A: Glossary1

Alternate care facility A temporary site, not located on hospital property, established to provide patient care. It may provide either ambulatory or nonambulatory care. It may serve to “decompress” hospitals that are maximally filled, or to bolster community-based triage capabilities. Has also been referred to as an “alternate care site.”

Certain data Data that require minimal verification and analysis to initiate a trigger.

Clinical care committee 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 (see disaster medical advisory committee). May appoint a triage team (see triage team) to evaluate case-by-case decisions.

Contingency surge The spaces, staff, and supplies used are not consistent with daily practices, but provide care that is functionally equivalent to usual patient care practices. These spaces or practices may be used temporarily during a major mass casualty incident or on a more sustained basis during a disaster (when the demands of the incident exceed community resources).

Conventional capacity The spaces, staff, and supplies used are consistent with daily practices within the institution. These spaces and practices are used during a major mass casualty incident that triggers activation of the facility emergency operations plan.

Crisis standards of care The level of care possible during a crisis or disaster due to limitations in supplies, staff, environment, or other factors. These standards will usually incorporate the following principles: (1) prioritize population health rather than individual outcomes; (2) respect ethical principles of beneficence,

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1 The definitions provided in this glossary are from the 2012 report (IOM, 2012) with the inclusion of several new terms that are specifically addressed in this report.



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A: Glossary1 Alternate care facility A temporary site, not located on hospital property, established to provide patient care. It may provide either ambulatory or nonambulatory care. It may serve to “decompress” hospitals that are maximally filled, or to bolster community-based triage capabilities. Has also been referred to as an “alternate care site.” Certain data Data that require minimal verification and analysis to initiate a trigger. Clinical care committee 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 (see disaster medical advisory committee). May appoint a triage team (see triage team) to evaluate case-by-case decisions. Contingency surge The spaces, staff, and supplies used are not consistent with daily practices, but provide care that is functionally equivalent to usual patient care practices. These spaces or practices may be used temporarily during a major mass casualty incident or on a more sustained basis during a disaster (when the demands of the incident exceed community resources). Conventional capacity The spaces, staff, and supplies used are consistent with daily practices within the institution. These spaces and practices are used during a major mass casualty incident that triggers activation of the facility emergency operations plan. Crisis standards of care The level of care possible during a crisis or disaster due to limitations in supplies, staff, environment, or other factors. These standards will usually incorporate the following principles: (1) prioritize population health rather than individual outcomes; (2) respect ethical principles of beneficence, 1 The definitions provided in this glossary are from the 2012 report (IOM, 2012) with the inclusion of several new terms that are specifi- cally addressed in this report. 185

