilators, medications, or staff ), which triggers activation of the crisis care process, but does not necessarily result in allocation or triage decisions, which are the last resort in crisis care (e.g., anesthesia machines may be used, substitute medications found, or staffing patterns changed to avoid triage). Optimally, this planning process begins before the trigger threshold is reached, as the shortage was anticipated based on monitor- ing of indicators (e.g., examining pandemic epidemiology vs. supplies). Sometimes, crisis situations may develop without notice, and staff in these situations should have guidelines to follow both from an opera- tions (adaptive strategies for space, staff, etc.) and an ethical (triage decisions) perspective. Facilities should determine what specifically occurs and who becomes involved when the incident commander activates the crisis care annex to the emergency operations plan. This should involve discrete triggers as well as the option to consider other factors and initiate the crisis care plan proactively based on indicators of demand. Factors other than shortage of clinical care resources may contribute to a crisis situation, including the demands of providing information and support for families seeking loved ones, family members of patients, and mass fatality situations. Of critical importance is emphasizing the interdependency of the health care response system among hospitals, EMS, other health care facilities (including the outpatient sector), and effective interventions and risk communication coordinated by public health and emergency management. Planning with these entities to ensure an integrated response with joint objective and strategy setting is critical. Discussions based on the discipline-specific templates may be helpful to frame common issues and key interfaces/areas of need. DISCUSSION AND DECISION-SUPPORT TOOL Suggested participants for a discussion focused on hospital and acute care are listed below. Building on the scenarios and overarching key questions presented in Chapter 3, this tool contains additional questions to help participants drill down on the key issues and details for hospital and acute care. It also contains a table that provides example hospital and acute care indicators, triggers, and tactics, and a blank chart for partici- pants to complete. The scenarios, questions, and example chart are intended to provoke discussion that will TOOLKIT PART 2: HOSPITAL AND ACUTE CARE 161

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help participants fill in the blank chart for their own situation.2 Participants may choose to complete a single, general blank chart, or one each for various scenarios from their HVA. Discussion Participants Suggested participants for a discussion focused on hospitals and acute care facilities are listed below. • Hospital administration; • Hospital emergency management; • Chief medical officer; • Legal counsel; • Subject matter experts (e.g., infection control for the pandemic scenario or trauma program man- ager for the earthquake scenario); and • Health care coalition members. Following these initial discussions, sharing and coordination of this information with a much broader range of stakeholders (e.g., blood bank, EMS, trauma networks, community Department of Defense medi- cal liaisons, federally qualified health centers, nursing homes, public health, primary care providers and emergency management, elected officials, and others listed in part one of the toolkit) is critical to an inte- grated response. Key Questions: Slow-Onset Scenario The questions below are focused on the slow-onset influenza pandemic scenario presented in Chapter 33: 1. What potential indicator data are available at the community or state level and who coordinates or has access to these (systems data, epidemiologic data, alerts)? 4. Who monitors and interprets these data; how are they communicated or used in decision making? 5. What additional information could be accessed during an incident or event that would be helpful to guide facility/agency actions? 6. Do any defined actions or notifications occur once an indicator is noted or a threshold exceeded? 7. Is the facility an active participant in their regional health care coalition and if so, what resources are available, what is the trigger for requesting them, and how are they requested (medical coordination center)? 8. What are the crisis care triggers for the institution that would signify a need to implement CSC? Are these similar to other hospitals within the health care coalition? 2  Theblank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards. 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. 162 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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9. At what threshold (indicator or trigger) does interfacility communication and/or coordination begin (including EMS, emergency management, public health, and coalition/community health care organizations)? 10. How do the facility and coalition share information (including impact, resource availability, case and clinical information) with state and local public health agencies to optimize situational aware- ness and resource management? 11. What triggers exist at the state level to provide declarations of emergency (and/or regulatory and liability protections) from public health or emergency management? If there are not predesignated triggers, how are requests handled on these actions? 12. How does the institution internally and externally (with local public health) recognize the need for and support alternate care sites? Key Questions: No-Notice Scenario The questions below are focused on the no-notice earthquake scenario presented in Chapter 3: 1. What alerts, system information, or situation information does the facility receive from outside agencies and how is it (or are they) processed? 2. What internal information is available from which indicator and trigger thresholds may be derived (e.g., information technology system status, staffing, bed capacity, ventilator availability, operating room use, supplies)? 3. What additional information would be needed during an event to inform decisions on level of care that can be provided? 4. What are thresholds that can reasonably be set for review or action based on specific external or internal measures (i.e., how is the information converted to staff actions, such as activating the disaster plan or calling back select staff )? 5. How does the facility determine staff absences, illness rates, availability to report, and other data that may be critical for response? 6. What information is available or potentially available to serve as a facility “dashboard” to monitor system status? How does this system reflect disaster status? (e.g., use of additional beds, use of procedure area beds for patient care)? 7. When a no-notice event moves immediately to a crisis trigger threshold, what specific actions are defined for staff to implement—not only incident management systems but also triage processes and policies? 8. How is support provided to providers and their families to allow them to reduce stress and focus on their job duties? 9. How would decisions be made about facility evacuation or shelter-in-place (e.g., decision tools, policy, damage assessment tools)? How are these decisions communicated to the licensing or regu- latory agencies? 10. What resources exist within the regional coalition/regional trauma network for impacted hospitals (e.g., diversion, specific staff, or supply resources)? TOOLKIT PART 2: HOSPITAL AND ACUTE CARE 163

