Indicators and triggers represent the information and actions taken at specific thresholds that guide incident recognition, response, and recovery. Box 2-1 provides definitions; the concepts behind the definitions are discussed in greater detail below.

Indicator information may be available in many forms. Sample indicators and associated triggers and tactics are listed in Table 2-1. More detailed descriptions are available in the discipline-specific discussion toolkits (Chapters 4-9). When specific indicators cross a threshold that is recognized by the community to require action, this represents a trigger point, with actions determined by community plans. These include plans for activation of a general disaster plan, which often occurs at the threshold between conventional and contingency care, and activation of crisis standards of care (CSC) plans, which would occur at the threshold between contingency and crisis care.

DEVELOPING USEFUL INDICATORS AND TRIGGERS

Key points: It can be challenging to identify useful indicators and triggers from among the large and varied sources of available data. Specific numeric “bright line” thresholds for indicators and triggers are concrete and attractive because they are easily recognized, but for many situations the community/agency actions are not as clear-cut or may require significant data analysis before action. Rather than creating a laundry list of possible indicators and triggers, it may be helpful to consider four steps: (1) identify key response strategies and actions, (2) identify and examine potential indicators, (3) determine trigger points, and (4) determine tactics.

The amount of information available in health care today is enormous and expanding. It is attractive to look at many metrics and consider their use as indicators. However, multiple factors may make data monitoring less useful than it originally appears, and it can be challenging to detect or characterize an evolving event amid usual variability in large and complex sets of data (see the “Indicators Limitations and Issues” section below). Specific numeric “bright line” thresholds for indicators and triggers are concrete and attractive because they are easily recognized, and for certain situations they are relatively easy to develop (e.g., a single case of anthrax). However, for many situations the community/agency actions are not as clear-cut or may require significant data analysis to determine the point at which a reasonable threshold may be established (e.g., multiple cases of diarrheal illness in a community).

The accompanying toolkits provide discipline-specific tables and materials to discuss potential indicators and triggers that guide CSC implementation. This section presents key concepts that will help inform the development of these discipline-, agency-, and organization-specific indicators and triggers. Rather than creating a laundry list of possible indicators and triggers, it may be helpful to consider the following four steps. These steps should be considered at the threshold from conventional to contingency care, from contingency to crisis care, and in the return to conventional care. They should also be considered for both slow-onset and no-notice incidents. Subsequent discussion below expands on these steps.

1. Identify key response strategies and actions that the facility or agency would use to respond to an incident. (Examples include disaster declaration, establishment of an emergency operations center [EOC] and multiagency coordination, establishment of alternate care sites, and surge capacity expansion.)



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