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

Chapter: 6: Toolkit Part 2: Behavioral Health

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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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6: Toolkit Part 2: Behavioral Health

INTRODUCTION

This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide decision making about behavioral health during a disaster. Because integrated planning across the emergency response system is critical for a coordinated response, it is important to first read the introduction to the toolkit and materials relevant to the entire emergency response system in Chapter 3. Reviewing the toolkit chapters focused on other stakeholders would also be helpful.

Behavioral health is a term encompassing many topics. While there is growing use of and consensus on the term’s application and meaning, there is also some inconsistency in its use and meaning. For the purposes of this document, behavioral health is intended to include factors related to overall psychological, psychiatric, and psychosocial healthiness and well-being. It also refers to specific psychiatric and substance abuse disorders.

Behavioral health is a pervasive factor affecting the response capabilities of decision makers and response personnel. It also affects the survival capabilities of the general public and those persons who require either acute or longer-term behavioral health treatment. Each of these groups faces common challenges in extreme events as well as unique stressors and intervention needs and opportunities.

It is important to highlight the centrality of understanding and attending to the sometimes unique needs of those whose roles include administration of, and response to, an extreme event. If the health of those involved (including behavioral health) is impacted in ways that adversely impact role function, the entire response can become compromised and, in extreme cases, fail. Preparedness activities must include detailed and strategic planning, which anticipates and addresses behavioral health consequences for both decision makers and responders. Preparedness activities should address issues such as strategies for identification, monitoring, and interventions geared toward stress reduction and management, as well as post-recovery resilience promotion and mitigation of posttraumatic stress disorder.

During an emergency, communities are confronted with a surge in demand and need for behavioral health intervention in health care facilities, in sheltering sites, at numerous public and private outpatient care venues, and through risk and crisis messaging and communications. When local health care capacity is being stretched beyond conventional care standards, the need for behavioral health alternative care strategies

Suggested Citation:"6: Toolkit Part 2: Behavioral 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.
×

becomes essential either as an adjunct to general health care treatment or as a primary intervention for major behavioral health conditions (including substance abuse and addictive disorders).

Nobody who experiences a crisis (e.g., one described by scenarios provided) is unaffected by its psychosocial impact. The individual and collective impact will introduce considerable variability in people’s ability to function. Behavioral health sequelae will impact the function of leaders, providers, and victims on both individual and collective levels. Understanding, anticipating, and specifically planning for these impacts is central to protection and promotion of the public’s health and successful event and recovery management.

Discussions within local communities that include the widest array of stakeholders with the goal of planning alternatives to conventional care and preparing for the eventuality of providing only crisis care can mitigate the premature and/or inappropriate movement to this level of care through a proactive planning and resource allocation process. The recognition and inclusion of behavioral health stakeholders and factors in these complex decisions is an essential component of sound preparedness, response, and recovery.

Roles and Responsibilities

In the broadest sense, nearly every organization and system and every governmental level has a stake in ensuring efficacious response to behavioral health factors in large-scale emergencies and disasters. Addressing adverse impacts of stress, suggesting actions, and implementing strategies that promote resilience, and ensuring efforts that provide appropriate care of those with behavioral health disorders, is in everybody’s best interest. Additional discussion about behavioral health in planning for and implementing crisis standards of care (CSC) is available in the Institute of Medicine’s (IOM’s) 2012 report Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response.

Special Circumstances

All extreme events require understanding of, and adaptation to, new and complex challenges. All of these challenges have behavioral health (as defined earlier in this chapter) elements. While all extreme events are stressful and demanding, some are especially difficult and complex. In these types of events, it is especially important that planners and incident leaders/managers understand the special psychosocial sequelae involved and ensure that behavioral health content experts are fully integrated into both decision making and response implementation. These include

Situations where a transition must be made in the fair and just allocation of resources and care when circumstances will not allow for the optimal level of care for all: These are among the most difficult challenges that health care professionals can face. These are extraordinarily complex and difficult decisions that not only involve ethical and legal factors but also have major psychological impact on those involved in these actions and choices. Planners are strongly encouraged to involve behavioral health professionals in preparing for and implementing these difficult transitions. Integrating behavioral health consultation and services into this process will enhance the probability that adverse psychological consequences for those involved can be reduced.

Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Situations resulting in large-scale incapacitation or death of health care workers: These situations not only degrade the capacity and capability of the health care system, they often bring grief and bereavement to remaining colleagues and coworkers. The result may increase the need for support services (including behavioral health) and result in performance problems in workers.

Events producing extremely large numbers of fatalities: These events (especially with special circumstances; e.g., contaminated, partial, unidentifiable, or difficult-to-retrieve remains) create special challenges. Although these regrettable circumstances may actually result in low use of prehospital and hospital care, they frequently result in a significant expansion of behavioral health issues and needs.

Events resulting in potential long-term or unknown health consequences: Events resulting in these types of health consequences can have a long-term impact on not only the medical status but also the psychosocial well-being of both workers and the general population.

Death or incapacity of key leaders and/or decision makers: Sound disaster and emergency preparedness and response rely heavily on capable and trusted leadership. In the event these leaders are unable to play their important roles, the entire response will likely be compromised. In preparing for these events it is critical that strategies be developed and implemented that anticipate absent and/or impaired (including psychological) leadership.

Events evoking extreme emotions: While all disasters provoke significant emotional responses in many, if not most, of those who experience them, some events evoke extreme emotions in large numbers of people. These reactions can have a significant impact on the health system (including behavioral health). As an example, some types of events can produce widespread rage. These events may include terrorism, violence disproportionately impacting the most vulnerable (e.g., children), and perceived social injustice. Planners should include these types of events and their impact on the public’s health in their preparedness activities.

Because panic is so widely misunderstood, a brief discussion about it may be helpful. Panic is defined as behavior in which individuals and groups engage in actions that are motivated exclusively by self-preservation, even at the expense of the health, safety, and lives of others. Issues about panic in extreme events are often not well understood. Inaccurate assumptions sometimes lead to compromised preparedness and response efforts. While panic does occur, it is extremely rare. Several conditions are typically present in those rare instances where panic does appear. These include imminent threat to life, novelty of the situation, absence of leadership and/or authority, and extremely limited or nonexistent behavioral options. Planners should challenge assumptions that panic is a common, widespread, and easily triggered phenomenon. Planning should include strategies to address conditions where panic may occur, but recognize that it is far less common than is often assumed.

DISCUSSION AND DECISION-SUPPORT TOOL

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 behavioral health. It also contains a chart that provides example behavioral health indicators, triggers, and tactics, and a blank chart

Suggested Citation:"6: Toolkit Part 2: Behavioral 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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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.

Discussion Participants and Key Stakeholders

Suggested participants and key stakeholders for a discussion focused on behavioral health are listed below.

• State and local public health agencies;

• State disaster medical advisory committee;

• State and local emergency medical services agencies;

• State and local emergency management agencies;

• Health care coalitions (HCCs), and where appropriate, U.S. Department of Veterans Affairs Medical Centers (VAMCs) and military treatment facilities (MTFs) that are part of those HCCs;

• State associations, including hospital, long-term care, home health, palliative care/hospice, and those that would reach private practitioners and other community-based providers;

• State and local law enforcement agencies;

• State and local elected officials;

• Representatives of key systems and stakeholders where changes in medical and public health (including behavioral health) status might present (e.g., large employers, primary and secondary schools, colleges and universities), law enforcement;

• Senior agency representatives for at-risk and vulnerable populations, such as persons with developmental disabilities, elder affairs, children and families, persons with acute and chronic behavioral health disorders, and developmental disabilities;

• Behavioral health practitioner associations and related licensing and regulatory boards;

• Members of the faith-based sheltering network and representatives of the behavioral health advocacy community, including, for example, Mental Health America and National Alliance on Mental Health, child/family advocacy groups, and the addiction recovery community;

• Behavioral health crisis response agencies tasked with operating various aspects of the community crisis response operations: (1) crisis lines, (2) mobile crisis teams that conduct face-to-face assessments, and (3) non-hospital-based crisis stabilization programs; and

• Additional nongovernmental agencies that could include chemical dependency recovery programs, methadone clinics, domestic abuse/sheltering agencies, and certified psychological first aid provider agencies.

