9: Toolkit Part 2: Out-of-Hospital Care

INTRODUCTION

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

Roles and Responsibilities

The out-of-hospital care delivery system is very diverse, with many roles and responsibilities within a community. These include community-based health care provided in diverse ambulatory care environments (public, private, tribal, veterans health, military), home health and hospice, assisted living and skilled nursing, specialty care and resources, and others. Additional discussion about the roles and responsibilities of out-of-hospital and alternate care systems in planning for and implementing crisis standards of care 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.

Planning and coordination among these entities can be difficult because no single entity has jurisdiction. The components of this broad care system need to work together to engage in disaster planning activities to maximize resources and ensure that the needs of patients, clients, and residents are met. In the large majority of situations, the out-of-hospital providers need to work collaboratively with the other emergency response sectors because it is a component of a larger system of health care resources. For example, hospitals and local agencies may need to work together to ensure that patients can be discharged safely to their homes, including assessing whether the home was damaged and determining whether basic food, water, and heating needs are sufficient. It is evident that the majority of health care services are provided in the outpatient setting, highlighting the importance of these specialized care providers in disaster response. In certain circumstances, ambulatory care should make linkages to the professional associations that oversee the policy formulation for a number of population-specific entities (e.g., renal response, long-term care, palliative care).



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9: Toolkit Part 2: Out-of-Hospital Care INTRODUCTION This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide out-of-hospital 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. Review the toolkit chapters focused on other stakeholders also would be helpful. Roles and Responsibilities The out-of-hospital care delivery system is very diverse, with many roles and responsibilities within a com- munity. These include community-based health care provided in diverse ambulatory care environments (public, private, tribal, veterans health, military), home health and hospice, assisted living and skilled nurs- ing, specialty care and resources, and others. Additional discussion about the roles and responsibilities of out-of-hospital and alternate care systems in planning for and implementing crisis standards of care 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. Planning and coordination among these entities can be difficult because no single entity has jurisdiction. The components of this broad care system need to work together to engage in disaster planning activities to maximize resources and ensure that the needs of patients, clients, and residents are met. In the large majority of situations, the out-of-hospital providers need to work collaboratively with the other emergency response sectors because it is a component of a larger system of health care resources. For example, hospitals and local agencies may need to work together to ensure that patients can be discharged safely to their homes, includ- ing assessing whether the home was damaged and determining whether basic food, water, and heating needs are sufficient. It is evident that the majority of health care services are provided in the outpatient setting, highlighting the importance of these specialized care providers in disaster response. In certain circumstances, ambulatory care should make linkages to the professional associations that oversee the policy formulation for a number of population-specific entities (e.g., renal response, long-term care, palliative care). 173

