This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide hospital and acute care decision making during a disaster. Because integrated planning across the emergency response system is critical for a coordinated response, it is important to first read the introduction to the toolkit and materials relevant to the entire emergency response system in Chapter 3. It would be helpful to also review the toolkit chapters focused on other stakeholders.
Roles and Responsibilities
Hospitals should ensure they are able to fulfill their mission to provide emergency care and inpatient/outpatient care to all members of the community, including specialty populations they may not normally serve (e.g., burn, trauma, pediatric) through development of response plans to include:
• Incident management systems such as the Hospital Incident Command System (HICS) that are compatible with the National Incident Management System (NIMS);
• Response communication and coordination capabilities with key stakeholders, including other health care organizations in the area, established health care coalitions, emergency management, emergency medical services (EMS), and public health;
• Appropriate space, staff, and supply planning to ensure the ability to meet the needs of a disaster relative to their Hazard Vulnerability Analysis (HVA) and role in the community; and
• Specific planning for scarce resource situations, including the role of incident management, how subject matter experts and/or a clinical care committee1 are used, triage processes, and the integration with scarce resource management processes at the coalition and jurisdictional levels.
1 “Composed of clinical and administrative leaders at a health care institution, this committee is responsible for prioritizing the allocation of critical life-sustaining interventions. 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. . . . May appoint a triage team . . . to evaluate case-by-case decisions” (IOM, 2012, p. 7-1). See IOM (2012) for additional information about the roles and composition of the clinical care committee and other entities involved in planning and implementing crisis standards of care.
Additional discussion about the roles and responsibilities of hospital and acute care facilities in planning for and implementing crisis standards of care (CSC) is available in the Institute of Medicine’s (IOM’s) 2012 report Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. This report also includes planning and implementation templates that outline core functions and tasks.
Key Issues for Hospitals
This brief overview is supported by a more robust discussion of indicators and triggers in the overview chapters as well as by discussion of crisis care planning, strategies, and tactics in the IOM 2012 report and other publications (see Chapter 1).
Hospitals should ensure that they have accounted for the following in their planning for disaster response, and for scarce resource situations in particular:
1. Situational awareness, including information availability and analysis
2. Disaster plan trigger(s)
3. Crisis care trigger(s)
Situational awareness, including information availability and analysis, requires that the hospital can receive, verify when possible, and communicate the information available. This includes understanding sources, formats, availability, and processes for information access, assessment, and action within the facility (e.g., who receives health alerts and what they do with them). The hospital should determine whether it has daily management goals (prediction of discharge date, bed management) where information that may be critical to successful disaster response can be captured to improve efficiency and preparedness concurrently. It may be helpful to brainstorm a list of information and data that would be helpful in making decisions and determine how easy it is to obtain those data, how accurate and useful they will be, and whether or not they are actionable: that is, can the facility take actions to change the variable or not?—an example is bed availability—and what are the likely actions to be taken? Considering information in the facility and regional HVA may be helpful. This will naturally lead to discussions about thresholds and decision making, and potentially to defining facility triggers.
Disaster plan triggers cause activation of the facility emergency operations plan, marking the transition to contingency care. The roles authorized to activate the plan should be able to analyze situational information in order to make this decision. There is often uncertainty, and full plan activation involves significant time and financial impact for the facility. The larger the event, the less uncertainty there may be. Suggested triggers (number of victims by time of day, types of victims) should be available to the decision makers, who should also have the experience to consider the current facility status, the likely impact, and other factors when deciding whether or not to activate. Emergency actions at the unit level can be based on more certain triggers (in case of fire on a unit, perform the following actions), but at the institutional level, many triggers require at least a degree of interpretation of the situation (e.g., complete vs. partial hospital evacuation, destination of evacuated psychiatric inpatients) that is not amenable to binary criteria.
Crisis care triggers should shift the incident management perspective to consideration of the overall, rather than individual patient demand and should prompt
• Use of adaptive strategies to reduce impact—extension of substitute, conserve, adapt, and reuse strategies, and introduction of reallocation if required;
• Creation of a clinical care committee (or at minimum, involvement of subject matter experts) to provide recommendations;
• Analysis of impact (using specific indicators for the resources in shortage) and development of recommended strategies and tactics to cope with the deficit;
• Proactive strategies to acquire additional resources from coalition or emergency management partners, or manage those available in a congruent fashion;
• Communication to staff, patients, and families about the situation and what is being done in concert with hospital and community (Joint Information System) incident management; and
• Determination if legal or regulatory actions are required to support crisis care strategies (e.g., from emergency management, public health).