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

Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Key Questions: Slow-Onset Scenario

The questions below focus on the slow-onset influenza pandemic scenario presented in Chapter 3.2

Assumptions for Responding to a Slow-Onset Event

The gradual-onset pandemic scenario presents a complex set of behavioral health issues. The pre-event readiness planning process activated preparedness structures addressing ethical, legal, public health emergency management, and public stakeholder/advocacy concerns and responsibilities. The medical advisory committee (critical care, emergency department physicians, infectious disease and pediatric specialists) established guidelines (indicators and triggers) necessary to ethically and legally move from conventional standards of care to contingency and ultimately to CSC. Each developing phase of the pandemic, starting with pre-event planning, the onset of the event, the initiation of emergency operations, monitoring of the event features, and ongoing situational awareness, is accompanied by a corresponding degree of behavioral health assessment and intervention. The emerging discrepancy between behavioral health response capabilities and increasing demand from providers, patients/families, and the general public correspond directly with the intensity and complexity of the disaster event. The behavioral health discussion will need to address the crosscutting issues and population needs before, during, and after the event. The five key elements of ethical grounding, community and provider involvement, legal authority, clearly specified indicators, triggers and lines of responsibility, and the provision of evidence-based interventions are applicable to the development of CSC for behavioral health.

Key Questions3

1. Has the specificity of the Concept of behavioral health Operations integrated into command and response structures been tested?

2. What are the specific capabilities and capacities required for patients and families?

3. What are the specific capabilities and capacities required for providers?

4. What are the specific capabilities and capacities required for the general public?

5. What is necessary for rapid triage assessment and self-assessment behavioral health triage?

6. What is the continuum of acute behavioral health interventions needed?

7. What is the continuum of acute behavioral health interventions available?

8. What is the behavioral health risk/crisis communications strategic plan for each phase of the event?

9. What is the plan for postevent gap analysis to determine short-term strategies to meet additional behavioral health demand for services?

10. What is the strategy for building and sustaining health care provider resilience for all phases of the event?

11. What epidemiological surveillance capabilities and indicators require monitoring of behavioral health factors?

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2 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.

3 Some of these questions are derived from Box 4-4 of IOM (2012, p. 1-90).

Suggested Citation:"6: Toolkit Part 2: Behavioral 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.
×

Key Questions: No-Notice Scenario

The questions below focus on the no-notice earthquake scenario presented in Chapter 3.

Assumptions for Responding to a Rapid-Onset Event

A rapid-onset event assumes immediate and massive destruction of the physical infrastructure and significant injury and loss of life to the general population within the incident area. The behavioral health impact is immediate and pervasive throughout the general population and the immediate responder community (also part of the general population). No-notice catastrophic events require strategies for addressing immediate loss of pre-event treatment capacity and accommodating mass fatalities and injury throughout the general population. Postincident trauma involves acute traumatic stress reactions throughout the responder and general population affecting all response capacity in the community. Activation and reassignment of behavioral health staff from non-impacted areas should be an integral feature of any initial (72-hour) response plan.

Key Questions

1. What behavioral health response strategy/resources can be deployed immediately and in 24-hour increments for the initial 72-hour postincident response period?

2. What specific actions should a hospital take to manage a surge involving both injured and uninjured (seeking information/bereaved) citizens?

3. Is/how is assessment of first responder capacity and fitness for duty (both physical and behavioral health) occurring?

4. Are triage strategies for the general population and delivery of low-level calming interventions in place?

5. What are the strategies for inpatient and residential behavioral health population evacuation? Are these strategies integrated with strategies of other required systems? What considerations have been made for the evacuation of the behavioral health population that receives care from community providers?

