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Crisis Standards of Care: A Toolkit for Indicators and Triggers (2013)

Chapter: 5: Toolkit Part 2: Public Health

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Suggested Citation:"5: Toolkit Part 2: Public Health." 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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5: Toolkit Part 2: Public Health

INTRODUCTION

This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide public health decision making during a disaster or public health or medical emergency. This tool focuses specifically on the role of public health in supporting the public health and medical sector across the spectrum, from prehospital care through end-of-life care. 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. Reviewing the toolkit chapters focused on other stakeholders would also be useful.

Roles and Responsibilities

Public health is a complex system focused on the health of the population residing within their jurisdiction. Activities focus on protecting people from unsafe or harmful conditions while providing methods to promote optimum health and prevent disease. Public health can be established as a local government function, sometimes called “home ruled,” in which the jurisdiction has the authority to set up their own governance and local ordinances. These cannot be counter to overall state authority. State public health has responsibility for the health of the population within the entire state, and may consist of locally run satellite state public health agencies. In either model, state public health has powers under the authority of the governor outlined in state statutes, which can be enacted in a public health, natural disaster, or catastrophic medical incident when usual mechanisms and powers are insufficient to meet the regulatory or response requirements of an incident.

Threats to human health are always present, whether caused by nature or humans. Without thorough preparation and coordinated planning between government and private-sector partners, communities and individuals will be unable to prevent, protect against, respond to, and mitigate incidents, and rapidly recover when an incident occurs. Public health and medical preparedness can only be achieved when component partners at the local, regional, and state/tribal level work in synergy through all-hazards preparedness. This becomes critical when resources are scarce. Local and state public health should lead the planning for crisis

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×

standards of care (CSC) and ensure both an implementation plan and incorporation into the culture of the health spectrum.

Additional discussion about public health roles and responsibilities in planning for and implementing 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.

DISCUSSION AND DECISION-SUPPORT TOOL

Suggested participants for a discussion focused on public health 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 public health. It also contains two charts (one for slow-onset and one for no-notice) that provide example public health 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.1 Participants may choose to complete a single, general blank chart, or one each for various scenarios from their Hazard Vulnerability Analysis.

The questions below and associated table of sample indicators and triggers are broken out by the two scenarios because the role of public health will vary significantly based on the incident. Nearly all incidents or planned events will need public health and medical assistance and possible response. The first scenario demonstrates a slow-onset incident in which local and state public health would monitor the activity of influenza worldwide. This would provide an opportunity for planning and anticipating response activities. The second scenario demonstrates the issues associated with a no-notice event and describes potential points of consideration to respond and support response activities. In this scenario, there will be an immediate role of medical response, supported by public health, and intermediate- and long-term responsibilities for local and state public health offices.

Discussion Participants

From a public health perspective, any agency or organization that will be impacted in their service delivery by public health decisions should be discussion participants at some point in the deliberation process.2

Public health impacts all sectors and thus the need for integrated planning and long-term follow-up should be a key component in planning for and implementing CSC and will have a critical supporting role throughout an incident.

Local public health discussions should include their agency emergency management/preparedness coordinator, health officer, and medical director at a minimum. Agency subject matter experts (SMEs) should be engaged based on incident type, with consideration of potential clinical services impacted: communi-

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1 The blank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards.

2 As discussed above, the structure and organization of public health and health varies across states and localities. The discussion participants listed here are provided as a suggestion; discussion organizers should develop a participant list that would be appropriate for the structures and organization of the particular jurisdiction.

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×

cable disease, epidemiology, environmental health, legal, and any departments that serve vulnerable populations potentially impacted. Other governmental entities, such as emergency management, behavioral health, county commissioners, coroner or medical examiner, and other key stakeholders, should also be included.

Local external discussion participants would include executive leadership of the impacted medical organizations, such as hospital chief executive officers (or chief medical officer and/or emergency department medical director or nurse manager), medical director or executive of emergency medical services (EMS) agency(s), Federally Qualified Health Centers, long-term care facilities, community mental health, dialysis center(s), home care, impacted primary care providers, funeral directors, etc., for SME input as the incident expands.

State public health entities involved may be a chief medical executive, state health officer, state epidemiologist, director of public health preparedness, an EMS and trauma system medical director or executive, a behavioral/mental health executive, health emergency management coordinator (EMC)3 and Emergency Support Function- (ESF-) 8 leads/state health operation center chiefs, and a legal advisor, including attorney general, if appropriate.