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Key Issues The out-of-hospital system could be impacted directly by the crisis scenario (e.g., damage to a long-term care facility or dialysis center) or indirectly by requested support for surge in the other components of the health care spectrum (e.g., early discharge from hospitals creating surge in home care needs). The engage- ment of the out-of-hospital care delivery partners with local public health and in health care coalitions is critical to ensuring that resources are maximized during disasters or public health or medical emergencies. Maximization of out-of-hospital care improves access to care (and thus potentially avoids complications) and reduces the pressure on emergency departments and inpatient care. Creating bidirectional communica- tion linkages among the components of the out-of-hospital providers and with the other traditional medical providers helps to ensure the ability to function effectively during crises. This is also important for better coordination with emergency management, which has the primary responsibility for ensuring the continuity of private-sector resources. DISCUSSION AND DECISION-SUPPORT TOOL Suggested participants for a discussion focused on out-of-hospital 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 out-of-hospital care. It also contains a chart that provides example out-of-hospital care 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. Discussion Participants Suggested participants for a discussion focused on out-of-hospital are listed below. • Local public health; • Home care agencies; • Assisted living; • Long-term care; • Skilled nursing facilities; • Outpatient clinics (multispecialty group practices, federally qualified health centers, dialysis centers, etc.); • Private practice community; • Hospice care; • Specialty associations (e.g., dialysis networks); • Behavioral health providers; • Poison control and other call centers; 1  The blank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards. 174 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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• Pharmacies; and • Building facilities managers, especially in urban areas. Key Questions: Slow-Onset Scenario The questions below are focused on the slow-onset influenza pandemic scenario presented in Chapter 32: 1. What relevant information is accessible pertaining to out-of-hospital (home care, hospice, long- term care, clinics, etc.) capacity and resources? 2. What additional information could be accessed in pre-event planning for contingency or crisis response? 3. How would this information drive actions? 4. What patient care delivery changes would be implemented, which ones are needed to address the scenario, and when would they be initiated? 5. What patient care delivery assets are preserved (prioritized) in order to support basic health care delivery needs? What information is needed to make the decision to conserve resources? 6. What indicators demonstrate that patient care services can no longer be sustained? 7. What would be done when durable medical equipment providers can no longer provide home oxygen? Does the agency have contingency plans or contracts to augment current resources? 8. What alternate care facility plans have been developed and exercised in the community and what is each stakeholder’s role in these plans? Are personnel or a facility available to serve in this capacity for response? 9. What would be done when alternate care facilities are at capacity? 10. What would be done when hospice patients are seeking treatment in acute care facilities? 11. How do stakeholders ensure consistency and coordination of community-derived patient care goals? 12. How does the agency ensure that its communications messages are shared with the Joint Informa- tion Center ( JIC)? 13. In what ways do community-based care providers interface with the broader public health and medical response community (Emergency Support Function- [ESF-] 8)? 14. How is the interdependence among the organizations within a given medical specialty and with other health care delivery systems managed? 15. What plans are made to ensure mission-critical functionality? 16. Does another care model depend on the facility as part of the development of its surge response plans? If so, how is the delivery of care to patients prioritized? 2  Note: Many of the key questions are intended to ensure that planners are thinking about the situational awareness that they will need to make decisions regarding the transition of care in the outpatient setting along the surge continuum, from conventional to contingency to crisis care response. In many cases, the out-of-hospital care facilities will not necessarily have access to such information on an agency basis. Recognition of community partnerships that may facilitate access to this needed information is an important aspect of planning for such events. In particular, participation in local/regional Healthcare Coalitions (see ASPR, 2012) will be a useful entrée to coordinating out-of-hospital care with the health and medical community. 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: OUT-OF-HOSPITAL CARE 175

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17. How does the facility prepare for evacuation due to incapacitation or shelter-in-place if instructed by local emergency management? Key Questions: No-Notice Scenario The questions below are focused on the no-notice earthquake scenario presented in Chapter 3: 1. What relevant information is accessible to pertaining to out-of-hospital (home care, hospice, long- term care, clinics, etc.) capacity and resources? 2. How would this information drive actions? 3. What planning efforts have been undertaken to promote resilience and continuity of operations in the face of severe infrastructure damage? Does the agency have redundant mechanisms to com- municate with personnel? 4. In the setting of presumed communications infrastructure disruption, are there alternate ways to receive needed situational awareness? 5. How is damage assessment information sent and received within the context of the broad public health and medical response system? 6. What systems or processes are in place to obtain universal damage assessments and how are damage assessments communicated to staff, personnel, patients, families, and vendors? 7. What strategies can be used to prevent home ventilator patients and those seeking medication from needing to go to overtaxed hospitals to seek assistance? 8. What would be done when roads are impassible and vulnerable home care, hospice, and long-term care patients cannot be reached? Are these strategies routinely communicated to patients currently receiving care (alternate dialysis sites, home preparedness kits, etc.)? 9. What would be done when there are not enough staff for those seeking care at alternate care sites? 10. What systems are in place to manage the medical records to preserve key patient information and support continuity of care if evacuation is required? 11. How do stakeholders ensure consistency and coordination of community-derived patient care goals? 12. How does the agency ensure that its communications messages are shared with the JIC? 13. In what ways does the facility/agency interface with the broader public health and medical response community (ESF-8)? 14. How is interdependence among organizations managed within the medical specialty and with other health care delivery systems? 15. What plans are made to ensure mission-critical functionality? 16. Does another care model depend on the facility as part of the development of its surge response plans? If so, how is the delivery of care to patients prioritized? 17. How does the facility prepare for evacuation due to incapacitation or shelter-in-place if instructed by local emergency management? 176 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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Decision-Support Tool: Example Table This example table (Table 9-1) provides sample indicators, triggers, and tactics for home care, ambulatory care, long-term care, and skilled nursing facilities. Because of the extensive variability among these types of entities, developing customized indicators and triggers for participants’ own situations will be particularly important. The indicators, triggers, and tactics shown in the table are intended 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, agen- cies, 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 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. TOOLKIT PART 2: OUT-OF-HOSPITAL CARE 177

