Additional discussion about the roles and responsibilities of hospital and acute care facilities in planning 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 chapters 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 availability—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 information 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, destination 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



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