6. How is the first responder stress management cadre staffed and deployed?

7. How is surveillance of alternate care and sheltering sites for surge in demand for behavioral health intervention accomplished?

8. What are the strategies for treating widespread addiction/withdrawal?

9. What is the continuum of acute behavioral health interventions needed?

10. Is a behavioral health risk/crisis communications strategic plan in place for each phase of the event? Is there a strategy to have behavioral health input into risk/crisis communications of other stakeholders (e.g., public health, political leadership)?

11. What is the plan for postevent gap analysis to determine short-term strategies to meet additional behavioral health demand for services?

12. What is the strategy for building and sustaining health care provider resilience for all phases of the event?

13. What epidemiological surveillance capabilities and indicators require monitoring?

14. Has a disaster crisis line been activated and contact information published through traditional and other social media outlets?

Suggested Citation:"6: Toolkit Part 2: Behavioral 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: Example Table

The indicators, triggers, and tactics shown in Table 6-1 are examples to help promote discussion and provide a sense of the level of detail and concreteness that is needed to develop useful indicators and triggers for a specific organization/agency/jurisdiction; they are not intended to be exhaustive or universally applicable. Prompted by discussion of the key questions above, discussion participants should fill out a blank table, focusing on key system indicators and triggers that will drive actions in their own organizations, agencies, and jurisdictions. As a reminder, indicators are measures or predictors of changes in demand and/or resource availability; triggers are decision points (refer back to the toolkit introduction [Chapter 3] for key definitions and concepts).

The example triggers shown in the table mainly are ones in which a “bright line” distinguishes functionally different levels of care (conventional, contingency, crisis). Because of the nature of this type of trigger, they can be described more concretely and can be included in a bulleted list. It is important to recognize, however, that expert analysis of one or more indicators may also trigger implementation of key response plans, actions, and tactics. This may be particularly true in a slow-onset scenario. In all cases, but particularly in the absence of bright lines, decisions may need to be made to anticipate upcoming problems and the implementation of tactics and to lean forward by implementing certain tactics before reaching the bright line or when no such line exists. These decision points vary according to the situation and are based on analysis, multiple inputs, recommendations, and, in certain circumstances, previous experience. Discussions about these tables should cover how such decisions would be made, even if the specifics cannot be included in a bulleted list in advance.

Note: (SO) designates indicators, triggers, and tactics that are most relevant to slow-onset scenarios, and (NN) designates indicators, triggers, and tactics that are most relevant to no-notice scenarios. Indicators, triggers, and tactics without such a marking are relevant to both no-notice and slow-onset scenarios.

Suggested Citation:"6: Toolkit Part 2: Behavioral 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 6-1
Example Behavioral Health (BH) Indicators, Triggers, and Tactics for Transitions Along the Continuum of Care

Indicator Category Contingency Crisis Return Toward Conventional
Surveillance data: Community indicators

Indicators

•   Widespread acute anxiety and agitation increases presentations for treatment to and beyond normal limits

•   Hospitals experience a surge of not only medical patients, but searching family members; increased calls to hospitals as more people search for missing family members (NN)

•   Police, social services, schools, and others report increasing incidents of disruptive/ anxiety-driven behaviors (e.g., civil unrest and domestic violence, driving under the influence, etc.)

•   Increased psychiatric presentations in emergency department (ED)

•   Increased calls to BH-related crisis lines (e.g., suicide, domestic abuse, etc.)

•   Increased waiting list for appointments in BH providers

•   Hospitals begin to prematurely discharge BH patients (e.g., psychiatric, detox)

Triggers:

•   X% increase in law enforcement/social services reports

•   Jail and alternative diversion programs are at capacity

•   X% increased psychiatric presentations in ED

•   X% increased calls to BH crisis lines

•   X% increased waiting list for appointments in BH providers

•   X% of BH providers report seeing only emergency cases

Tactics:

•   Implement and expand early BH intervention strategies (e.g., psychological first aid, or PFA)

•   Implement/expand strategies to enhance crisis leadership

•   Increase overtime shifts for existing staff

•   Appropriately adjust and implement comprehensive risk/crisis communication strategies

Indicators

•   All data indicate continuing and increasing demand for BH-related services

•   Hospital services become increasingly compromised as a result of demands of searching family members (NN)

•   BH service providers are at capacity and refuse to take on new cases

•   Increased public presentation of BH casualties (e.g., overtly psychotic citizens, people ill from detox, increased drug-related crimes, etc.)