State external discussion participants would be the State Disaster Medical Advisory Committee (SDMAC) or designee, impacted local health agencies, regional health care coalition leadership or similar group (e.g., state EMS/trauma advisory committees), executive leadership of impacted medical health organizations (e.g., hospital association, state medical society, behavioral/mental health, state pediatric association) and other stakeholders or SMEs based on incident or event.

Key Questions: Slow-Onset Scenario

The questions below are focused on the slow-onset influenza pandemic scenario presented in Chapter 34:

1. What routine medical and public health surveillance systems are in place? Who or what agency submits the data, and who routinely monitors? Are these systems integrated to ensure multiple data feeds such as electronic communicable disease and laboratory results, influenza-like illness, sentinel physician reports, and pharmacy and over-the-counter medication sales, etc.? In reviewing these systems, are there thresholds already established that trigger actions or the need for further public health review?

2. Is an emergency department syndromic surveillance system in place? What are the components, thresholds, triggers, etc.? Is a protocol in place for further investigation once a threshold is identified? How would trending data indicate or contribute to the local/state potential impact on delivery of services and standards of care?

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3 A state health emergency management coordinator (EMC) serves as the liaison from state health to the state emergency operations center (EOC). In this role, the state health EMC or similar role would identify collaboration or resources needed through other state agencies. Depending on the state, the entity coordinating on public health and health may be referred to in different ways, including, for example, state (public) health emergency coordination center, department of (public) health operations center, or state (public) health operations center.

4 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.

Suggested Citation:"5: Toolkit Part 2: Public Health." 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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3. What information would be communicated to the local or state emergency management that would trigger an EOC activation for a public health/medical event? How do incidents that have ESF-8 as the lead agency impact operations in the EOC?

4. Has the local or state health department identified triggers to impact or restrict public gatherings to minimize exposures and thus decrease demand for medical resources?

5. Because this is a slow-onset incident, is there a local trigger for request of Strategic National Stockpile (SNS) medical materiel through the state-identified process?

6. What is needed to initiate points of dispensing (PODs)? How does the health department identify the sequence of POD placement and staff resources? Are the hospitals closed PODs and are there any anticipated variations in planning and response during CSC activities? Will there be separate POD(s) for first responders and their families, and will this include off-duty as well as on-duty workers?

7. How does the risk communication/public information officer modify messaging to address evolving conditions and coordinate messages with other agencies? When and by what mechanism does the state or an interjurisdictional information system become necessary?

8. What is the status of the public health workforce? Does the individual agency have plans in place to identify and meet essential public health functions while supporting medical care delivery during CSC? How does the agency Continuity of Operations Planning impact delivery of services, especially if clinical services are offered within the public health agency?

9. How is the impacted workforce and a need to solicit and use volunteer health care providers addressed? For example, volunteers may be accessed through the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), Medical Reserve Corps (MRC), etc.

10. What data or information are/is needed by public health executive leadership to consider a declaration or regulatory relief to facilitate contingency or crisis care within the medical health community? What lead time is needed to educate and communicate with senior policy leaders?

11. What activity would follow a declaration of emergency by the governor (health or general depending on legal environment of jurisdiction) or executive orders by the local or state public health authority? Does the local depend on the state to generate? What is needed for the agency?

12. State public health—what is the threshold for activation of the SDMAC or engagement of other SMEs? What communications need to occur internally with state government?

13. A slow-onset incident with high mortality rate will impact ESF-8 activities specific to fatality management. What resources are needed to assist the local coroner/medical examiner? Are there local or state plans for surge of decedents that may include surge storage, temporary interment, etc.?

Key Questions: No-Notice Scenario

The questions below are focused on the no-notice earthquake scenario presented in Chapter 3:

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×

1. What is the status of infrastructure within the impacted area and has public health identified what is needed to support response? This will vary dramatically with available health care resources at the local level and the degree to which they are impacted.

2. Do any governmental regulations or rules need modification to facilitate incident response? If so, what information is needed and which agency serves as the lead to modify (e.g., state vs. federal regulations)? An example would be an “1135 waiver”5 (state request approved federally), modifications to regulations on spacing between patient beds, cribs, dialysis chairs (state), staffing ratios, etc.

3. What are the applicable public health authorities, and if actions are needed how and when are these initiated and by whom? These are often outlined in a state public health code, licensing regulations, or applicable legislation.

