Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response: Volume 1: Introduction and CSC Framework (2012) / Chapter Skim
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Volume 3--EMS
Volume 3--EMS
Pages 156-212
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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response EMS
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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response Volume 3: EMS Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations Board on Health Sciences Policy Dan Hanfling, Bruce M Altevogt, Kristin Viswanathan, and Lawrence O
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Library of Congress Cataloging-in-Publication Data Crisis standards of care : a systems framework for catastrophic disaster response / Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations, Board on Health Sciences Policy ; Dan Hanfling ...
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"Knowing is not enough; we must apply. Willing is not enough; we must do." -- Goethe Advising the Nation.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars 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 technical matters.
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SHAH, Harris County Public Health and Environmental Services, Houston, TX JOLENE R WHITNEY, Bureau of Emergency Medical Services (EMS)
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The review comments 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: Richard Alcorta, Maryland Institute for Emergency Medical Services Systems Knox Andress, Louisiana Poison Center Connie Boatright-Royster, MESH Coalition Susan Cooper, Tennessee Department of Health Lance Gable, Wayne State University Center for Law and the Public's Health Carol Jacobson, Ohio Hospital Association Amy Kaji, Harbor-UCLA Medical Center Jon Krohmer, Department of Homeland Security Onora Lien, King County Healthcare Coalition Suzet McKinney, The Tauri Group Peter Pons, Denver Health Medical Center Clifford Rees, University of New Mexico School of Law Linda Scott, Michigan Department of Community Health Robert Ursano, Uniformed Services University School of Medicine Lann Wilder, San Francisco General Hospital and Trauma Center Matthew Wynia, American Medical Association 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 before vii
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its release. The review of this report was overseen by Dr.
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Core Functions of EMS Systems and EMS Personnel in the Implementation of CSC Plans, 3-29 References, 3-41 Additional Resources, 3-43 ix
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VOLUME 4: HOSPITAL 7 Hospitals and Acute Care Facilities 4-1 VOLUME 5: ALTERNATE CARE SYSTEMS 8 Out-of-Hospital and Alternate Care Systems 5-1 VOLUME 6: PUBLIC ENGAGEMENT 9 Public Engagement 6-1 VOLUME 7: APPENDIXES 7-1 Appendixes x CONTENTS
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Acronyms ACS American College of Surgeons ALS advanced life support ASPR Assistant Secretary for Preparedness and Response BLS basic life support CDC Centers for Disease Control and Prevention CONOPS concept of operations CSC crisis standards of care DHS Department of Homeland Security DMAT disaster medical assistance team EIRRA EMS Incident Response and Readiness Assessment EMA emergency management agency EMAC Emergency Management Assistance Compact EMD emergency medical dispatch EMR emergency medical responder EMS emergency medical services EMT emergency medical technician EOC emergency operations center ESAR-VHP Emergency System for Advance Registration of Volunteer Health Professionals ESF Emergency Support Function FEMA Federal Emergency Management Agency HHS Department of Health and Human Services HRSA Health Resources and Services Administration xi
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ICS incident command system JIC joint information center JIS joint information system MIEMSS Maryland Institute for Emergency Medical Services Systems MMRS Metropolitan Medical Response System MRC Medical Reserve Corps NASEMSO National Association of State EMS Officials NDMS National Disaster Medical System NHTSA National Highway Traffic Safety Administration NIMS National Incident Management System PIO public information officer PSAP public safety answering point SALT sort, assess, life-saving interventions, treatment/transport SDMAC state disaster medical advisory committee START simple triage and rapid treatment VA Department of Veterans Affairs VF ventricular fibrillation xii ACRONYMS
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This chapter outlines the roles and responsibilities of state EMS in CSC planning and implementation in the overall context of a CSC response system, as well as operational considerations entailed in carrying out those roles and responsibilities. Two templates provide core functions for EMS systems in CSC planning and for EMS systems and EMS personnel in the implementation of CSC plans.
