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Suggested Citation:"B Glossary." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Suggested Citation:"B Glossary." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Page 112
Suggested Citation:"B Glossary." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Page 113
Suggested Citation:"B Glossary." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Page 114
Suggested Citation:"B Glossary." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Page 115
Suggested Citation:"B Glossary." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Page 116
Suggested Citation:"B Glossary." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Page 117
Suggested Citation:"B Glossary." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Page 118

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B Glossary Alternate care facility A temporary site that is not located on hospital property, established to provide patient care. It may provide either ambu- latory or non-ambulatory care. It may serve to “decompress” hospitals that are maximally filled, or to bolster commu- nity-based triage capabilities. Has also been referred to as an “alternate care site.” Clinical care committee Composed of clinical and administrative leaders at a healthcare institution, this committee is responsible for making prioritization decisions about the alloca- tion of critical life-sustaining interven- tions. The clinical care committee may also be formed at the healthcare coali- tion level (e.g., hospital, primary care, emergency medical services agency, public health, emergency management. and others), playing the role of the dis- aster medical advisory committee at the regional level (see disaster medical ad- visory committee). May appoint a triage team (see triage team) to evaluate case- by-case decisions. 111

112 CRISIS STANDARDS OF CARE GUIDANCE Contingency surge The spaces, staff, and supplies used are not consistent with daily practices, but provide care that is functionally equiva- lent to usual patient care practices. These spaces or practices may be used temporarily during a major mass casu- alty incident or on a more sustained ba- sis during a disaster (when the demands of the incident exceed community re- sources) (Hick et al., 2009). 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 (Hick et al., 2009). 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, stewardship, equity, and trust; (3) modify regulatory require- ments to provide liability protection for healthcare providers making resource al- location decisions; and/or (4) designate a crisis triage officer and include provi- sions for palliative care in triage models for scarce resource allocation (e.g., ven- tilators) (Chang et al., 2008). Crisis standards of care will usually follow a formal declaration or recognition by state government during a pervasive (pandemic influenza) or catastrophic (earthquake, hurricane) disaster which

LETTER REPORT 113 recognizes that contingency surge re- sponse strategies (resource-sparing strategies) have been exhausted, and cri- sis medical care must be provided for a sustained period of time. Formal recog- nition of these austere operating condi- tions enables specific legal/regulatory powers and protections for healthcare provider allocation of scarce medical re- sources and for alternate care facility operations. Under these conditions, the goal is still to supply the best care pos- sible 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 (Hick et al., 2009). Disaster medical advisory At the state or regional level, evaluates committee vidence-based, peer-reviewed critical e care and other decision tools and rec- ommends 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.

114 CRISIS STANDARDS OF CARE GUIDANCE Emergency response system A formal or informal organization cov- ering a specified geographic area mini- mally composed of healthcare institutions, public health agencies, emergency management agencies, and emergency medical service providers to facilitate regional preparedness planning and response. EMS (emergency medical A system of healthcare professionals, services/system) facilities, and equipment providing out- of-hospital emergency care. Healthcare coalition A group of individual healthcare assets (e.g., hospitals, clinics, long-term care facilities, 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 appropriate structures, proc- esses, and procedures. During response, the goals of the coalition are to facilitate situational awareness, resource support, and coordination of incident manage- ment among the participating organiza- tions (ICDRM, 2009). Healthcare institution Any facility providing patient care. This includes acute care hospitals, commu- nity health centers, long-term care insti- tutions, private practices, and skilled nursing facilities. Healthcare practitioners Includes “healthcare professionals” and other non-licensed individuals who are involved in the delivery of healthcare services.