4. What unique information should be collected by local and state public health and provided to local and state EOCs to support the spectrum of health care response? What is the most efficient method to collect the information, which may include the health care coalition medical coordination center? This could include bed availability, patient tracking strategies, and anticipated shortfalls of equipment or supplies, etc.

5. What support is needed for impacted person tracking and/or family reunification?

6. What critical health-related services to the community have been impacted? Are resources available outside the immediately impacted area?

7. Can any of the impacted services be assisted by local or state public health agencies, such as public health laboratories?

8. Is there a secondary environmental impact to the health of the public in the impacted area (presence of nuclear power plant and hazardous materials production or storage sites, including “SARA Title III” sites6) for which local and state public health should initiate assessment and mitigation strategies?

9. How quickly and by what means can the risk communication and public information officer implement communication strategies in circumstances when usual means of communication are compromised? What additional resources may be needed to facilitate messaging in these situations?

10. What is the status of the public health workforce? What essential functions should be maintained and what resources should be mobilized to support medical care during CSC? How is the impacted workforce identified and paid, or volunteer health care workforce solicited and used (ESAR-VHP, MRC, etc.)?

11. What other governmental agency resources are needed to support response (priority contract access, transportation, vulnerable children/population services, vaccines, laboratory, etc.)?

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5 Waiver or modification of requirements under section 1135 of the Social Security Act. See http://www.ssa.gov/OP_Home/ssact/title11/1135.htm (accessed May 31, 2013).

6 The Superfund Amendments and Reauthorization Act (SARA) of 1986 created the Emergency Planning and Community Right-to-Know Act (known as “SARA Title III” or EPCRA), which is aimed at enhancing emergency planning and “community right-to-know” regarding hazardous and toxic chemicals. For additional information, see http://www.epa.gov/agriculture/lcra.html (accessed May 31, 2013).

Suggested Citation:"5: Toolkit Part 2: Public Health." 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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Decision-Support Tool: Example Tables

The indicators, triggers, and tactics shown in Tables 5-1 and 5-2 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 (or a table per scenario), 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 tables 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 in advance of 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.

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×

TABLE 5-1
Example Public Health Indicators, Triggers, and Tactics for Transitions Along the Continuum of Care in a Slow-Onset Scenario

Indicator Category Contingency Crisis Return Toward Conventional
Surveillance data

Indicators:

•   Epidemiologic data identify significantly increased or novel activity

•   Epidemiologic data identify unusual population affected

•   Trends over time indicate escalation and/or significant impact

Triggers:

•   Health care organizations unable to submit data due to impact of medical surge volumes

Tactics:

•   Investigate indicators further with additional data, case finding, etc., to attain improved situational awareness

•   Work closely with health care coalition and medical health partners to target data collection to key elements only

•   Develop additional data elements based on incident and potential workload impact

•   Consider what is already collected electronically and modify to minimize health care organization stressors

Indicators:

•   Epidemiologic data indicate benchmarks and thresholds for critical resources and maximum critical care capacity will be exceeded

•   (Fatality) Communications from local medical examiner or coroner that morgue/storage capacity has been exceeded

Crisis triggers:

•   Epidemic curves continue to rise with unclear peak of cases

•   Surveillance has to be modified to highest priority or impact-only with minimal set of identifiers for future follow-up

Tactics:

•   Event-specific data collection to provide common operating picture and potential treatment/outcome information

•   Surveillance data collection narrowed to only automated data streams related to incident

•   Governmental entities waive communicable disease reporting rules to only that which is directly related to the incident and key health issues

Indicators:

•   Epidemiologic data indicate sustained decrease in “new” incident-related reports

•   Electronic reporting mechanisms indicate return to normal reporting processes by health care organizations

Triggers:

•   Event-specific data collection is no longer required

Tactics:

•   Public health initiates “catch-up” work to capture health data from the prolonged incident; this is a critical role for public health for future incident response and demand forecasting

Community and communications infrastructure

Indicators:

•   Communications systems (Health Alert Network [HAN], telephone, etc.) disrupted within and external to jurisdiction

Triggers:

•   Multiple requests for assistance from multiple agencies or jurisdictions

•   Interruption or contamination of water supply or utilities

•   Identified need to establish communication hotlines

•   Requests for specialized services and needs for broad public communications

Indicators:

•   Continued need to communicate with public about high risk, evolving situation

•   Water supply contamination

Crisis triggers:

•   Reports of disturbances at health care organizations or public shelters, etc.

