Crisis Standards of Care

A Toolkit for Indicators and Triggers

Committee on Crisis Standards of Care: A Toolkit for Indicators and Triggers

Board on Health Sciences Policy

Dan Hanfling, John L. Hick, and Clare Stroud, Editors

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

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Committee on Crisis Standards of Care: A Toolkit for Indicators and Triggers Board on Health Sciences Policy Dan Hanfling, John L. Hick, and Clare Stroud, Editors

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THE NATIONAL ACADEMIES PRESS    500 Fifth Street, NW    Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. HHSP23337003T between the National Academy of Sciences and the Department of Health and Human Services and Contract No. DTNH22-10-H-00287 between the National Academy of Sciences and the Department of Transportation’s National Highway Traffic Safety Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number-13:  978-0-309-28552-0 International Standard Book Number-10:  0-309-28552-6 Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2013 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carv- ing from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2013. Crisis standards of care: A toolkit for indicators and triggers. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished schol- ars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and techni- cal matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sci- ences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associ- ate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sci- ences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS DAN HANFLING (Co-Chair), Inova Health System, Falls Church, VA JOHN L. HICK (Co-Chair), Hennepin County Medical Center, Minneapolis, MN SARITA CHUNG, Harvard School of Medicine and Boston Children’s Hospital, MA CAROL CUNNINGHAM, Ohio Department of Public Safety, Columbus BRIAN FLYNN, Uniformed Services University of the Health Sciences, Bethesda, MD W. NIM KIDD, Texas Department of Public Safety, Austin ANN R. KNEBEL, National Institute of Nursing Research, National Institutes of Health, Bethesda, MD LINDA SCOTT, Michigan Department of Community Health, Lansing ANTHONY H. SPEIER, State of Louisiana’s Department of Health and Hospitals, Baton Rouge JOLENE R. WHITNEY, Bureau of Emergency Medical Services and Preparedness, Utah Department of Health, Salt Lake City IOM Staff CLARE STROUD, Study Director BRUCE M. ALTEVOGT, Senior Program Officer SHEENA M. POSEY NORRIS, Research Associate DOUGLAS KANOVSKY, Senior Program Assistant LORA TAYLOR, Financial Associate DONNA RANDALL, Administrative Assistant ANDREW M. POPE, Director, Board on Health Sciences Policy v

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and techni- cal expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review com- ments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Hany Abdelaal, VNSNY CHOICE Health Plans Knox Andress, Louisiana Poison Center Tracy Buchman, HSS, Inc. Barbara B. Citarella, RBC Limited Peggy Connorton, American Health Care Association Nancy W. Dickey, Texas A&M Health Science Center Chris Kelenske, Michigan State Police Arthur L. Kellermann, RAND Corporation Danita Koehler, Governor’s Alaska Council on Emergency Medical Services Deborah Levy, Centers for Disease Control and Prevention Onora Lien, Northwest Healthcare Response Network Suzet McKinney, Chicago Department of Public Health Ann Norwood, Center for Biosecurity of UPMC Sarah Park, Hawaii Department of Health Nels Sanddal, American College of Surgeons Leslee Stein-Spencer, National Association of State EMS Officials Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report vii

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before its release. The review of this report was overseen by Mark R. Cullen, Stanford University. Appointed by the Institute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were care- fully considered. Responsibility for the final content of this report rests entirely with the authoring commit- tee and the institution. viii REVIEWERS

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Contents USER GUIDE xi ACRONYMS xiii SUMMARY 1 1 INTRODUCTION 11 Study Goals and Methods, 12 Organization of the Report and How to Use the Toolkit, 13 Previous IOM Work on Crisis Standards of Care, 14 Continuum of Care: Conventional, Contingency, and Crisis, 15 A Systems Approach to Catastrophic Disaster Response, 16 Implementation of the Disaster Response Framework, 29 The Need to Develop Indicators and Triggers, 31 References, 36 2 INDICATORS AND TRIGGERS 41 What Are Indicators and Triggers?, 41 Developing Useful Indicators and Triggers, 42 Indicator Limitations and Issues, 53 Systems-Level Considerations for Indicators and Triggers, 55 Summary, 68 References, 69 3 TOOLKIT PART 1: INTRODUCTION 75 Toolkit Objective, 75 Using the Toolkit, 76 Slow-Onset Scenario (Pandemic Influenza), 81 No-Notice Scenario (Earthquake), 84 ix

