Providing Mass Medical Care With Scarce Resources

Disasters and public health emergencies can stress health care systems to the breaking point and disrupt delivery of vital medical services. During such crises, hospitals and long-term care facilities may be without power; trained staff, ambulances, medical supplies and beds could be in short supply; and alternate care facilities may need to be used. Planning for these situations is necessary to provide the best possible health care during a crisis and, if needed, equitably allocate scarce resources. Crisis Standards of Care: A Toolkit for Indicators and Triggers examines indicators and triggers that guide the implementation of crisis standards of care and provides a discussion toolkit to help stakeholders establish indicators and triggers for their own communities. Together, indicators and triggers help guide operational decision making about providing care during public health and medical emergencies and disasters. Indicators and triggers represent the information and actions taken at specific thresholds that guide incident recognition, response, and recovery. This report discusses indicators and triggers for both a slow onset scenario, such as pandemic influenza, and a no-notice scenario, such as an earthquake. Crisis Standards of Care features discussion toolkits customized to help various stakeholders develop indicators and triggers for their own organizations, agencies, and jurisdictions. The toolkit contains scenarios, key questions, and examples of indicators, triggers, and tactics to help promote discussion. In addition to common elements designed to facilitate integrated planning, the toolkit contains chapters specifically customized for emergency management, public health, emergency medical services, hospital and acute care, and out-of-hospital care.

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.

Most experts define a mass casualty event (MCE) as a natural (e.g., earthquake, pandemic) or manmade (e.g., detonation of a nuclear device, conventional explosive, bioterror attack) incident that suddenly or progressively generates large numbers of injured and/or ill people who require medical and/or mental health care. The magnitude of demand for medical care resources has the potential to vastly outstrip the ability of a health care facility or a local, regional, or national public health and health care delivery system to deliver medical care services consistent with generally established standards of care. The scope and complexity of an MCE can severely challenge even the most highly experienced and well-equipped health care providers and systems. By definition, an MCE generates a level of demand for health care resources that outstrips available supply. Under those circumstances, local and regional health care providers are unable to meet victims' needs at the level normally expected of a modern health care delivery system. Because such situations are difficult to predict and can occur with little or no warning, health care systems and providers must be prepared to swiftly implement contingency plans to reduce less-urgent demand for health care services; optimize the use of existing resources; and secure additional resources, if possible, from backup sources. If these measures are insufficient to meet demand, providers may be forced to shift from the traditional treatment approach, which strives to deliver optimum care to every patient, to one that seeks to do the most good for the most people with the available resources. This latter concept has come to be known as “crisis standards of care.” The Institute of Medicine (IOM) Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations published a landmark Letter Report recommending that health care providers, organizations, government officials, and the public approach the challenge in a thoughtful and proactive way, anchored in four values: fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. The IOM Letter Report also recommended that State plans incorporate, among other things, evidence-based clinical processes and operations. To help Federal, State, and local policymakers, providers, and interested members of the public address the issue with the best available evidence, we were asked to build on the work of the IOM and previous reviews by conducting a thorough review of the evidence regarding allocation of scarce medical resources during MCEs. This report addresses the following Key Questions: Key Question 1. What current or proposed strategies are available to policymakers to optimize the allocation and management of scarce resources during MCEs? What outcomes are associated with these strategies? What factors act as facilitators or barriers to their implementation or effectiveness? Key Question 2. What current or proposed strategies are available to providers to optimize the allocation of scarce resources during MCEs? What outcomes are associated with these strategies? What factors are identified as facilitators or barriers to their implementation or effectiveness? Key Question 3. What are the public's key perceptions and concerns regarding the development and implementation of strategies to allocate and manage scarce resources during actual and potential MCEs? Key Question 4. What current or proposed methods are available to engage providers in discussions regarding the development and implementation of strategies to allocate and manage scarce resources, both in planning for and during an MCE? What outcomes are associated with these strategies? What factors are identified as facilitators or barriers to engaging providers in these discussions?

Problems contacting emergency services and delayed assistance are not unusual when incidents occur in rural areas, and the consequences can be devastating, particularly with mass casualty incidents. The IOM's Forum on Medical and Public Health Preparedness for Catastrophic Events held a workshop to examine the current capabilities of emergency response systems and the future opportunities to improve mass casualty response in rural communities.

During a wide-reaching catastrophic public health emergency or disaster, existing surge capacity plans may not be sufficient to enable health care providers to continue to adhere to normal treatment procedures and follow usual standards of care. This is a particular concern for emergencies that may severely strain resources across a large geographic area, such as a pandemic influenza or the detonation of a nuclear device. Under these circumstances, it may be impossible to provide care according to the standards of care used in non-disaster situations, and, under the most extreme circumstances, it may not even be possible to provide basic life sustaining interventions to all patients who need them. Although recent efforts to address these concerns have accomplished a tremendous amount in just a few years, a great deal remains to be done in even the most advanced plan. This workshop summary highlights the extensive work that is already occurring across the nation. Specifically, the book draws attention to existing federal, state, and local policies and protocols for crisis standards of care; discusses current barriers to increased provider and community engagement; relays examples of existing interstate collaborations; and presents workshop participants' ideas, comments, concerns, and potential solutions to some of the most difficult challenges.

Potential terrorist attacks and the possibility of naturally occurring disease outbreaks have raised concerns about the ¿surge capacity¿ of the nation¿s health care systems to respond to mass casualty events. This report identified 4 key components of preparing for a medical surge: (1) increasing hospital capacity; (2) identifying alternate care sites; (3) registering medical volunteers; and (4) planning for altering established standards of care. The author was asked to examine: (1) what assistance the fed. gov¿t. has provided to help states prepare for medical surge; (2) what states have done to prepare for a medical surge; and (3) concerns states have identified related to medical surge. Includes recommendations. Charts and tables.

Potential terrorist attacks and the possibility of naturally occurring disease outbreaks have raised concerns about the ¿surge capacity¿ of the nation¿s health care systems to respond to mass casualty events. This statement summarizes a 2008 report, ¿Emergency Preparedness: States are Planning for Medical Surge, but Could Benefit from Shared Guidance for Allocating Scare Medical Resources,¿ which examined the assistance the fed. gov¿t. had provided to help states prepare for medical surge and what states had done to prepare for medical surge. To do this the auditor reviewed documents from the 50 states and fed. agencies and interviewed officials from a sample of 20 states and from fed. agencies, as well as emergency preparedness experts.