•   Prolonged and widespread utilities (power, natural gas) outages

Tactics:

•   Use all established resources to coordinate and communicate health messages

Indicators:

•   Decreased requests for messaging

•   Decreased activity on established hotlines

Triggers:

•   Media and health care requests returning to “normal”

Tactics:

•   Continue to provide appropriate levels of communication to the media, community, and impacted health care organizations

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×
Indicator Category Contingency Crisis Return Toward Conventional
Community and communications infrastructure (continued)

Tactics:

•   Work with established media and professional organizations to ensure consistent messaging

•   Implement statewide hotlines through established mechanisms such as poison control center, 211, etc.

•   Coordinate risk communication strategies with governmental public information officials

•   Increase availability of coordinated communications for gaps identified

•   Focused review of communications strategies to identify gaps in targeted populations vulnerable or causing disturbances

Staff

(Refer also to the worker functional capacity table in Toolkit Part 1 [Table 3-1])

Indicators:

•   Increasing absenteeism among public health staff; increased demand for staffing for community-based interventions, etc.

Triggers:

•   Community-based interventions required (e.g., vaccine, countermeasure distribution, “flu centers”)

Tactics:

•   Eliminate routine or non-life safety laboratory testing, surveillance of community organizations, etc.

•   Initiate Continuity of Operations Planning to ensure that essential functions for local and state public health are implemented to support health care organization response

•   Identify services to put on “pause” as personnel resources continue to decline

•   Activate mutual aid/support plans from other agencies, disciplines, predesignated volunteer sources as required

•   Off-load tasks onto technology as possible (e.g., hotlines rather than face-to-face assessments)

•   Change staffing patterns and hours

Indicators:

•   Increasing absenteeism and inability to fulfill critical missions to community

•   Increased demand for resources

Crisis triggers:

•   Unable to fulfill critical missions (e.g., support alternate care sites) with appropriate staff

Tactics:

•   Eliminate all nonessential functions to support local and state response to the incident

•   Reallocate any health professionals whose training allows them a more active role to support health care organizations

•   Assist if needed in coordination of health volunteers to support public health and medical functions identified

•   Triage personnel resources to services of most benefit (community vaccination, etc.)

•   Use just-in-time recruiting and training as required to fulfill missions

•   Obtain regulatory relief as required to facilitate facility crisis responses (e.g., who may administer vaccinations)

Indicators:

•   Impact of incident decreasing

•   Personnel absenteeism is decreasing

•   Personnel communicating need to initiate activities to “return to normal operations”

Triggers:

•   Missions able to be completed with adequate staffing

Tactics:

•   Review and prioritize key services for reimplementation at the local and state levels

•   Initiate data analysis of impact of crisis standards of care (CSC) implementation on personnel

•   Revert to normal staffing patterns/hours/duties

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×
Space/infrastructure

Indicators:

•   Health care organizations are unable to meet demands with traditional bed capacity with all surge strategies implemented

•   Local and state public health initiated strategies to authorize alternate care site initiation; this includes assurances related to governmental waivers

Triggers:

•   Space expansion is required for community-based interventions (vaccination campaign, etc.)

•   Recognition of the need to open alternate care sites for screening clinics/early treatment

Tactics:

•   Requests are made for waivers to authorize alternate care sites for care delivery

•   Local public health departments work with their local health care organizations and regional health care coalitions to ensure that inpatient sites, including skilled nursing facilities, are prioritized for support

•   Public health provides risk communication and coordination assistance for medical care system—when to seek care, etc.

•   Local health departments work with their primary care providers to identify mechanisms to expand services and protect personnel

•   Emergency Support Function-8 lead to keep each local emergency operations center aware of impact and contingency care implemented

•   State health implement statewide plans for nurse triage lines, 211, poison control support for callers related to event

•   State public health works with all health care coalitions to support implementation of statewide medical surge strategies

•   State health emergency coordination center to keep each local health department aware of impact and contingency care implemented

Indicators:

•   Health care organizations have narrowed admission criteria to maximize available resources

Crisis triggers:

•   Health care organizations have implemented all medical surge strategies and should seek alternate care site locations for inpatient care overflow

Tactics:

•   Supply or support mobilization of deployment of volunteer health professionals

•   Implementation of governmental waivers to establish alternate care sites

•   State emergency operation centers and health emergency coordination centers work with state and federal agencies to establish declarations and emergency order rules specific to the necessary tactics to respond to the incident

