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Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
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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.

www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
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THE NATIONAL ACADEMIES PRESS     500 Fifth Street, NW     Washington, DC 20001

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.

International Standard Book Number-13: 978-0-309-28552-0
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.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×

Knowing is not enough; we must apply.
Willing is not enough; we must do.

—Goethe

image

INSTITITE OF MEDICINE
OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×

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.

The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council.

www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
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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

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
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Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
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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

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
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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.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
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User Guide

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.

Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
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Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
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Acronyms

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
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
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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
Suggested Citation:"Front Matter." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
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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
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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.

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