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11. Are any specific indicators and triggers needed for specialty care (e.g., burn, trauma, pediatrics) or other at-risk individuals? Decision-Support Tool: Example Table The indicators, triggers, and tactics shown in Table 8-1 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 the table mainly are ones in which a “bright line” distinguishes function- ally 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 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 particu- larly 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. Note that these sample indicators, triggers, and tactics are geared toward a smaller community hospital and are not comprehensive in scope, but meant to support discussion at the facility level. 164 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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TABLE 8-1 Example Hospital Indicators, Triggers, and Tactics for Transitions Along the Continuum of Care Indicator Category Contingency Crisis Return Toward Conventional Community and Indicators: Indicators: Indicators: communications • Impact on community, including • Community-wide and likely prolonged • Restoration of services and transportation infrastructure transportation and communications impact on infrastructure affecting access infrastructure employee homes, transportation, and Triggers: Triggers: communication • Restored electrical service • Loss of paging and/or cellular service Crisis Triggers: Tactics: in area • Loss of electrical power or generator • Scale back tactics or revert to conventional • Loss of phone service to hospital failure operations • Loss of electrical service to hospital Tactics: • Closure of transit system • Hospital evacuation/diversion if Tactics: possible • Use alternate communications • Consider whether shelter-in-place is an strategies such as mass media and option text messages, 700 or 800 MHz radio, • Provide bag-valve ventilation for satellite phones, HAM radios ventilator-dependent patients or • Provide employee alternate place on battery-operated transport transportation options and on-site ventilators temporary housing • Anticipate need to switch to gravity • Provide information to staff, visitors, drip IV medications with monitoring of and family members about impacts drip rates as pump batteries fail and response actions/options Surveillance data Indicators: Indicators: Indicators: • Pandemic or epidemic (e.g., SARS) • Epidemiologic projections will exceed • Surveillance streams show decline in activity virus detected resources available • Improvement in regional/community ED • Health alert or other notification Crisis Triggers: volumes/wait times/boarding times received • Epidemiology projections exceed Triggers: • Natural disaster occurs or mass surge capacity of facility for space • Not specified for predictive data, will adjust casualty incident (MCI) declaration in or specific capability (e.g., critical based on specific actionable data community care)—see below space and supply Tactics: • Epidemiologic forecasts (Centers for considerations, as triggers should • Stand down incident management (scaled) Disease Control and Prevention [CDC], be based on depletion of available • Lengthen duration of planning cycles etc.) resources • Reduce/deactivate regional information • Local surveillance/epidemiology data exchange • Standard metrics such as NEDOCS • Facility practices revert toward conventional (National Emergency Department • Revert to normal system monitoring (defer Overcrowding Score) this until incident clearly concludes) • Regional/community emergency department (ED) volume, ED wait times/boarding times • Regional/community hospital capacity or subset data, such as available intensive care unit (ICU) beds continued 165