•   Widespread acute anxiety, agitation, and demand for care threaten integrity of treatment systems/sites

•   Alternative care/diversion programs (e.g., domestic violence shelters) are at capacity and cannot admit more

•   Jails are at capacity

Crisis triggers:

•   HCOs report that they can no longer admit patients exhibiting acute anxiety and agitation

•   Roads become impassable as a result of citizens evacuating and searching for members (NN)

•   EDs threaten closure because of inability to manage BH-related cases (e.g., no beds, no referral options)

Tactics:

•   Implement a variety of local mutual aid agreements and federal disaster medical assistance teams and National Disaster Medical System resources (NN)

•   Diversion of psychiatric patients

•   Seek funding and other resources including government and refer to Disaster Medical Response Units (DMRUs) and medical special needs shelters

•   Route calls searching for missing family members to disaster hotline

Indicators

•   Decline in demands for services

•   Reduction of waiting lists to preevent levels

•   Number and severity of “new” cases declines

•   Reduced reports from police, social services, schools, and others regarding BH issues

Triggers:

•   X% decline in demands for services

•   Reduction of waiting lists to preevent levels

•   X% decline in number and severity of “new” cases

•   X% reduction in reports from law enforcement, social services, schools, and others regarding BH issues

•   Pre-event BH service capacity reestablished

Tactics:

•   Continue and enhance monitoring of BH issues and service needs

•   Identify areas and/or populations with different patterns of recovery

Suggested Citation:"6: Toolkit Part 2: Behavioral 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.
×

•   Seek and expand temporary employment of workers (including retirees, former employees, etc.)

•   Implement health care organization (HCO) plan to cope with surge, sort BH and other health issues, and support staff and searching family members (NN)

•   Route calls searching for missing family members to disaster hotline

•   Transfer patients to alternative psychiatric and correctional sites designated for disaster response (SO)

•   Expand sheltering and treatment capacity of state hospitals for civil and forensic patients (SO)

Community and communications infrastructure

Indicators:

•   Families cannot find their loved ones (NN)

•   Family members are separated (e.g., in different locations at time of earthquake or transported to different treatment sites) (NN)

•   As a result of building damage, transportation system degradation, and communications systems failure, the population is unable to gather for support and ceremonies (NN)

•   Communication mechanisms are degraded or nonexistent (NN)

•   Other utilities (e.g., water, electricity) are degraded or nonexistent (NN)

•   Roads and systems are becoming overloaded as a result of families trying to find their members (NN)

•   Road congestion is complicated by arriving emergency vehicles from other jurisdictions (NN)

•   General services are compromised and goods are in short supply, causing increased anxiety and agitation

•   BH providers report delays and short supplies of prescription medication (e.g., antipsychotic, methadone, antidepression) because of supply line disruption

•   Agitation increases as many/most basic community services are compromised

•   Workplaces and schools close; status of persons in those structures unknown (NN)

•   Work and school logistics become increasingly complex as schedules adapt to impact of event (causing increased fatigue and agitation) (SO)

Indicators:

•   Road congestion becomes increasingly acute (NN)

•   All data indicate continuing and increasing demand for BH-related services

•   BH service providers are at capacity or have compromised facilities and refuse to take on new cases

•   Increased public presentation of BH casualties (e.g., overtly psychotic citizens, people ill from detox, increased drug-related crimes, etc.)