Crisis situations may begin with a discrete indicator of excess demand (e.g., inadequate numbers of ventilators, medications, or staff), which triggers activation of the crisis care process, but does not necessarily result in allocation or triage decisions, which are the last resort in crisis care (e.g., anesthesia machines may be used, substitute medications found, or staffing patterns changed to avoid triage). Optimally, this planning process begins before the trigger threshold is reached, as the shortage was anticipated based on monitoring of indicators (e.g., examining pandemic epidemiology vs. supplies). Sometimes, crisis situations may develop without notice, and staff in these situations should have guidelines to follow both from an operations (adaptive strategies for space, staff, etc.) and an ethical (triage decisions) perspective. Facilities should determine what specifically occurs and who becomes involved when the incident commander activates the crisis care annex to the emergency operations plan. This should involve discrete triggers as well as the option to consider other factors and initiate the crisis care plan proactively based on indicators of demand. Factors other than shortage of clinical care resources may contribute to a crisis situation, including the demands of providing information and support for families seeking loved ones, family members of patients, and mass fatality situations.
Of critical importance is emphasizing the interdependency of the health care response system among hospitals, EMS, other health care facilities (including the outpatient sector), and effective interventions and risk communication coordinated by public health and emergency management. Planning with these entities to ensure an integrated response with joint objective and strategy setting is critical. Discussions based on the discipline-specific templates may be helpful to frame common issues and key interfaces/areas of need.
Suggested participants for a discussion focused on hospital and acute care are listed below. Building on the scenarios and overarching key questions presented in Chapter 3, this tool contains additional questions to help participants drill down on the key issues and details for hospital and acute care. It also contains a table that provides example hospital and acute care indicators, triggers, and tactics, and a blank chart for participants to complete. The scenarios, questions, and example chart are intended to provoke discussion that will
help participants fill in the blank chart for their own situation.2 Participants may choose to complete a single, general blank chart, or one each for various scenarios from their HVA.
Suggested participants for a discussion focused on hospitals and acute care facilities are listed below.
• Hospital administration;
• Hospital emergency management;
• Chief medical officer;
• Legal counsel;
• Subject matter experts (e.g., infection control for the pandemic scenario or trauma program manager for the earthquake scenario); and
• Health care coalition members.
Following these initial discussions, sharing and coordination of this information with a much broader range of stakeholders (e.g., blood bank, EMS, trauma networks, community Department of Defense medical liaisons, federally qualified health centers, nursing homes, public health, primary care providers and emergency management, elected officials, and others listed in part one of the toolkit) is critical to an integrated response.
Key Questions: Slow-Onset Scenario
1. What potential indicator data are available at the community or state level and who coordinates or has access to these (systems data, epidemiologic data, alerts)?
4. Who monitors and interprets these data; how are they communicated or used in decision making?
5. What additional information could be accessed during an incident or event that would be helpful to guide facility/agency actions?
6. Do any defined actions or notifications occur once an indicator is noted or a threshold exceeded?
7. Is the facility an active participant in their regional health care coalition and if so, what resources are available, what is the trigger for requesting them, and how are they requested (medical coordination center)?
8. What are the crisis care triggers for the institution that would signify a need to implement CSC? Are these similar to other hospitals within the health care coalition?
3 These questions are provided to help start discussion; additional important questions may arise during the course of discussion. The questions are aimed at raising issues related to indicators and triggers, and are not comprehensive of all important questions related to disaster preparedness and response.
9. At what threshold (indicator or trigger) does interfacility communication and/or coordination begin (including EMS, emergency management, public health, and coalition/community health care organizations)?
10. How do the facility and coalition share information (including impact, resource availability, case and clinical information) with state and local public health agencies to optimize situational awareness and resource management?
11. What triggers exist at the state level to provide declarations of emergency (and/or regulatory and liability protections) from public health or emergency management? If there are not predesignated triggers, how are requests handled on these actions?
12. How does the institution internally and externally (with local public health) recognize the need for and support alternate care sites?
Key Questions: No-Notice Scenario
The questions below are focused on the no-notice earthquake scenario presented in Chapter 3:
1. What alerts, system information, or situation information does the facility receive from outside agencies and how is it (or are they) processed?
2. What internal information is available from which indicator and trigger thresholds may be derived (e.g., information technology system status, staffing, bed capacity, ventilator availability, operating room use, supplies)?
