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 7--Appendixes
Volume 7--Appendixes
Pages 464-506
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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response Appendixes
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Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response Volume 7: Appendixes 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 Institute acts under the responsibility given to the National Academy of Sciences 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.
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, O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, DC DAN HANFLING (Vice-Chair) , Inova Health System, Falls Church, VA DAMON T
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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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Georges Benjamin, American Public Health Association. 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 carefully considered.
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Contents VOLUME 1: INTRODUCTION AND CSC FRAMEWORK Summary 1-1 1 Introduction 1-15 2 Catastrophic Disaster Response: Creating a Framework for Medical Care Delivery 1-31 3 Legal Issues in Emergencies 1-55 4 Cross-Cutting Themes: Ethics, Palliative Care, and Mental Health 1-71 VOLUME 2: STATE AND LOCAL GOVERNMENT 5 State and Local Governments 2-1 VOLUME 3: EMS 6 Prehospital Care: Emergency Medical Services (EMS) 3-1 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 ix
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VOLUME 7: APPENDIXES A Glossary, 7-1 B Hospital Emergency Operations Plan Crisis Standard of Care Annex, 7-7 C Potentially Scarce Medical Resources by Category, 7-15 D Resource Challenges by Disaster Type, 7-17 E Statement of Task, 7-23 F Committee Biographies, 7-25 x CONTENTS
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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)
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Emergency response system A formal or informal organization covering a specified geographic area minimally composed of health care institutions, public health agencies, emergency management agencies, and emergency medical service providers to facilitate regional preparedness planning and response. EMS (emergency medical services)
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Health care professionals Individuals who are licensed to provide health care services under state law. Indicator Measurement or predictor that is used to recognize surge capacity and capability problems within the health care system, suggesting that crisis standards of care may become necessary and requiring further analysis or system actions to prevent overload.
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Regional Disaster Medical Advisory Committee (RDMAC) A designated group of subject-matter experts that can homogenize state and local crisis care clinical guidance when the affected region encompasses areas across state lines.
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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)
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of situation and attempt to obtain needed resources -- this may include needed supplies, staff, or assistance with patient movement or evacuation to re-balance the standard of care in the area: o RHC 24/7 phone o LPH 24/7 phone (or emergency management, depending on availability of LPH) 1 This template is designed to provide an example of structure of a sample hospital annex to their Emergency Operations Plan which may be used as a discussion document with institutional stakeholders.
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The IC, in consultation with appropriate technical specialists and the medical care branch director (critical care, nursing, respiratory care, other sources of specific information) , may recommend strategies such as (many of these elaborated in the surge capacity annex to the emergency operations plan)
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Strategies may include • Staffing: in addition to usual staff sharing, medical reserve corps, local American Red Cross, public health, public works, schools, or other agencies and state/federal staff may be used as needed. o Determine need for nonemployee assistance in the facility (provision of non-medical responsi bilities, supervision by hospital staff "mentor," etc.)
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medical duties Use of non-health-care Nurse educators workers to provide Stable ventilator Send patients to pulled to clinical basic patient cares patients managed on o -site care duties (bathing, assistance, stepdown beds feeding) Cancel most/all Disaster Allocate limited anti outpatient Minimal lab and x-ray documentation forms virals to select appointments and testing used patients procedures FIGURE B-1 Changes to usual care in relation to demand/severity of effect (from AHRQ -- providing mass medical care with scarce resources 2006)
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2. Planning chief gathers any guidelines, epidemiologic information, resource information, and regional hospital information and schedules meeting or conference call with IC, Medical Care Branch Director, and designees to clinical care committee.
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4. Clinical care committee should review available guidance and modify according to current knowl edge of the specific disease state to provide decision tool for triage team.
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c. Tertiary triage team -- Two critical care physicians or one critical care and one infectious disease consider ventilator and other resource allocation decisions acting on data supplied by units/ teams in concordance with decision tool.