•   State public health to communicate with state disaster medical advisory committee to review status of CSC guidelines and distribute to impacted health care organizations

Indicators:

•   Surveillance indicates declining new infections

•   Health care organizations are able to broaden admission based on available resources

Triggers:

•   Decreasing census in alternate care sites within jurisdiction

•   State observes multiple health care coalitions readying for demobilization of alternate care sites

Tactics:

•   Support health care alternate care site demobilization strategies

•   Patient records, resources, and supplies should be accounted for and returned as required; local and state public health departments mobilize resources to assist as available

•   State public health works with local partners and nongovernental organizations to communicate plans to return to conventional care

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×
Indicator Category Contingency Crisis Return Toward Conventional
Space/infrastructure (continued)

•   State health to initiate process for implementing executive orders for public health emergency; may or may not implement at this time

•   Local and state public health begin planning strategies for CSC if anticipated event expansion

Supplies

Indicators:

•   Local and state monitoring of supplies and inventory data indicate shortage/ potential shortage

•   Benchmark supply availability to disease reporting and mortality data

•   Anticipate challenges with medical supply chain based on expanding incident; review communications from each health care coalition for the impact to their health care organizations

Triggers:

•   Decreased availability of critical medical resources anticipated

•   Requests to health care coalition medical coordination center for allocation of regional cache supplies

Tactics:

•   Prioritize resource allocation by urgency of need and risk

•   Determine time frame and availability from other vendors/sources

•   Review and update risk communication strategies specific to users of critical resources and community

•   State health emergency coordination center work with each health care coalition to allocate regional cache contents and other resources

•   State health emergency coordination center initiates internal mechanisms to move anticipated Strategic National Stockpile (SNS) materiel requests to the state emergency operations center

Indicators:

•   Demand forecasting/projections exceed available critical resources

•   No national source of specific supplies available

Crisis triggers:

•   Shortages of critical equipment, drugs, or vaccine present significant risk to persons who cannot receive them

•   National guidance on rationing distributed

Tactics:

•   Focus allocation of scarce resources to maintaining critical social/ public safety function (civil order maintenance)

•   Coordinated risk communication strategies are critical

•   Use government purchasing powers to support critical medical supplies

•   Maintain communications with federal SNS program

•   State and regional disaster medical advisory committees review triage guidance available and propose recommendations

•   State public health circulates guidelines on allocation of resources

•   Legal, regulatory, and emergency powers invoked as required to facilitate fair, planned allocation process

Indicators:

•   Vaccine manufacturers have increased supply chain so targeted groups for vaccination is expanded based on disease trends and ethical guidelines

•   Additional resources are obtained

•   Demand for resources (e.g., ventilators) is declining as event wanes

Triggers:

•   Critical medical supplies are sufficient to meet the needs of the patients requiring them

Tactics:

•   Continued, coordinated risk communication

•   Assessment if transition is temporary or likely to be permanent

•   Local public health should augment Points of Dispensing plans to meet demands when vaccination is expanded as vaccine is available

•   Demobilization of SNS

•   State public health to review CSC guidelines for possible revision based on resource availability

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×
Fatality management

Indicators:

•   Rising death toll

•   Rate of deaths projected to exceed local capabilities

Triggers:

•   Health care organizations are reporting an inability to manage the number of decedents within facilities

•   Local medical examiners/coroners are unable to meet the demands of their jurisdiction with usual processing

Tactics:

•   Local public health works with medical examiners/coroners to determine if the bottleneck is processing (medical examiner caseload) or body management

•   Local public health contacts funeral home, mortuaries, morgues, or crematoriums to assess current impact on capacity and expansion capacity

•   Local governmental agencies should identify potential cultural barriers to modifications in death processes and prepare strategies to address these

•   Initiate strategies to expedite the completion of death certificates/ investigations

•   State public health investigates modifications to laws, regulations, etc., for dealing with decedents

•   Governmental authorities initiate planning for possible alternate storage strategies

•   Consider federal or state disaster mortuary team resources

•   Consider temporary storage facilities implementation plan

Indicators:

•   Funeral homes communicating limited resources to conduct funeral services

•   Rate of deaths projected to exceed regional/surge capabilities

Crisis triggers:

•   With disaster plans implemented, fatality processing demand exceeds available resources and threat of civil unrest or decomposition is real

Tactics:

•   Risk communication strategies coordinated at local and state levels

•   Activation of all available mortuary resources, including response teams and expanded cremation and processing operations

•   Governor declaration for expedited burials and/or temporary interment upon state public health recommendation. (NOTE: Requires extensive planning with multiple state agencies to identify a location, tracking, and personnel support to implement such a response to manage mass fatality incident.)