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In the case of a mass casualty incident, in which emergency health care personnel, medical and transport equipment, and hospital beds are scarce, local EMS personnel will be forced to modify their care from conventional to crisis care (see Chapter 2, Box 2-4 and Figure 2-2)
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Extraordinary circumstances may require EMS personnel to assist in the evacuation of patients at a health care facility to alternate care sites. This, in turn, may require them to provide care to patients for longer than is usual for EMS providers, who normally provide care for patients at the scene and during transport and transfer (AHRQ, 2009b)
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The state EMS office, together with regional and state advisory committees/councils and in collaboration with state health and emergency management departments, should ensure that CSC plans and protocols are consistent across jurisdictions and among emergency health care system stakeholders. The state EMS office can utilize existing committee structures for planning and the expertise of consultants serving on these committees for activating disaster plans, policies, and CSC strategies.
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The state EMS office, whether it is formally part of the state health department or a separate agency, may augment state health departments in their role as the Emergency Support Function (ESF) -8 lead (although the state health department does not have this role in all states)
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This alignment may be beneficial in providing a coordinated and integrated response for public health and medical needs during a disaster. In collaboration with the state health department and other state agencies, the state EMS office is in a unique position to take a leadership role in the development of both contingency and crisis standards of care plans and to coordinate the response to a disaster within established regional systems of care.
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• Rehabilitation services • Exercises • Highway mass casualty playbook (plans and procedures) • Governance PREHOSPITAL CARE 3-7
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Also essential is to ensure connectivity and uniformity within regional advisory committees/councils/coalitions for CSC planning efforts. The state EMS office and state medical director should ensure the application of consistent disaster triage guidelines during a crisis, similar to the application of EMS field triage guidelines in use for trauma patients (National Expert Panel on Field Triage, 2012)
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As every disaster begins at the local level, situational awareness among local EMS providers and regional EMS councils will make it possible to quickly determine when additional resources are needed or recognize when resources are scarce. For example, dispatch centers and EMS agencies may see that call volumes have doubled, recognize that resources are insufficient to meet the increased demand, and subsequently recognize that the activation of contingency plans is in order.
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The state EMS office, in cooperation with the state health department, should ensure that EMS agencies have an opportunity to review and discuss the CSC plan at the state, regional, and local levels. EMS agencies should be engaged in the planning process from the beginning, and this can easily be accomplished through regional advisory councils or committees.
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The last of these suggestions is relevant for all stakeholders in CSC planning and implementation. It is important not only to review after-action reports from disaster exercises and responses but also to review patient care data collected during a CSC incident.
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Core Functions of EMS Systems in the Development of State CSC Plans This template outlines the optimal core functions and specific tasks under each function for EMS systems -- including state EMS offices, regional infrastructure, and local prehospital care providers -- in the development of state CSC plans. These functions and tasks are described below.
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The state EMS office and state EMS medical director can assist the state health department and SDMAC in the development of consistent CSC pertinent to EMS personnel and providers. Conducting an inventory/assessment of existing plans and available resources within the state before initiating CSC planning will assist in identifying gaps.
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It is essential for dispatch centers/call centers, EMS providers, and the state EMS office to recognize when to activate and authorize implementation of the CSC plan, including resources such as poison control centers, 211 centers, and nurse referral centers, based on the triggers identified in the plan. Function 2.
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during a disaster. The state EMS office, along with regional and local EMS agencies, should utilize the ICS within affected jurisdictions.
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To facilitate better communications among organizations, the state EMS office, regional and local EMS agencies, and medical directors need to understand the roles and functions of the SDMAC, state EMS medical director, state health officer/commissioner, regional medical coordination centers, regional call centers, regional EMS or trauma advisory committees, and local agencies and resources, and how information is received from or communicated to these bodies. Function 6.
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With conventional care, it is important for the state EMS office, regional infrastructure, and local EMS providers to understand their roles and authority in providing routine care through medically approved triage, treatment, and transport protocols and the use of normal modes of transportation, staff ing, and equipment, including mutual-aid resources. W hen contingency care is necessary, local EMS providers deploy and engage mutual-aid agreements/ operations and response plans to substitute, conserve, and adapt staffing, transportation, patient triage, and destinations while still providing medical care that is functionally equivalent to conventional care.