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9. A regional triage team may be utilized according to plans of the RHC in which case the clinical care committee will work with the RHC and any regional medical advisory team (RMAT)
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May use oxygen saturation monitors with high/low rate alarms as surrogate monitoring for tachy/brady dysrhythmias. Health care providers Particularly emergency medicine, critical Hospital staff, coalition, regional/ state/federal teams.b,c,d,e Must care, burn, and surgical/anesthesia staff include credentialing/privilegingf (nurses and physicians)
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transport resources and coordinate during an incident NOTE: BiPAP = bilevel positive airway pressure ventilator; EMS = emergency medical services; MCI = mass casualty incident. a IOM (Institute of Medicine)
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D: Resource Challenges by Volume 7 Disaster Type 7-17
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• Medications including antivirals, antibiotics, analgesics, paralytics • Critical care capacity • Triage criteria and process for life-saving interventions • Outpatient care capacity • Outpatient care and inpatient care • Triage criteria for emergency care (vs. referral to "flu center" or spaces may be insufficient and similar location)
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k • Selective use of CT and other • Limit definitive imaging and procedures (e.g., for example, limit imaging -- plan and exercise CT to cranial for decreased level of consciousness, perform bailout surgical procedures with temporary closures) • Ultrasound may contribute to rapid assessments of casualtiesl,m,n Burn • Lack of burn beds and burn • Burn centers should stock supplies • Use knowledge of contributing injuries, inhalational injury, age, centers for large-scale burn incidents, and extent of burns when triaging burn patientsp including adequate analgesia • Educational background often • Provide palliative care to those who cannot be offered definitive interventions lacking for burn resuscitation and • All facilities should be prepared management to stabilize and initially treat burn • Provide temporizing measures such as escharotomy and airway patients management while deferring formal burn dressings initially in • Intravenous fluids, dressings, and analgesics limited favor of sterile sheets and towels • Community plan should concentrate critical burns at burn centers (may • Limited number of burn surgeons o and nurses involve redistributing other patient groups)
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Both of these situations may require community screening centers and potentially a mass screening and/or decontamination response on the part of the hospital, but this would mainly be to prevent low-level contamination and reassure patients. REMM (Radiation Emergency Medical Management)
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2011. Radiation emergency medical management (REMM)
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• Develop templates for states, emergency medical services (EMS) systems, hospitals, and individual clinicians to guide decision making when implementing crisis standards of care that can be easily read, understood and executed during an incident.
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, local, regional and national healthcare system clinical and administrative leadership in private health care systems; § he role of state EMS authorities in providing medical oversight and coordination of a shift T to crisis response for a state's EMS system, including 911 dispatch and prehospital emergency medical care. o Identify clinical and administrative indicators that govern the transition from conventional surge response and conventional standards of care to crisis surge response and crisis standards of care, and the return to conventional standards of care.
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law reform initiatives, including the drafting of the Model Emergency Health Powers Act to combat bioterrorism and the Turning Point Model State Public Health Act. He is also leading a drafting team on developing a Model Public Health Law for WHO.
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Stephen V Cantrill, M.D., FACEP, is an emergency physician from Denver who recently retired from serving as the associate director of Emergency Medicine at Denver Health Medical Center for 18 years.
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Gabriel, M.P.A., AEMT-P,1 is director, Global Crisis Management, for The Walt Disney Company, and is responsible for the development and implementation of global policy, planning, training, and exercises to manage crisis for The Walt Disney Company. He is also responsible for East and West Coast Medical and Emergency Medical Operations and the Walt Disney Studio's Fire Department.
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and an associate professor of Emergency Medicine at the University of Minnesota. He serves as the associate medical director for Hennepin County Emergency Medical Services and medical director for Emergency Preparedness at HCMC.
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public health law case studies in multiple states. He is a national expert on public health information privacy law and ethics, having consulted with HHS, CDC, FDA, CMS, OHRP, APHA, CSTE, APHL, and others on these privacy issues.
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He coordinated the NCCTS/TDB Rapid Response Support Team of National Child Traumatic Stress Network for disasters, terrorism, and mass casualty events impacting children and families. He also served as cochair of the Pediatric Emergency Mental Health Taskforce as the American Psychological Association to the HHS/Emergency Medical Services for Children Program.
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; Health Resources and Services Administration (HRSA) rural trauma grant reviewer; and contributor to the development of the HRSA model trauma system plan, the National Association of State Emergency Medical Services Officials trauma system planning guide, National Trauma Data Standards, and the NHTSA curriculum for an EMT refresher course.
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