•   Consider transfer of decedents to other locations for processing if required

Indicators:

•   Number of deaths from influenza are stabilizing or sustained decline

Triggers:

•   Decedent processing is able to be accommodated within surge or conventional systems

Tactics:

•   Risk communication on decedent management

•   Local and state public health, in conjunction with medical examiners/coroners, resume normal processes, which include funerals and traditional burials

•   Alterations that had occurred should be addressed to return to “normal state,” recognizing the complexity associated with variation in cultural and societal death routines

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×
Indicator Category Contingency Crisis Return Toward Conventional
Congregate gatherings

Indicators:

•   Epidemiologic models indicate person-to-person spread is prevalent

•   Multiple jurisdictions reporting that large gatherings implicated in outbreak investigations

•   Outbreaks linked to funeral services

Triggers:

•   Epidemiologic data indicate increasing outbreaks directly related to known congregate gatherings in more than one jurisdiction

Tactics:

•   Local and state review immediate and future large-scale venues for anticipated cancellation

•   Local and state recommendations on school closures

•   State public health readies quarantine guidelines working with governor’s office

Indicators:

•   Statewide indication of high transmission in gathering settings

Crisis triggers:

•   Forced quarantine is required to prevent spread of dangerous pathogen

•   Public gatherings prohibited

Tactics:

•   Executive order or governor’s declaration to eliminate congregate gatherings

•   Quarantine orders implemented as indicated

•   Governmental agencies collaborate to enforce congregate-gathering bans

Indicators:

•   Decrease in evidence for person-to-person trends

•   Criteria for identifying “superspreaders” as individuals allows targeted interventions

Triggers:

•   Sustained decrease in disease transmission trends

Tactics:

•   Governor rescinds gathering orders

•   Initiate public gatherings

•   Local and state continue close monitoring of epidemiologic data to ensure continued decline and are prepared to reinstate bans if cases increase

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×

TABLE 5-2
Example Public Health Indicators, Triggers, and Tactics for Transitions Along the Continuum of Care in a No-Notice (Earthquake) Scenario

Indicator Category Contingency Crisis Return Toward Conventional
Surveillance data

Indicators:

•   Collection of Essential Elements of Information indicates disruption of services that impact local public health and health care organizations within jurisdiction

•   Local health department identifies specific population health surveillance data impacted by incident

•   Impacted persons are being taken to multiple health care organizations through traditional and nontraditional methods

•   Forecast temperature extremes

Triggers:

•   Communications from health care organizations to their health care coalitions that many facilities have infrastructure damage

•   Communications from local emergency operations centers (EOCs) to state EOC (SEOC) that medical and public health have significant impact to service delivery

•   Incident disrupts medical supply chain; anticipate shortages

•   Unable to locate or track all patients impacted by incident

Tactics:

•   Data collection to local EOC

•   State health emergency coordination center queries all health care coalitions to identify statewide impact to service delivery and plan response strategies (patient and resource movement)

•   Local health department implements focused assessments and modification specific to impact of incident for jurisdictional population

•   Implement patient tracking system statewide

Indicators:

•   Scope of incident indicates need to focus surveillance on key elements to support medical and public health operations

•   Communications indicate emergency management and/or American Red Cross or other nongovernmental organization establishing multiple sheltering operations

•   Incident-related injuries necessitate modification of surveillance strategies

•   Shelters established, need for augmented surveillance to protect shelter population

Crisis triggers:

•   Health care organization capacity is overwhelmed based on casualty counts and impact on health care infrastructure

Tactics:

•   Collection of key information only to maximize/distribute resources or reunite families

•   Continue established patient tracking system and allow access by nongovernmental and other organizations as required to facilitate reunification

Indicators:

•   Focused surveillance indicates diminishing impact of incident

Triggers:

•   No additional victims being entered into system

•   Decreasing numbers in shelters and consolidation of sheltering services

Tactics:

•   Return to routine surveillance activities

•   Extensive review of incident-specific surveillance data to determine long-term follow-up or further focused surveillance

•   Archiving of patient tracking from event

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×
Indicator Category Contingency Crisis Return Toward Conventional
Community and communications infrastructure