•   X% of workplaces and schools are closed (NN)

•   Workplaces and schools report X% increases in lateness/absenteeism and decreases in productivity resulting from infrastructure degradation (SO)

Crisis triggers:

•   HCOs report that they can no longer admit patients exhibiting acute anxiety and agitation

•   Alternative care/diversion programs (e.g., domestic violence shelters) are at capacity and cannot admit more

•   BH providers report they can no longer provide prescription medication (e.g., antipsychotic, methadone, antidepression) because of supply line disruption

•   Widespread acute anxiety, agitation, and demand for care threaten integrity of treatment systems/sites

Indicators:

•   Restoration of public services

Triggers:

•   Acute anxiety, agitation, and demand for care no longer threaten integrity of treatment systems/sites

Tactics:

•   Continue and enhance monitoring of BH issues and service needs

•   Identify areas of infrastructure improvement and degradation

•   Identify populations with different patterns of recovery and different infrastructure challenges

Suggested Citation:"6: Toolkit Part 2: Behavioral 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)

•   Agitation increases as mail is delayed, automated teller machines are not replenished, etc.

Triggers:

•   HCOs report that they can no longer admit patients exhibiting acute anxiety and agitation

•   Alternative care resources and diversion-receiving facilities are at capacity and cannot admit more

•   EDs threaten closure because of inability to manage BH-related cases (e.g., no beds, not referral options)

•   Jails are damaged and/or at capacity

•   Crisis phone lines and hotlines are disrupted

•   Forensic psychiatric unit is severely damaged; there is an immediate need to treat injured patients and evacuate others (NN)

•   Treatment facilities are damaged; extent of damage and continued use is unclear (NN)

Tactics:

•   Implement risk/crisis communications strategies to inform, comfort, and reassure the public

•   Implement strategies for alternative sources for, and reallocation of, prescription medications

•   Monitor and prioritize infrastructure and supply degradation for early identification and anticipatory response

•   Identify regional facilities or temporary facilities that can provide capacity

Tactics:

•   Expand mutual aid arrangements for BH medications and staff

•   Expand work-from-home programs (SO)

•   Seek funding and other resources, including government

•   Implement alternative internal and response-related communication protocols (NN)

Staff

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

Indicators:

•   Staff are also earthquake victims; their ability to report to work is unclear (NN)

•   Requests for evaluations and services from BH staff increase

•   Requests from ED for BH specialty care (e.g., children, etc.) begin to increase

•   Increased frequency of psychological stress responses among health workforce (e.g., distractibility, hostility, hypervigilance, emotional extremes, interpersonal conflicts, etc.)

•   Increased absenteeism/presenteeism of critical staff persons

Indicators:

•   Requests to BH staff for patient evaluations and services approach capacity

•   Requests for BH specialty care (e.g., children, etc.) approach capacity

•   Frequency and severity of psychological stress responses among health workforce (e.g., distractibility, hostility, hypervigilance, emotional extremes, interpersonal conflicts, etc.) compromise patient care

•   Frequency and severity of psychological stress responses among health workforce compromise relationships among staff at any or all levels within the organization

Indicators:

•   BH staff become more able to provide patient evaluations and services

•   Availability of BH specialty care (e.g., children, etc.) begins to return toward baseline

•   Staff resources increase and exhausted staff are able to rotate out of deployment

Suggested Citation:"6: Toolkit Part 2: Behavioral 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.
×
                                    

•   Increased demands on employee assistance programs (EAPs); private BH practitioners are not readily available (SO)

•   Increases in requests for psychological fitness for duty assessments of staff

•   Increased reports of stress-related sequelae in other systems (e.g., law enforcement, social services, faith organizations, etc.)

Triggers:

•   Requests to BH staff for patient evaluations and services increase by X%

•   Requests for BH specialty care (e.g., children, etc.) increase by X%

•   X% increase in staff absenteeism (NN)/ presenteeism (SO)

•   X% increases in frequency of psychological stress responses among health workforce (e.g., distractibility, hostility, hypervigilance, emotional extremes, interpersonal conflicts, unscheduled time away from duty station, increased demand for stress management support, etc.)

•   X% increase in demands on EAPs

•   X% increases in requests for psychological fitness for duty assessments of staff

•   X% increase in informal personnel complaints

Tactics:

•   Implement and expand early BH intervention strategies (e.g., PFA)

•   Implement/expand strategies to enhance crisis leadership

•   Implement expanded and alternative ways to establish and maintain contact with staff (NN)

•   If possible explore and establish a means for staff families to be housed and supported at HCO (NN)

•   Appropriately adjust and implement comprehensive risk/crisis communication strategies

•   Expand temporary employment of workers (including retired, former employees, etc.)

•   Review and appropriately modify personnel policies and practices where possible

•   Assess the potential to obtain or enhance specialized consultation in areas of workplace stress and disaster BH

•   Mobilize stress management team for responders and staff

•   Absenteeism/presenteeism compromises patient care and/or organizational function

•   EAP resources approach capacity

•   Requests for psychological fitness for duty assessments of staff approach capacity to process

•   Increasing reports of stress-related sequelae in other systems (e.g., law enforcement, social services, faith organizations, etc.), school, employers (SO)

Crisis triggers:

•   Requests to BH staff for patient evaluations and services reach capacity and no additional service can be provided

•   Existing services cannot be maintained

•   Requests for BH specialty care (e.g., children, etc.) can no longer be fulfilled

•   Absenteeism/presenteeism causes shutdown of services

•   EAPs can no longer accept new referrals and/or manage existing caseloads

•   Requests for psychological fitness for duty assessments of staff increase to a level where they cannot be processed in a timely/quality manner

•   Increase in formal personnel complaints cannot be processed in a timely/quality manner

Tactics:

•   Implement and expand early BH intervention strategies (e.g., PFA)

•   Implement or expand strategies to support leadership

•   Appropriately adjust and implement comprehensive risk/crisis communication strategies

•   Seek to expand temporary employment of workers (including retired, former employees, etc.)

•   Review and appropriately modify personnel policies and practices where possible

•   Assess the potential to obtain or enhance specialized consultation in areas of workplace stress and disaster BH

•   Implement mutual aid and other resource enhancement strategies

•   Mobilize stress management team for responders and staff (NN)

•   Frequency and severity of psychological stress responses among health workforce allows for resumption of routine staffing ratios

•   Absenteeism/presenteeism declines

•   Requests for psychological fitness-for-duty assessments of staff decline

•   Reports of stress-related sequelae in other systems (e.g., law enforcement, schools, employers, etc.) decline

Triggers:

•   BH staff are able to meet needs for patient evaluations and services

•   Reduction in absenteeism/ presenteeism to level where services begin functioning

•   EAPs begin to accept new referrals and/or can now manage existing caseloads

•   Requests for psychological fitness for duty assessments of staff decrease to baseline and can be processed in a timely/ quality manner

•   Decrease in formal personnel complaints/litigation to baseline and can be processed in a timely/ quality manner

Suggested Citation:"6: Toolkit Part 2: Behavioral 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:

•   Specialty psychiatric units experience increased use

•   Specialty psychiatric units experience damage and must treat injured and/or consider evacuation (NN)

•   Hospital triage results in BH (e.g., psychiatric, detox) patients being discharged before scheduled

•   Health care facilities initiate alternative space use plans to accommodate additional beds and space for families

•   Increases in service provision/consultation in ways other than face to face

•   Social distancing reduces support for patients, families, community (SO)

Triggers:

•   Specialty psychiatric units exceed capacity

•   Hospital triage results in BH patients being discharged before scheduled

Tactics:

•   Increase alternate care sites/services for BH patients

•   Increase surveillance of BH needs and resources across systems

•   Update mutual aid strategies/plans

•   Update plans and strategies for obtaining outside BH or other help

•   Refer to DMRUs and medical special needs shelters (NN)

Indicators:

•   Specialty psychiatric units exceed capacity

•   Specialty psychiatric units experience damage and must treat injured and/or the decision is made to evacuate (NN)

•   Hospital triage results in reduction of BH (e.g., psychiatric, detox) patients admitted

•   Increased numbers of BH patients being maintained in ED or general medical treatment areas

•   Very heavy use of service provision/ consultation in ways other than face to face