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Overarching Key Questions, 87 Worker Functional Capacity, 88 References, 89 4 TOOLKIT PART 2: EMERGENCY MANAGEMENT 93 Introduction, 93 Discussion and Decision-Support Tool, 94 References, 104 5 TOOLKIT PART 2: PUBLIC HEALTH 105 Introduction, 105 Discussion and Decision-Support Tool, 106 Reference, 124 6 TOOLKIT PART 2: BEHAVIORAL HEALTH 125 Introduction, 125 Discussion and Decision-Support Tool, 127 Reference, 143 7 TOOLKIT PART 2: EMERGENCY MEDICAL SERVICES 145 Introduction, 145 Discussion and Decision-Support Tool, 147 Reference, 158 8 TOOLKIT PART 2: HOSPITAL AND ACUTE CARE 159 Introduction, 159 Discussion and Decision-Support Tool, 161 Reference, 171 9 TOOLKIT PART 2: OUT-OF-HOSPITAL CARE 173 Introduction, 173 Discussion and Decision-Support Tool, 174 References, 183 APPENDIXES A Glossary 185 B Open Session Agenda 191 C Committee Biosketches 195 x CONTENTS

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User Guide This report focuses on indicators (measurements or predictors of change in demand for health care services or availability of resources) and triggers (decision points about adaptations to health care service delivery) that guide operational decision making about providing care during public health and medical emergencies and disasters. It includes a discussion toolkit designed to facilitate discussions about indicators and triggers within and across health care organizations, health care coalitions, emergency response agencies, and juris- dictions. This report builds on previous Institute of Medicine reports on crisis standards of care, including Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations (2009) and Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response (2012). The report is divided into two parts; it is possible to start with either part, depending on the reader’s goals: To review background information about crisis standards of care and explore concepts related to indicators and triggers, start by reading Chapters 1 and 2. To jump directly into the discussion toolkit, start with Chapter 3, which provides the introduction to the toolkit and material relevant to the entire emergency response system. Then proceed to the chapter cor- responding to the component of the emergency response system of greatest interest: emergency management (Chapter 4), public health (Chapter 5), behavioral health (Chapter 6), emergency medical services (Chapter 7), hospital and acute care (Chapter 8), and out-of-hospital care (Chapter 9). Because integrated planning across the emergency response system is critical for a coordinated response, it is important to read the toolkit introduction (Chapter 3) as well as the discipline-specific chapters. xi

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Acronyms ALS advanced life support ASPR Assistant Secretary for Preparedness and Response BARDA Biomedical Advanced Research and Development Authority BH behavioral health BLS basic life support CDC Centers for Disease Control and Prevention COP Common Operating Picture CSC crisis standards of care DHS Department of Homeland Security DMAT Disaster Medical Assistance Team DMORT Disaster Mortuary Operational Response Team DMRU Disaster Medical Response Unit DoD Department of Defense EAP employee assistance program ED emergency department EMAC Emergency Management Assistance Compact EMS emergency medical services EOC emergency operations center ESAR-VHP Emergency System for Advance Registration of Volunteer Health Professionals ESF Emergency Support Function FEMA Federal Emergency Management Agency FQHC federally qualified health center GFT Google Flu Trends xiii

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HAN Health Alert Network HCC health care coalition HCF health care facility HCO health care organization HHS Department of Health and Human Services HICS Hospital Incident Command System HIPAA Health Insurance Portability and Accountability Act HPP Hospital Preparedness Program HRSA Health Resources and Services Administration HVA Hazard Vulnerability Analysis IC incident command ICU intensive care unit ILI influenza-like illness IMSURT International Medical Surgical Response Team IOM Institute of Medicine JIC Joint Information Center LTC long-term care MAA mutual aid agreement MAC Medical Advisory Committee MAC multiagency coordination MCI mass casualty incident MOU Memorandum of Understanding MRC Medical Reserve Corps MSCC Medical Surge Capacity and Capability MSSS Michigan Syndromic Surveillance System MTF Military Treatment Facility NASEMSO National Association of State EMS Officials NCIPC National Center for Injury Prevention and Control NDMS National Disaster Medical System NEDOCS Naitonal Emergency Department Overcrowding Score NHTSA National Highway Traffic Safety Administration NIMS National Incident Management System NN no notice NVRT National Veterinary Response Team NWS National Weather Service xiv ACRONYMS

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PACU postanesthesia care unit PFA psychological first aid PH public health PHEP Public Health Emergency Preparedness POD point of dispensing PPE personal protective equipment RDMAC Regional Disaster Medical Advisory Committee RMCC Regional Medical Coordination Center SARS severe acute respiratory syndrome SDMAC State Disaster Medical Advisory Committee SEOC state emergency operations center SME subject matter expert SNS Strategic National Stockpile SO slow onset SOFA Sequential Organ Failure Assessment VA Department of Veterans Affairs VAMC U.S. Department of Veterans Affairs Medical Center ACRONYMS xv

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