Indicators:

•   Initial and subsequent damage reports indicate substantial loss of 911 or other communications

•   Initial and subsequent damage reports indicate substantial loss of health care or residential infrastructure

•   Numbers of persons are missing and the pressure families are putting on 911 and other systems to find them

•   Disruption of roads impact ability to meet the needs of patient movement

Triggers:

•   Requests from multiple health care organizations and health care coalitions for governmental assistance due to infrastructure damage

•   Significant reports of safety issues that could impact community, thus indicating a need for coordinated risk communication strategies

•   Local EOCs getting queries from health care organizations about utility restoration

Tactics:

•   Support requests from health care organizations through health care coalition

•   Prioritize key public health activities to support critical jurisdictional needs and health care organization service delivery

•   Local public information officials work with media on health-related risk communication strategies

•   State public information officials working with other state agency and local public information officials for coordinated risk communications

•   Local EOCs establishing mechanisms to implement family reunification systems

Indicators:

•   Local EOCs and state emergency operation center are fully activated statewide to respond to catastrophic incident

•   Widespread loss of utilities

•   Widespread loss of critical communications (cellular, Internet, public safety radio, etc.)

Crisis triggers:

•   Incident unfolding with health care coalitions communicating more than X% of facilities with significant infrastructure damage (the level of care provided by health care organizations and their roles in the community will impact the number of damaged facilities that cause a transition to crisis response)

•   Inability for multiple hospitals to remain in their current building without significant support

•   Multiple health care facilities require evacuation and inadequate transport resources to accomplish this

•   Local emergency management indicates a need to establish multiple shelters, including functional needs

Tactics:

•   Continued need for risk communications to community

•   Identify needs of health care organizations in collaboration with health care coalitions

•   Local health departments should identify staff, including volunteers, to assist with public health issues in shelters, including those targeted to functional needs

•   State public information officials working with other state agency and local public information officials for coordinated risk communications

•   State working with locals to ensure that family reunification systems can meet demands

Indicators:

•   Public safety communications back online

•   Repairs to health care organizations provide the ability to repopulate or resume previous level of service

Triggers:

•   Emergency communications systems reestablished

Tactics:

•   Communicate deescalation of incident to community through established methods and using risk communication strategies

•   Local and state public health assist with assessments or surveys to clear impacted health care organizations for repopulation or resume suspended services

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×
Staff

Indicators:

•   Personnel availability impacted by access, family obligations, injury/direct effects

Triggers:

•   Request for additional medical or public health personnel to support operations

Tactics:

•   Identify cross-trained personnel to support services linked to incident

•   Modifications to services will be based on staff available

•   Plan to support response with volunteer health professionals (Emergency System for Advance Registration of Volunteer Health Professionals [ESAR-VHP], Medical Reserve Corps [MRC], coalition, etc.)

Indicators:

•   Personnel availability impacted widely by access, family obligations, injury/direct effects

•   Local infrastructure damage will prevent mutual aid in a timely manner

•   Alternate care sites and shelters initiated

Crisis triggers:

•   Multiple organizations requesting medical staff support and inadequate availability of staff via usual programs (ESAR-VHP, etc.)

•   Specialty consultation unavailable to hospitals boarding burn, pediatric, or other patients due to demands or communication issues at referral centers

Tactics:

•   Use available staff and provide support for nonspecialized tasks to maximize response

•   Limit services to those related to life/ safety issues only

•   Facilitate out-of-area specialty consultation as applicable

•   Use volunteer health professional if available

•   State to seek additional personnel resources through federal programs (Department of Health and Human Services, Department of Defense, etc.)

Indicators:

•   Decreasing use of alternate care sites

•   Decreasing requests for staff support

Triggers:

•   Health care organizations releasing volunteer and other supplemental staff

•   Alternate care sites demobilizing

Tactics:

•   Initiate processes to return staff to routine positions

•   Implement demobilizations strategies if volunteers were used

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×
Indicator Category Contingency Crisis Return Toward Conventional
Space/infrastructure

Indicators:

•   Emergency management has initiated shelters

•   Emergency medical services (EMS) reporting evacuations of long-term care (LTC) and similar facilities

•   Hospital data indicate capacity exceeded at multiple facilities despite surge capacity plan activation

Triggers:

•   Local requests for assistance with patient movement

•   Inadequate EMS resources to accommodate demands

Triggers:

•   Need anticipated to modify EMS transport protocols statewide and suspend specific staffing and other response requirements