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TABLE 9-1 178 Example Out-of-Hospital Indicators, Triggers, and Tactics for Transitions Along the Continuum of Care Indicator Category Contingency Crisis Return Toward Conventional Surveillance data Indicators: Indicators: Indicators: • Epidemiological surveillance data • Dramatic demand for patient care • Normal patient care census and length highlights specific population services (e.g., surge in hospital of stay at hospitals predilection (e.g., pediatrics, geriatrics) discharges) • Decreasing disease burden based on • Local/regional surveillance and Crisis Triggers: surveillance/epidemiological data epidemiological data • Unable to deliver home care to meet Triggers: Triggers: patient needs • Demand for services lessens and/or • Increasing discharges from hospital • Large numbers of long-term care availability of resources improves • Increased demand for patient care patients requiring hospitalization due Tactics: services to increasing acuity • Patient care delivery adjusted toward Tactics: • Failure to adapt to changing baseline • Coordinate with local/regional health conditions, including ability to expand care coalition capacity of services • Anticipate impact of these events on Tactics: sustainment of patient care service • Postpone elective appointments delivery and make adjustments based • Implement changes to patient care on existing emergency operations service delivery and make adjustments plans based on existing emergency operations plans Community and Indicators: Indicators: Indicators: communications • Communications are delayed because • Communications infrastructure is • Communications are returning to infrastructure of partial damage to infrastructure severely damaged and will take weeks normal • Utility (e.g., power/water) failures to restore • Utility restoration allows technology- impacting patients who depend on • Surge of technology-dependent dependent patients to return to their technology (e.g., home ventilator and patients seeking care at hospitals usual care dialysis patients) and/or long-term Crisis Triggers: Triggers: care and other utility-dependent • Absence of patient care records • Evacuated residents returning to long- facilities or inability to provide patient care term care facilities Triggers: records • Home care providers able to contact • Inability to track patients during mass • Home care and hospice providers patients evacuation with wide geographic unable to make visits, unable to Tactics: dispersal contact clients • Ability to use standard patient care • Sole reliance on paper-based Tactics: records and reporting mechanisms (minimal) patient care records • Emergency plans put in place for reestablished Tactics: managing home-bound patients • Adjust patient charting requirements • Establishment of alternate care sites to manage outpatient surge • Use of surge response tactics, including nurse triage lines, expanded scope of practice for pharmacy/ emergency medical services