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stewardship, equity, and trust; (3) modify regulatory requirements to provide liability protection for health care providers making resource allocation decisions; and/or (4) designate a crisis triage officer and include provisions for palliative care in triage models for scarce resource allocation (e.g., ventilators). Crisis standards of care will usually follow a formal declaration or recognition by state government during a pervasive (pan- demic influenza) or catastrophic (earthquake, hurricane) disaster which recognizes that contingency surge response strategies (resource-sparing strategies) have been exhausted, and crisis medical care must be pro- vided for a sustained period of time. Formal recognition of these austere operating conditions enables spe- cific legal/regulatory powers and protections for health care provider allocation of scarce medical resources and for alternate care facility operations. Under these conditions, the goal is still to supply the best care possible to each patient. Crisis surge Adaptive spaces, staff, and supplies are not consistent with usual standards of care, but provide sufficiency of care in the setting of a catastrophic disaster (i.e., provide the best possible care to patients given the circumstances and resources available). Crisis capacity activation constitutes a significant adjustment to standards of care. Disaster medical advisory committee At the state or regional level, evaluates evidence-based, peer-reviewed critical care and other decision tools and recommends decision-making algorithms to be used when life- sustaining resources become scarce. May also be involved in providing broader recommendations regarding disaster planning and response efforts. When formed at the regional level, this group may take on the same functions as that of the clinical care committee. Those functions are focused in two distinct areas—medical advisory input and resource allocation decision approval. Emergency Management Assistance Compact (EMAC) The first national disaster-relief compact, the EMAC has been adopted by all 50 states and the District of Columbia. It uses a responsive system that connects states with each other and federal government agencies during governor-declared emergencies, allowing them to request and send personnel, equipment, and other resources to the site of disasters. Emergency medical services (EMS) The full spectrum of emergency care, from recognition of the emer- gency, telephone access of the system, and provision of prehospital care, through definitive care in the hos- pital. It often also includes medical response to disasters, planning for and provision of medical coverage at mass gatherings, and interfacility transfers of patients. However, for the purposes of this document, the definition of EMS is limited to the more traditional, colloquial meaning: prehospital health care for patients with real or perceived emergencies from the time point of emergency telephone access until arrival and transfer of care to the hospital. Emergency response system A formal or informal organization covering a specified geographic area mini- mally composed of health care institutions, public health agencies, emergency management agencies, and emergency medical services providers to facilitate regional preparedness planning and response. 186 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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Health care coalition A group of individual health care assets (e.g., hospitals, clinics, long-term care facili- ties, etc.) in a specified geographic location that have partnered to respond to emergencies in a coordinated manner. The coalition has both a preparedness element and a response organization that possess appro- priate structures, processes, and procedures. During response, the goals of the coalition are to facilitate situational awareness, resource support, and coordination of incident management among the participating organizations. Health care institution Any facility providing patient care. This includes acute care hospitals, community health centers, long-term care institutions, private practices, and skilled nursing facilities. Health care practitioners Include “health care professionals” and other non-licensed individuals who are involved in the delivery of health care services. Health care professionals Individuals who are licensed to provide health care services under state law. Indicator A measurement, event, or other data that is a predictor of change in demand for health care ser- vice delivery or availability of resources. This may warrant further monitoring, analysis, information sharing, and/or select implementation of emergency response system actions. • Actionable indicator: An indicator that can be impacted through actions taken within an orga- nization or component of the emergency response system (e.g., a hospital detecting high patient census). • Predictive indicator: An indicator that cannot be impacted through actions taken within an orga- nization or component of the emergency response system (e.g., a hospital receiving notification that a pandemic virus has been detected). Legal standard of care The minimum amount of care and skill that a health care practitioner must exercise in particular circumstances based on what a reasonable and prudent health care practitioner would do in similar circumstances; during non-emergencies and disasters, they are based on the specific situation. Medical standard of care The type and level of medical care required by professional norms, professional requirements, and institutional objectives; these standards vary as circumstances change, including during emergencies or crisis events. Memorandums of Understanding (MOUs) Voluntary agreements among agencies and/or jurisdictions for the purpose of providing mutual aid at the time of a disaster. Mutual aid agreements (MAAs) Written instruments among agencies and/or jurisdictions in which they agree to assist one another on request by furnishing personnel and equipment. An “agreement” is generally more legally binding than an “understanding.” APPENDIX A 187