•   Local EOCs work with regional health care coalitions to identify and prioritize transport resources

•   State health emergency coordination center to work on statewide available resources through health care coalition structure

•   State public health and SEOC identify additional resources through Mutual Aid Agreements (MAAs) or Emergency Management Assistance Compact (EMAC)

Indicators:

•   Communications indicate demand exceeds patient transport supply

•   Hospitals have inadequate space for victims

Crisis triggers:

•   Requests to modify EMS transport protocols

•   Requests for alternate care sites for inpatient overflow

Tactics:

•   State ESF-8 works to implement protocol waivers to support modified transport plans

•   State public information official communicates efforts to all medical health entities

•   State coordination of field hospital and patient transportation assets from state, EMAC, and federal sources

Indicators:

•   EMS indicates return to normal dispatch and transport protocols

•   Alternate care sites no longer required/use diminishing

Triggers:

•   System data indicate returning to baseline transport status

Tactics:

•   Support efforts to return EMS to normal operations and regulations

•   Support demobilization of alternate care sites and shelter medical support

•   Local and state public health staff gather all after-action reports, meet with key stakeholders to identify challenges, and plan to support future operations

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×
Supplies

Indicators:

•   Interruption in supply chain impacts resource availability

•   Local use of resources exceeds supply (e.g., blood products, surgical supplies)

Triggers:

•   Resource shortages reported, including medical material and pharmaceuticals

•   Local request for Strategic National Stockpile (SNS) or cache materiel

Tactics:

•   Local health care organizations work with their health care coalition to distribute regional resources, including obtaining resources from health care coalitions that are not impacted by the incident

•   State Emergency Support Function-(ESF-) 8 should identify possible waivers, including the reuse of equipment and supplies within health care organizations

•   Initiate process to request SNS or other materiel through state EOC

Indicators:

•   Critical medical supplies are unavailable

Crisis triggers:

•   Unable to locate additional medical supplies to support medical care, presenting a life/safety risk

Tactics:

•   Local and state public health should continue to identify resources to support organizational response; this would include implementing MAA and EMAC requests for services and supplies needed to deliver care

•   Executive orders or public health/ emergency declaration if needed to support altering the use of equipment, supplies, or human resources

•   Public health guidance on allocation of specific scarce resources may be required, with input from state disaster medical advisory committee

Indicators:

•   Mobilization of equipment, supplies, and resources to meet demand

Triggers:

•   Decreasing requests for additional supplies to support response

Tactics:

•   Data collection and financial accountability to assess impact of incident and plan for remediation of gaps

•   Continue situational monitoring —is this a temporary or sustained improvement?

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×

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.7

Reminders:

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 public health—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.

____________________

7 The blank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards.

Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×

Scope and Event Type: _______________________________

Indicator Category Contingency Crisis Return Toward Conventional
Surveillance data Indicators: Indicators: Indicators:
Triggers: Crisis triggers: Triggers:
Tactics: Tactics: Tactics:
Communications and
community infrastructure
Indicators: Indicators: Indicators:
Triggers: Crisis triggers: Triggers:
Tactics: Tactics: Tactics:
Staff Indicators: Indicators: Indicators:
Triggers: Crisis triggers: Triggers:
Tactics: Tactics: Tactics:
Space/infrastructure Indicators: Indicators: Indicators:
Triggers: Crisis triggers: Triggers:
Tactics: Tactics: Tactics:
Supplies Indicators: Indicators: Indicators:
Triggers: Crisis triggers: Triggers:
Tactics: Tactics: Tactics:
Other categories Indicators: Indicators: Indicators:
Triggers: Crisis triggers: Triggers:
Tactics: Tactics: Tactics:
Suggested Citation:"5: Toolkit Part 2: Public Health." Institute of Medicine. 2013. Crisis Standards of Care: A Toolkit for Indicators and Triggers. Washington, DC: The National Academies Press. doi: 10.17226/18338.
×

REFERENCE

IOM (Institute of Medicine). 2012. Crisis standards of care: A systems framework for catastrophic disaster response. Washington, DC: The National Academies Press. http://www.nap.edu/openbook.php?record_id=13351 (accessed April 3, 2013).

Suggested Citation:"5: Toolkit Part 2: Public Health." 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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×
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×
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×
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×
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×
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×
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×
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×
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Suggested Citation:"5: Toolkit Part 2: Public Health." 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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×
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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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