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TABLE 8-1 166 Continued Indicator Category Contingency Crisis Return Toward Conventional Surveillance data Triggers: (continued) • Receipt of health alert triggers group notification by receiving infection prevention personnel • Disaster plan activated when >X seriously injured victims expected at facility—Hospital Command Center opens • “Full capacity” plan initiated when ED wait times exceed X hours Tactics: • Change or increase monitoring parameters, additional situational awareness activities • Partial or full activation of incident command system/hospital command center • Communication/coordination with stakeholders/coalition partners • Change hours, staffing, internal processes in accord with facility plans • Assess predicted impact on institution Staff Indicators: Indicators: Indicators: • Increasing staff absenteeism • Increasing staff requirements in face of • Staff impact is reduced, schools back in [Refer also to the • Specialized staff needed (pediatrics, increasing demand session, damage to community mitigated worker functional burn, geriatrics) for incident patients • Contingency spaces maximized • Staff absenteeism reduced capacity table • School closures • Contingency staffing maximized • Specialty staff obtained or demand in Toolkit Part 1 • Staff work action anticipated (e.g., Crisis Triggers: decreased (Table 3-1)] strike) • Unable to safely increase staff to Trigger: • High patient census patient ratios or broaden supervisory • Staff to patient ratios of 1:X achieved on • Staffing hours adjustment required to responsibilities medical floor maintain coverage • Lack of qualified staff for specific Tactics: • Staffing supervision model changes cares—especially those with high life- • Shorten shift lengths required to maintain coverage safety impact • Adjust staff to patient ratios toward normal Triggers: Tactics: • Transition toward usual staff—releasing less • X% staff ill call rate prompts • Tailor responsibilities to expertise, qualified staff first notification of emergency management diverting nontechnical or non- • Resume care routines group essential care to others • Resume administrative duties • School closures across area trigger • Recruit and credential staff from opening of staff day care volunteer (Medical Reserve Corps • Normal staff to patient ratios exceeded [MRC], Emergency System for Advance • Specific staff expertise demands Registation of Volunteer Health exceeded (e.g., mass burn event— Professionals [ESAR-VHP]) or federal depletion of burn nurses) sources (Disaster Medical Assistance Team [DMAT], other National Disaster Medical System [NDMS] source, etc.)

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Tactics: • Establish remote consultation • Assess likely impact on facility of specialized services such as • Hold staff telemedicine, phone triage, etc., if • Change hours, staffing patterns possible • Change staff to patient ratios • Evacuate patients to other facilities • Specialty staff provide only specialty/ with appropriate staff available technical care, while other staff provide more general care • Callback, obtain equivalent staff from coalition, hiring, administrative staff • Change charting responsibilities • Curtail nonessential staffing (cancel elective cases, specialty clinic visits, etc.) • Provide support for staff (and their families as required) to help them continue to work and provide quality care (e.g., stress “immunization,” rest periods, housing support) Space/ Indicators: Indicators: Indicators: infrastructure • Increased ED volumes • Inpatient/outpatient contingency • Favorable epidemiologic curves • Increased clinic/outpatient volumes spaces maximized or near-maximized • Restoration of critical system function • Increased inpatient census • Escalating or sustained demand on • ED/outpatient volumes decreasing • Increased pending admits/ED boarding ED/outpatient despite implementing Trigger: Triggers: contingency strategies • Patients able to be matched to appropriate • Inpatient census exceeds conventional • Damage to infrastructure affecting areas for care beds critical systems Tactics: • Damage to infrastructure Crisis Triggers: • Transitional movement of sickest patients • Clinics unable to accommodate • Contingency inpatient beds maximized back into ICU environment demand for acute care (may include subset of ICU, burn, • Broaden admission criteria • >X hours ED boarding time pediatrics, etc.) • Reduce/eliminate care in nontraditional • Electronic health record downtime • Contingency outpatient adaptations spaces (stop providing assessment/care in • Telephone or Internet systems failures inadequate to meet demand using non-patient care areas/cot-based) Tactics: equivalent spaces or strategies • Shift toward normal hours • Expand hours of outpatient care • Damage to infrastructure affecting • Open additional outpatient care space critical systems and presenting a safety by adjusting specialty clinic space/ issue to staff/patients times Tactics: • Provide “inpatient” care on • Establish nontraditional alternate preinduction, postanesthesia care, care locations (e.g., auditorium, tents, other equivalent areas conference rooms), recognizing • Divert patients to clinics/other facilities governmental role in authorizing • Transfer patients to other facilities waivers • “Reverse triage” appropriate patients • “Reverse triage” stable patients to home (with appropriate home care) these areas, move stable ICU patients • Implement downtime procedures for IT to monitored bed areas (i.e., step-down systems units deliver ICU-level care) continued 167

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TABLE 8-1 168 Continued Indicator Category Contingency Crisis Return Toward Conventional Space/ • Consider other methods of outpatient infrastructure care, including telephone treatment (continued) and prescribing • Change admission criteria—manage as outpatients with support/early follow-up • Evacuate patients to other facilities in the region/state/nation that have appropriate capabilities and capacity Supplies Indicators: Indicators: Indicators: • Vendor supply or delivery disruption • Coalition lack of available ventilators • Reduced use of PPE or other supplies • Supply consumption/use rates • Anesthesia machines and other • Reduced caseload or demand for care and • Epidemiology of event predicts supply adaptive ventilation strategies in use services impact • Coalition/vendor lack of available • Improved delivery of supplies Triggers: critical supplies/medications • Reduced need for ventilator or other triage • Event epidemiology predicts ventilator Crisis Triggers: Triggers: or other specific resource shortages • Inadequate ventilators (or other life- • Able to provide contingency ventilation and (e.g., pediatric equipment) sustaining technology) for all patients critical care strategies to all that require • Medication/vaccine supply limited that require them them • Consumption rates of personal • Inadequate supplies of medications Tactics: protective equipment (PPE) or supplies that cannot be effectively • Retriage patients as resources become unsustainable conserved or substituted for without available • Vendor shortages impact ability to risk of disability or death without • Broaden indications for interventions as provide normal resources treatment conditions improve Tactics: Tactics: • Transition back from reallocation and • Use nontraditional vendors • Implement triage team/clinical care reuse to safer adaptive and conservation • Obtain from coalition facilities/ committee process strategies stockpiles (including potential state/ • Determine bridging therapies (bag- • Loosen restrictions on use of supplies federal sources) valve ventilation, etc.) • Conserve, substitute, or adapt • Coordinate care/triage policies with functionally equivalent resources; reuse coalition facilities (in no-notice event, if appropriate this may not be possible) • Triage access to live-saving resources (ventilators, blood products, specific medications) and reallocate as required to meet demand according to state/ regional consensus recommendations • Restrict medications to select indications • Restrict PPE to high-risk exposures (and/or permit PPE reuse) • Reuse or reallocate resources when possible (benefit should outweigh risks of reuse; reallocate only when no alternatives—see criteria in IOM, 2012)

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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 hospitals and acute care— about the following 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, (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. TOOLKIT PART 2: HOSPITAL AND ACUTE CARE 169

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170 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:

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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). TOOLKIT PART 2: HOSPITAL AND ACUTE CARE 171

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