LETTER REPORT 115 Healthcare professionals Individuals who are licensed to provide healthcare services under state law. Indicator Measurement or predictor that is used to recognize surge capacity and capability problems within the healthcare system, suggesting that crisis standards of care may become necessary and requiring further analysis or system actions to prevent overload. Legal standard of care The minimum amount of care and skill that a healthcare practitioner must exer- cise in particular circumstances based on what a reasonable and prudent health- care practitioner would do in similar cir- cumstances; during non-emergencies and disasters, they are based on the spe- cific situation. Medical standard of care The type and level of medical care re- quired by professional norms, profes- sional requirements, and institutional objectives; these standards vary as cir- cumstances change, including during emergencies or crisis events. Memorandums of A voluntary agreement among agencies Understanding (MOUs) cies and/or jurisdictions for the purpose of providing mutual aid at the time of a disaster. Mutual aid agreements Written instrument between agencies (MAAs) and/or jurisdictions in which they agree to assist one another on request by fur- nishing personnel and equipment. An “agreement” is generally more legally binding than an “understanding” (Barbera and Macintyre, 2007).

116 CRISIS STANDARDS OF CARE GUIDANCE Palliative care Medical care provided by an interdisci- plinary team to prevent and relieve suf- fering 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 fu- ture, 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 spe- cific problem or condition. Public health system A complex network of individuals, or- ganizations, and relevant critical infra- structures that have the potential to act individually and together to create con- ditions of health, including communi- ties, healthcare delivery systems (e.g., home care, ambulatory care, private practice, hospitals, skilled nursing facili- ties, and others), employers and busi- ness, the media, homeland security and public safety, academia, and the gov- ernmental public health infrastructure (IOM, 2008). Resource sparing The process of maximizing the utility of supplies and material through conserva- tion, substitution, reuse, adaptation, and reallocation. Scope of practice The extent of a professional’s ability to provide health services pursuant to their competence and license, certification,

LETTER REPORT 117 privileges, or other lawful authority to practice. SOFA score The Sequential Organ Failure Assess- ment (SOFA) score is a scoring system to determine the extent of a person’s or- gan function or rate of failure. The score is based on six different body systems: respiratory, cardiovascular, hepatic, he- matopoietic, renal, and neurologic. Triage The process of sorting patients and allo- cating aid on the basis of need for or likely benefit from medical treatment. Several types of triage are referenced in this letter: • Primary triage: The first triage of patients into the medical system (it may occur out of hospital), at which point patients are assigned an acuity level based on the sever- ity of their illness/disease. • Secondary triage: Reevaluation of the patient’s condition after initial medical care. This may occur at the hospital following EMS inter- ventions or after initial interven- tions in the emergency department. This often involves the decision to admit the patient to the hospital. • Tertiary triage: Further reevalu- ation of the patients’ response to treatment after further interven- tions; this is ongoing during their hospital stay. This is the least practiced and least well-defined type of triage.

118 CRISIS STANDARDS OF CARE GUIDANCE Triage team Appointed by the clinical care commit- tee, uses decision tools appropriate to the event and resource being triaged, making tertiary triage using scarce re- source allocation decisions. This is simi- lar in concept to triage teams established to evaluate incoming patients to the emergency department requiring pri- mary 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 standard of care practices will be required. This may occur at an institutional, and often regional, level of response. It suggests the need for the immediate implementation of response pathways that are required to manage a crisis surge response emanating from the disaster situation.

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Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report Get This Book
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The influenza pandemic caused by the 2009 H1N1 virus underscores the immediate and critical need to prepare for a public health emergency in which thousands, tens of thousands, or even hundreds of thousands of people suddenly seek and require medical care in communities across the United States.

Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations draws from a broad spectrum of expertise--including state and local public health, emergency medicine and response, primary care, nursing, palliative care, ethics, the law, behavioral health, and risk communication--to offer guidance toward establishing standards of care that should apply to disaster situations, both naturally occurring and man-made, under conditions in which resources are scarce.

This book explores two case studies that illustrate the application of the guidance and principles laid out in the report. One scenario focuses on a gradual-onset pandemic flu. The other scenario focuses on an earthquake and the particular issues that would arise during a no-notice event.

Outlining current concepts and offering guidance, this book will prove an asset to state and local public health officials, health care facilities, and professionals in the development of systematic and comprehensive policies and protocols for standards of care in disasters when resources are scarce. In addition, the extensive operations section of the book provides guidance to clinicians, health care institutions, and state and local public health officials for how crisis standards of care should be implemented in a disaster situation.

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