3. What additional information would be needed during an event to inform decisions on level of care that can be provided?
4. What are thresholds that can reasonably be set for review or action based on specific external or internal measures (i.e., how is the information converted to staff actions, such as activating the disaster plan or calling back select staff)?
5. How does the facility determine staff absences, illness rates, availability to report, and other data that may be critical for response?
6. What information is available or potentially available to serve as a facility “dashboard” to monitor system status? How does this system reflect disaster status? (e.g., use of additional beds, use of procedure area beds for patient care)?
7. When a no-notice event moves immediately to a crisis trigger threshold, what specific actions are defined for staff to implement—not only incident management systems but also triage processes and policies?
8. How is support provided to providers and their families to allow them to reduce stress and focus on their job duties?
9. How would decisions be made about facility evacuation or shelter-in-place (e.g., decision tools, policy, damage assessment tools)? How are these decisions communicated to the licensing or regulatory agencies?
10. What resources exist within the regional coalition/regional trauma network for impacted hospitals (e.g., diversion, specific staff, or supply resources)?
11. Are any specific indicators and triggers needed for specialty care (e.g., burn, trauma, pediatrics) or other at-risk individuals?
Decision-Support Tool: Example Table
The indicators, triggers, and tactics shown in Table 8-1 are examples to help promote discussion and provide a sense of the level of detail and concreteness that is needed to develop useful indicators and triggers for a specific organization/agency/jurisdiction; they are not intended to be exhaustive or universally applicable. Prompted by discussion of the key questions above, discussion participants should fill out a blank table, focusing on key system indicators and triggers that will drive actions in their own organizations, agencies, and jurisdictions. As a reminder, indicators are measures or predictors of changes in demand and/or resource availability; triggers are decision points (refer back to the toolkit introduction [Chapter 3] for key definitions and concepts).
The example triggers shown in the table mainly are ones in which a “bright line” distinguishes functionally different levels of care (conventional, contingency, crisis). Because of the nature of this type of trigger, they can be described more concretely and can be included in a bulleted list. It is important to recognize, however, that expert analysis of one or more indicators may also trigger implementation of key response plans, actions, and tactics. This may be particularly true in a slow-onset scenario. In all cases, but particularly in the absence of bright lines, decisions may need to be made to anticipate upcoming problems and the implementation of tactics and to lean forward by implementing certain tactics before reaching the bright line or when no such line exists. These decision points vary according to the situation and are based on analysis of multiple inputs, recommendations, and, in certain circumstances, previous experience. Discussions about these tables should cover how such decisions would be made, even if the specifics cannot be included in a bulleted list in advance. Note that these sample indicators, triggers, and tactics are geared toward a smaller community hospital and are not comprehensive in scope, but meant to support discussion at the facility level.
Example Hospital Indicators, Triggers, and Tactics for Transitions Along the Continuum of Care
|Indicator Category||Contingency||Crisis||Return Toward Conventional|
|Community and communications infrastructure||
• Impact on community, including transportation and communications infrastructure
• Loss of paging and/or cellular service in area
• Loss of phone service to hospital
• Loss of electrical service to hospital
• Closure of transit system
• Use alternate communications strategies such as mass media and text messages, 700 or 800 MHz radio, satellite phones, HAM radios
• Provide employee alternate transportation options and on-site temporary housing
• Provide information to staff, visitors, and family members about impacts and response actions/options
• Community-wide and likely prolonged impact on infrastructure affecting employee homes, transportation, and communication
• Loss of electrical power or generator failure
• Hospital evacuation/diversion if possible
• Consider whether shelter-in-place is an option
• Provide bag-valve ventilation for ventilator-dependent patients or place on battery-operated transport ventilators
• Anticipate need to switch to gravity drip IV medications with monitoring of drip rates as pump batteries fail
• Restoration of services and transportation access
• Restored electrical service
• Scale back tactics or revert to conventional operations
• Pandemic or epidemic (e.g., SARS) virus detected
• Health alert or other notification received
• Natural disaster occurs or mass casualty incident (MCI) declaration in community
• Epidemiologic forecasts (Centers for Disease Control and Prevention [CDC], etc.)