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Non-scripted tactic A tactic that varies according to the situation; it is based on analysis, multiple or uncer- tain indicators, recommendations, and, in certain circumstances, previous experience. Palliative care Care provided by an interdisciplinary team to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies. Palliative care affirms life by supporting the patient and family’s goals for the future, including their hopes for cure or life prolongation, as well as their hopes for peace and dignity throughout the course of illness, the dying process, and death. Protocol A written procedural approach to a specific problem or condition. Public health system A complex network of individuals, organizations, and relevant critical infrastructures that have the potential to act individually and together to create conditions of health, including communi- ties, health care delivery systems (e.g., home care, ambulatory care, private practice, hospitals, skilled nursing facilities, and others), employers and business, the media, homeland security and public safety, academia, and the governmental public health infrastructure. Region An organizational area defined for the purpose of efficiently coordinating, administering, and facil- itating disaster preparedness, response, and recovery activities. The area is typically determined by geo- graphic, jurisdictional, demographic, political, and/or functional service area boundaries. For example, it may be based on areas that are already established for activities conducted by public-sector partners (e.g., federal, state, local, or tribal governments), such as existing regions defined by public health, emergency manage- ment, EMS, or law enforcement agencies, or for activities conducted by private-sector partners, such as existing regions defined for delivering hospital and trauma care. The area may be within a state’s boundaries (i.e., an intrastate region), including spanning substate jurisdictional lines (e.g., county and city lines); may cross state boundaries (i.e., an interstate region); or may be a hybrid (e.g., adjacent counties in bordering states). These factors also may be used to help define the boundaries of health care coalitions. Regional Disaster Medical Advisory Committee (RDMAC) A designated group of subject matter experts who can homogenize state and local crisis care clinical guidance when the affected region encompasses areas across state lines. The RDMAC is necessary because state guidance alone may not address the specific needs of an area. Although regional guidance can provide greater clarity on applying state guidance in local situa- tions, it must not be inconsistent with it. The RDMAC can also serve as the coordinator of information and process improvement where appropriate. Resource sparing The process of maximizing the utility of supplies and material through conservation, substitution, reuse, adaptation, and reallocation. Scope of practice The extent of a professional’s ability to provide health services pursuant to their compe- tence and license, certification, privileges, or other lawful authority to practice. 188 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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Scripted tactic A tactic that is predetermined (i.e., can be listed on a checklist) and is quickly implemented by frontline personnel with minimal analysis. SOFA score The Sequential Organ Failure Assessment (SOFA) is a scoring system to determine the extent of a person’s organ function or rate of failure. The score is based on six different body systems: respiratory, cardiovascular, hepatic, hematopoietic, renal, and neurologic. State Disaster Medical Advisory Committee (SDMAC) The dedicated body within a state that is respon- sible, in planning for or during an emergency, for providing clinical and other crisis standards of care (CSC) guidance when prolonged or widespread crisis care is necessary to maintain a consistent basis for life- sustaining resource allocation decisions. During a response, the SDMAC should draw on the expertise of its membership and that of other preidentified subject matter experts to address ongoing issues as crisis care is implemented. The SDMAC’s guidance should accompany other state declarations or invocations of emer- gency powers to empower and protect providers during their provision of crisis care. Threshold “A level, point, or value above which something is true or will take place and below which it is not or will not” (Merriam-Webster Dictionary, 2013). A trigger point may be designed to occur at a threshold recognized by the community or agency to require a specific response. Trigger points and thresholds may be the same in many circumstances, but each threshold does not necessarily have an associated trigger. Triage The process of sorting patients and allocating aid on the basis of need for or likely benefit from medi- cal treatment. Types of triage include •  rimary triage: The first triage of patients into the medical system (it may occur out of hospital), P at which point patients are assigned an acuity level based on the severity of their illness/disease. •  econdary triage: Reevaluation of the patient’s condition after initial medical care. This may S occur at the hospital following EMS interventions or after initial interventions in the emergency department. This often involves the decision to admit the patient to the hospital. •  ertiary triage: Further reevaluation of the patients’ response to treatment after further interven- T tions; this is ongoing during their hospital stay. This is the least practiced and least well-defined type of triage. Triage team Appointed by the clinical care committee, uses decision tools appropriate to the event and resource being triaged, making tertiary triage using scarce resource allocation decisions. This is similar in concept to triage teams established to evaluate incoming patients to the emergency department requiring primary or secondary triage, usually in a sudden-onset, no-notice disaster event (e.g., explosive detonation). Trigger Evidence that austere conditions prevail so that crisis standards of care practices will be required. This may occur at an institutional, and often regional, level of response. It suggests the need for the immedi- ate implementation of response pathways that are required to manage a crisis surge response emanating from the disaster situation. APPENDIX A 189

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• Crisis care trigger: The point at which the scarcity of resources requires a transition from con- tingency care to crisis care, implemented within and across the emergency response system. This marks the transition point at which resource allocation strategies focus on the community rather than the individual. • Non-scripted: A decision point that requires analysis and leads to implementation of non-scripted tactics. • Scripted trigger: A predefined decision point that can be initiated immediately upon recognizing a qualifying indicator. Scripted triggers lead to scripted tactics. Uncertain data Data that require interpretation to determine appropriate triggers and tactics. REFERENCES IOM (Institute of Medicine). 2012. Crisis standards of care: A systems framework for catastrophic disaster response. Wash- ington, DC: The National Academies Press. http://www.nap.edu/catalog.php?record_id=13351. Merriam-Webster Dictionary. 2013. Definition of “threshold.” Springfield, MA: Encyclopaedia Britannica. http://www. merriam-webster.com/dictionary/threshold (accessed April 3, 2013). 190 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS