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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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.
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International Standard Book Number-10: 0-309-28552-6
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Suggested citation: IOM (Institute of Medicine). 2013. Crisis standards of care: A toolkit for indicators and triggers. Washington, DC: The National Academies Press.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
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. 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 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. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
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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
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical 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 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:
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
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 carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Contents
Organization of the Report and How to Use the Toolkit
Previous IOM Work on Crisis Standards of Care
Continuum of Care: Conventional, Contingency, and Crisis
A Systems Approach to Catastrophic Disaster Response
Implementation of the Disaster Response Framework
The Need to Develop Indicators and Triggers
What Are Indicators and Triggers?
Developing Useful Indicators and Triggers
Indicator Limitations and Issues
Systems-Level Considerations for Indicators and Triggers
3 TOOLKIT PART 1: INTRODUCTION
4 TOOLKIT PART 2: EMERGENCY MANAGEMENT
Discussion and Decision-Support Tool
5 TOOLKIT PART 2: PUBLIC HEALTH
Discussion and Decision-Support Tool
6 TOOLKIT PART 2: BEHAVIORAL HEALTH
Discussion and Decision-Support Tool
7 TOOLKIT PART 2: EMERGENCY MEDICAL SERVICES
Discussion and Decision-Support Tool
8 TOOLKIT PART 2: HOSPITAL AND ACUTE CARE
Discussion and Decision-Support Tool
9 TOOLKIT PART 2: OUT-OF-HOSPITAL CARE
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 jurisdictions. 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 corresponding 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.
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 |
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 |
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 |