• Local surveillance/epidemiology data
• Standard metrics such as NEDOCS (National Emergency Department Overcrowding Score)
• Regional/community emergency department (ED) volume, ED wait times/boarding times
• Regional/community hospital capacity or subset data, such as available intensive care unit (ICU) beds
• Epidemiologic projections will exceed resources available
• Epidemiology projections exceed surge capacity of facility for space or specific capability (e.g., critical care)—see below space and supply considerations, as triggers should be based on depletion of available resources
• Surveillance streams show decline in activity
• Improvement in regional/community ED volumes/wait times/boarding times
• Not specified for predictive data, will adjust based on specific actionable data
• Stand down incident management (scaled)
• Lengthen duration of planning cycles
• Reduce/deactivate regional information exchange
• Facility practices revert toward conventional
• Revert to normal system monitoring (defer this until incident clearly concludes)
|Indicator Category||Contingency||Crisis||Return Toward Conventional|
|Surveillance data (continued)||
• Receipt of health alert triggers group notification by receiving infection prevention personnel
• Disaster plan activated when >X seriously injured victims expected at facility—Hospital Command Center opens
• “Full capacity” plan initiated when ED wait times exceed X hours
• Change or increase monitoring parameters, additional situational awareness activities
• Partial or full activation of incident command system/hospital command center
• Communication/coordination with stakeholders/coalition partners
• Change hours, staffing, internal processes in accord with facility plans
• Assess predicted impact on institution
[Refer also to the worker functional capacity table in Toolkit Part 1 (Table 3-1)]
• Increasing staff absenteeism
• Specialized staff needed (pediatrics, burn, geriatrics) for incident patients
• School closures
• Staff work action anticipated (e.g., strike)
• High patient census
• Staffing hours adjustment required to maintain coverage
• Staffing supervision model changes required to maintain coverage
• X% staff ill call rate prompts notification of emergency management group
• School closures across area trigger opening of staff day care
• Normal staff to patient ratios exceeded
• Specific staff expertise demands exceeded (e.g., mass burn event—depletion of burn nurses)
• Increasing staff requirements in face of increasing demand
• Contingency spaces maximized
• Contingency staffing maximized
• Unable to safely increase staff to patient ratios or broaden supervisory responsibilities
• Lack of qualified staff for specific cares—especially those with high life-safety impact
• Tailor responsibilities to expertise, diverting nontechnical or nonessential care to others
• Recruit and credential staff from volunteer (Medical Reserve Corps [MRC], Emergency System for Advance Registation of Volunteer Health Professionals [ESAR-VHP]) or federal sources (Disaster Medical Assistance Team [DMAT], other National Disaster Medical System [NDMS] source, etc.)
• Staff impact is reduced, schools back in session, damage to community mitigated
• Staff absenteeism reduced
• Specialty staff obtained or demand decreased Trigger:
• Staff to patient ratios of 1:X achieved on medical floor
• Shorten shift lengths
• Adjust staff to patient ratios toward normal
• Transition toward usual staff—releasing less qualified staff first
• Resume care routines
• Resume administrative duties
• Assess likely impact on facility
• Hold staff
• Change hours, staffing patterns
• Change staff to patient ratios
• Specialty staff provide only specialty/technical care, while other staff provide more general care
• Callback, obtain equivalent staff from coalition, hiring, administrative staff
• Change charting responsibilities
• Curtail nonessential staffing (cancel elective cases, specialty clinic visits, etc.)
• Provide support for staff (and their families as required) to help them continue to work and provide quality care (e.g., stress “immunization,” rest periods, housing support)
• Establish remote consultation of specialized services such as telemedicine, phone triage, etc., if possible
• Evacuate patients to other facilities with appropriate staff available
• Increased ED volumes
• Increased clinic/outpatient volumes
• Increased inpatient census
• Increased pending admits/ED boarding
• Inpatient census exceeds conventional beds
• Damage to infrastructure
• Clinics unable to accommodate demand for acute care
• >X hours ED boarding time
• Electronic health record downtime
• Telephone or Internet systems failures
• Expand hours of outpatient care
• Open additional outpatient care space by adjusting specialty clinic space/ times
• Provide “inpatient” care on preinduction, postanesthesia care, other equivalent areas
• Divert patients to clinics/other facilities
• Transfer patients to other facilities
• “Reverse triage” appropriate patients home (with appropriate home care)
• Implement downtime procedures for IT systems
• Inpatient/outpatient contingency spaces maximized or near-maximized
• Escalating or sustained demand on ED/outpatient despite implementing contingency strategies
• Damage to infrastructure affecting critical systems
• Contingency inpatient beds maximized (may include subset of ICU, burn, pediatrics, etc.)