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The state EMS office, with medical direction, should define the role of EMS personnel in providing symptomatic management for patients needing palliative care and should provide the necessary training and resources for EMS personnel (San Francisco Emergency Medical Services Agency, 2011)
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Finally, the state EMS office and local EMS providers, through state and regional advisory commit tees/councils and medical directors, should identify special populations -- patient groups requiring special consideration with respect to transportation, treatment, equipment, and supplies. EMS personnel must be trained in managing children, the elderly, burn patients, special-needs patients, and non-English speaking patients.
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During a crisis, policy makers may require additional communications and coordination with the incident commander, and the structure of the ICS will most likely be a unified command. EMS Personnel Functions It is important for not only state EMS offices, regional infrastructure, local EMS agencies, and dispatch centers but also individual personnel to be prepared to respond to a CSC incident.
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It is important that EMS personnel understand how to execute their individual roles -- including to whom and where they should report, how to request resources, and how to use backup communications systems -- prior to the imple mentation of CSC. Routine training and exercising of each role in the command structure can improve knowledge of the triage protocols, alternate resources, and staffing provided for by the CSC plan.
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EMS personnel will be better able to respond to a disaster if they are sure of their legal responsibilities and protection with regard to implementing CSC. A component of this awareness is an understanding of how and by whom a disaster is declared, and of their obligations and liabilities in providing care in traditional (in ambulances)
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Assess Jurisdictional Authority and Planning Resources State and Regional/Local Tasks Notes and Resources State Task 1 State EMS office participates with the state lead agencies responsible Guidance for for CSC planning and implementation (state health department/ Establishing Standards emergency management agency [EMA]
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State and Regional/Local Task 3 State EMS, regional infrastructure, and local EMS agencies identify and State, regional, and review existing state, regional, and local surge capacity, mass casualty, local surge capacity and CSC plans. Includes plans • dentifying gaps in the state/regional/local plans; i State, regional, and • eviewing after-action reports from previous functional exercises r local mass casualty addressing surge capacity and CSC needs; plans • earching resources from other states and national organizations s (see the "Notes and Resources" column)
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; • stablishing a CSC component activation and notification e process; • dentifying how stakeholders will collaborate with state and i federal partners; • dentifying communications and monitoring systems that i support resource distribution and allocation; • dentifying strategies and processes for situational awareness; i and • nsuring that private-sector entities are included in planning e efforts and identifying their roles. State and Regional/Local Task 3 State EMS office, regional infrastructure, and local EMS agencies ensure connectivity and uniformity with regional advisory committees/councils and other regional resources.
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; • raining EMS personnel in mass casualty variant of psychological t first aid that includes rapid mental health triage; and • roviding a comprehensive EMS responder resilience system for p mental health support for all EMS personnel that includes pre event stress inoculation, personal resilience planning, and triage/ self monitoring of responder stress. State and Regional/Local Task 7 State EMS office, regional infrastructure, and local EMS agencies ensure that CSC planning at all levels • stablishes clear lines of authority and roles and responsibilities e of stakeholders (e.g., state health department, local health departments, state EMA, local EMAs, EMS, health care, federal partners)
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Function 3. Stakeholder and Public Engagement Notes and Resources State and Regional/Local Tasks State and Regional/Local Task 1 State EMS office may assist the state health department and the See Chapter 9 for a SDMAC in engagement with local EMS stakeholders on CSC planning.
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State EMS office and regional infrastructure conduct an awareness campaign throughout the state to inform stakeholders about the state CSC plan and processes. State and Regional/Local Task 5 State EMS office, regional infrastructure, and local EMS agencies ensure that state, regional, and local EMS components of the overall CSC plan are operational, up-to-date, and ready for activation.
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Regional/Local EMS and Dispatch Center Task 5 Regional/local EMS and dispatch centers understand when to initiate jurisdictional CSC plans based on local and regional emergency response plan triggers and the state CSC plan Function 2. Alerts and Notifications Notes and Resources State and Regional/Local Task 1 State EMS office utilizes the statewide integrated communications All EMS system system to provide and receive timely alerts during a CSC incident.
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State Task 2 All stakeholders understand the ESF-8 role in CSC incident and how the State EMS office works chains of command of the state emergency operations center (EOC) closely with the state and agency internal operations center coordinate the development, EMA to regularly communication, and implementation of new CSC strategies in response exercise operations of to incident-specific demands.
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n systems. State and Regional/Local Task 4 State EMS office, regional and local EMS agencies, and medical Implementation of CSC directors understand the roles and functions of the SDMAC, state EMS is exercised regularly to medical director, state health officer/commissioner, regional medical ensure understanding coordination center, regional call centers, and regional EMS or trauma of roles.
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Function 7. Public Information Notes and Resources State and Regional/Local Task 1 Through the ICS, state EMS office and local EMS agencies ensure Organizational public appropriate risk communication and consistent messaging to the public information officers via the media, as well as organization-/agency-specific means (website, (PIOs)
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Medical Care Branch State Task 1 State EMS office understands when to shift from contingency to crisis care on assessment of a response in progress or recommendation of the SDMAC and knows how to identify specific needs of response organizations and the resources at risk. State Task 2 State EMS office understands the process for requesting resources and coordinating these resources with federal partners and regional and local response organizations.
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4 for additional information. State Task 2 With palliative care experts, state EMS office provides just-in-time training that may be appropriate for EMS personnel, especially in a sustained CSC incident.
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State and Regional/Local Task 5 State EMS office, regional infrastructure, and local EMS providers ensure that staff receive personal preparedness training to assist with family needs and are prepared for on-site accommodation of staff and family members, as appropriate. Transportation and Equipment Resources State and Regional/Local Task 1 State EMS office, regional infrastructure, and local EMS agencies conduct an assessment of the types and location of EMS transportation and equipment resources available within the state and know how to request resources from other jurisdictions (through EMAC, the federal ambulance contract, medication caches, equipment trailers)
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Special Populations State and Regional/Local Task 1 State EMS office, regional infrastructure, local EMS providers, Refer to the Pediatric and medical directors identify patient groups requiring special Emergency Mass consideration with respect to transportation, treatment, equipment, and Critical Care Task Force supplies. supplement (Task Force for Pediatric State and Regional/Local Task 2 Emergency Mass Local EMS personnel are trained and exercised in managing special Critical Care, 2011)
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appropriate annexes. State and Regional/Local Task 2 In collaboration with existing regional structures, state and local EMS agencies develop an educational program and materials to orient external staffing resources on local, regional, and state triage and treatment policies and applicable elements of the state CSC plan.
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Operations Task 1 EMS personnel understand how to utilize the resource management system and assess the need to expand from conventional to crisis care and activate the CSC plan. Task 2 EMS personnel understand when and how to apply disaster triage protocols, the EMS pandemic influenza plan, and mass casualty plans, if available.
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Mental Health Notes and Resources Task 1 EMS personnel understand how to access local mental health and The mental health employee support resources, including any incident-specific mental section of Chapter 4 health information or resources. provides a more PREHOSPITAL CARE 3-39
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Legal Issues Notes and Resources Task 1 EMS personnel understand their legal obligations and liabilities in Chapter 3 describes providing crisis care in the ambulance and in alternate patient care legal issues in depth. settings when • disaster or public health emergency is declared; a • disaster or public health emergency has not been declared; a and • hey have other disaster relief functions (for example, serving as t an MRC or DMAT member)
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2011. Crisis standards of care for EMS: State level implementation.
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2007b. State emergency medical services systems: A model.
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Washington, DC: The National Academies Press. IOM and Committee on Pediatric Emergency Medical Services.
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2010. State emergency medical services system models project: Model statutory and regulatory content for state EMS systems.
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