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Staff Indicators: Indicators: Indicators: • Decreased availability of staff for work; • Critical shortages of staff in outpatient • Staff available for work (Refer also to the worker increasing staff absenteeism clinics, home and hospice care, and • Schools reopen functional capacity table • Closure of schools long-term care facilities Triggers: in Toolkit Part 1 [Table • Travel restrictions and/or reduced • Out-of-hospital sector staff are being • Sufficient staff available so family 3-1]) mass transportation impedes asked to volunteer (e.g., MRC) to members no longer need to provide movement of staff to work provide care to higher acuity patients care Triggers: (e.g., alternate care sites/hospital • Home and hospice personnel are able • Need for staffing augmentation surge) to make home visits through Emergency System for Crisis Triggers: Tactics: Advance Registration of Volunteer • Unable to provide necessary health • Staffing hours and routines return to Health Professionals (ESAR-VHP) and care staff to support patient needs conventional operations Medical Reserve Corps (MRC) (e.g., home care visits less frequent Tactics: than indicated and change in provider • Adjust staffing hours and routines to to patient ratios, families of patients accommodate more patients and staff seeking care at long-term • Consider provisions needed to allow care facilities) family members to augment care Tactics: • Staffing in long-term care facilities predominantly provided by family members • Coordination of care with neighbors and other community-based assets • Home care staff designated as emergency responders so they can travel and access gasoline supplies to see critically ill home care patients. continued 179

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TABLE 9-1 180 Continued Indicator Category Contingency Crisis Return Toward Conventional Space/infrastructure Indicators: Indicators: Indicators: • Increasing mortality due to event • Mass fatalities • Decreasing mortality rate so local • Community-wide sanitation and food • Critical shortages of sanitation and resources able to manage fatalities service delivery impacted by event food • Sanitation and food are no longer in • Travel restrictions due to disruption of • Transportation infrastructure severely short supply transportation infrastructure disrupted • Alternate transportation methods have Triggers: • Need for mass fatality management been identified and deployed • Infrastructure loss in community, Crisis Triggers: Triggers: including loss of utilities (supply of • Many home care and hospice patients • Home care and hospice patients able to gasoline for travel, electricity, etc.) calling ambulances requesting return home Tactics: transport to hospitals to seek care/ • Remains are processed by local • Expand hours of care in existing admission (no longer able to be resources outpatient setting managed at home) • Alternate care facilities are no longer • Establish shelter care/use alternate • Alternate care facilities beyond needed care facilities to manage patient care capacity • Long-term care facilities and FQHCs needs • FQHCs are damaged and unable to returning to normal operations Dual purpose out-of-hospital clinics to provide surge capacity Tactics: accept surge (e.g., federally qualified • Long-term care facilities damaged and • Demobilization of federal resources health centers [FQHCs]) destination facilities unable to accept • Closing alternate care facilities • Long-term care facilities and home transfers • Outpatient clinics return to normal care accepting early discharges from Tactics: operations hospitals • Establish federal alternate care sites (e.g., Federal Medical Stations) • Use alternate spaces for management of decedents (e.g., mass fatality plan implementation); engagement of Disaster Mortuary Assistance Teams Equipment/supplies Indicators: Indicators: Indicators: • Some shortages of critical supplies • Supplies targeted to this sector are • Increasing supplies are available noted for outpatient clinics, home diverted to higher acuity patients (e.g., Triggers: care, and hospice patients hospital-based patients) • Demand no longer exceeds available Triggers: • Critical shortages require rationing of resources • Demand for key equipment and supplies Tactics: supplies exceeds available resources • Reusing, repurposing of equipment • Reestablishing normal supply chains Tactics: and supplies no longer meet the needs • Centralized equipment distribution • Reusing/repurposing key equipment Crisis Triggers: discontinued and supplies in order to meet demands • Difficult decisions required to fairly allocate available resources • Rationing of equipment and supplies Tactics: • Centralize supply distribution to support fair allocation of scarce resources (this may require limitation of certain hospital-based services in favor of supporting outpatient management)

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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.3 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 out-of-hospital 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, 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. 3  The blank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards. TOOLKIT PART 2: OUT-OF-HOSPITAL CARE 181

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Scope and Event Type: __________________________________ 182 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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REFERENCES ASPR (Assistant Secretary for Preparedness and Response). 2012. Hospital preparedness program (HPP) performance measure manual, guidance for using the new HPP performance measures. Washington, DC: Department of Health and Human Ser- vices. http://www.phe.gov/Preparedness/planning/evaluation/Documents/hpp-coag.pdf (accessed June 5, 2013). 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: OUT-OF-HOSPITAL CARE 183

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