• Contingency outpatient adaptations inadequate to meet demand using equivalent spaces or strategies
• Damage to infrastructure affecting critical systems and presenting a safety issue to staff/patients
• Establish nontraditional alternate care locations (e.g., auditorium, tents, conference rooms), recognizing governmental role in authorizing waivers
• “Reverse triage” stable patients to these areas, move stable ICU patients to monitored bed areas (i.e., step-down units deliver ICU-level care)
• Favorable epidemiologic curves
• Restoration of critical system function
• ED/outpatient volumes decreasing Trigger:
• Patients able to be matched to appropriate areas for care
• Transitional movement of sickest patients back into ICU environment
• Broaden admission criteria
• Reduce/eliminate care in nontraditional spaces (stop providing assessment/care in non-patient care areas/cot-based)
• Shift toward normal hours
|Indicator Category||Contingency||Crisis||Return Toward Conventional|
• Consider other methods of outpatient care, including telephone treatment and prescribing
• Change admission criteria—manage as outpatients with support/early follow-up
• Evacuate patients to other facilities in the region/state/nation that have appropriate capabilities and capacity
• Vendor supply or delivery disruption
• Supply consumption/use rates
• Epidemiology of event predicts supply impact
• Event epidemiology predicts ventilator or other specific resource shortages (e.g., pediatric equipment)
• Medication/vaccine supply limited
• Consumption rates of personal protective equipment (PPE) unsustainable
• Vendor shortages impact ability to provide normal resources
• Use nontraditional vendors
• Obtain from coalition facilities/ stockpiles (including potential state/federal sources)
• Conserve, substitute, or adapt functionally equivalent resources; reuse if appropriate
• Coalition lack of available ventilators
• Anesthesia machines and other adaptive ventilation strategies in use
• Coalition/vendor lack of available critical supplies/medications
• Inadequate ventilators (or other life-sustaining technology) for all patients that require them
• Inadequate supplies of medications or supplies that cannot be effectively conserved or substituted for without risk of disability or death without treatment
• Implement triage team/clinical care committee process
• Determine bridging therapies (bag-valve ventilation, etc.)
• Coordinate care/triage policies with coalition facilities (in no-notice event, this may not be possible)
• Triage access to live-saving resources (ventilators, blood products, specific medications) and reallocate as required to meet demand according to state/ regional consensus recommendations
• Restrict medications to select indications
• Restrict PPE to high-risk exposures (and/or permit PPE reuse)
• Reuse or reallocate resources when possible (benefit should outweigh risks of reuse; reallocate only when no alternatives—see criteria in IOM, 2012)
• Reduced use of PPE or other supplies
• Reduced caseload or demand for care and services
• Improved delivery of supplies
• Reduced need for ventilator or other triage
• Able to provide contingency ventilation and critical care strategies to all that require them
• Retriage patients as resources become available
• Broaden indications for interventions as conditions improve
• Transition back from reallocation and reuse to safer adaptive and conservation strategies
• Loosen restrictions on use of supplies
Decision-Support Tool: Blank Table to Be Completed
Prompted by discussion of the key questions above, participants should fill out this blank table (or multiple tables for different scenarios) with key system indicators and triggers that will drive actions in their own organizations, agencies, and jurisdictions.4
• Indicators are measures or predictors of changes in demand and/or resource availability; triggers are decision points.
• The key questions were designed to facilitate discussion—customized for hospitals and acute care— about the following four steps to consider when developing indicators and triggers for a specific organization/agency/jurisdiction: (1) identify key response strategies and actions, (2) identify and examine potential indicators, (3) determine trigger points, (4) determine tactics.
• Discussions about triggers should include (a) triggers for which a “bright line” can be described, and (b) how expert decisions to implement tactics would be made using one or more indicators for which no bright line exists. Discussions should consider the benefits of anticipating the implementation of tactics, and of leaning forward to implement certain tactics in advance of a bright line or when no such line exists.
• The example table may be consulted to promote discussion and to provide a sense of the level of detail and concreteness that is needed to develop useful indicators and triggers for a specific organization/agency/jurisdiction.
• This table is intended to frame discussions and create awareness of information, policy sources, and issues at the agency level to share with other stakeholders. Areas of uncertainty should be noted and clarified with partners.
• Refer back to the toolkit introduction (Chapter 3) for key definitions and concepts.
Scope and Event Type: _______________________________
|Indicator Category||Contingency||Crisis||Return Toward Conventional|