•   BH problems increase in hospitals as patient families, searching family members, and bereaved family members share space and services (NN)

•   Increasing BH problems resulting from social distancing (e.g., depression, suicide, substance abuse, etc.) (SO)

Crisis triggers:

•   Specialty psychiatric units not available and unable to safely board in ED or other locations

•   Alternative BH treatment sites/services are at capacity

•   BH patients can no longer be maintained in ED or general medical treatment areas

•   Most service provision/consultation occurs in ways other than face to face

•   BH problems compromise function/ services in hospitals as patient families, searching family members, and bereaved family members share space and services; key hospital resources are redirected to manage the situation (NN)

•   Pervasive BH problems resulting from social distancing (e.g., depression, suicide, substance abuse, etc.) (SO)

Tactics:

•   Increase surveillance of BH needs and resources across systems

•   Update mutual aid strategies/plans

•   Activate plans and strategies for obtaining outside BH or other help

Indicators:

•   Specialty psychiatric units are no longer at capacity

•   Admission of and services to BH (e.g., psychiatric, detox) patients admitted increases (NOTE: This marker of recovery involves increasing admits because it is relative to the ability to admit vs. prior lack of beds.)

•   Decreasing numbers of BH patients being maintained in ED or general medical treatment areas

•   Health care facilities require less alternative space usage, freeing up beds for BH patients

•   Care and consultation again begin to occur face to face

•   Decreasing BH problems resulting from social distancing (e.g., depression, suicide, substance abuse, etc.)/less social distancing

Triggers:

•   Specialty psychiatric units admissions and census return to baseline

•   Admission of and services to BH (e.g., psychiatric, detox) patients returns to baseline

•   BH patients being maintained in ED or general medical treatment areas returns to baseline

Tactics:

•   Maintain/increase surveillance of BH needs and resources across systems

•   Deactivate incident-specific hotlines and alternate care spaces

•   Activate plans and strategies for release or return of outside BH or other help

Suggested Citation:"6: Toolkit Part 2: Behavioral 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:

•   Demand increases for psychiatric medications and medications used to treat substance abuse disorders

•   Supply of psychiatric medications and medications used to treat substance abuse disorders decreases

•   Patients have lost their prescriptions/medications in the earthquake or are unable to access them (NN)

•   Remaining functioning pharmacies have limited computer capacity to confirm prescription status (NN)

•   Reports of self-medication increase

•   Increasing numbers of patients begin to experience/exhibit withdrawal symptoms

Triggers:

•   Demand for psychiatric medications and medications used to treat substance abuse disorders increases by X%

•   X% reduction in supply of psychiatric medications and medications used to treat substance abuse disorders

•   X% increase in numbers of behaviorally agitated patient requests for detox services for withdrawal symptoms of any type (from a wide variety of licit and illicit drugs)

Tactics:

•   Increase monitoring of supply and demand for BH-related medications

•   Implement strategies to optimize efficiency of supply lines/processes

•   Explore alternative supply lines and processes to ensure medication availability

•   Circulate guidance on alternative medications, dangers of self-dosing, and resources for help/detox

Indicators:

•   Demand or projected demand for psychiatric medications and medications used to treat substance abuse disorders exceeds supply

•   Supply of psychiatric medications and medications used to treat substance abuse disorders decreases to the point of limited medication provision

•   Self-medication becomes a significant factor in large numbers of law enforcement, emergency medical services (EMS), hospital encounters

•   Health care organizations are referring increasing numbers of patients experiencing/exhibiting withdrawal symptoms

Crisis triggers:

•   Key psychiatric and substance abuse treatment medications are no longer available

•   Self-medication becomes a significant factor in large numbers of law enforcement and health care organization encounters and compromises systems function (e.g., adverse impact on worker productivity, high demand for medical intervention, increased costs, etc.)

Tactics:

•   Increase monitoring of supply and demand for BH-related medications

•   Implement strategies to optimize efficiency of supply lines/processes

•   Implement alternative supply lines processes to ensure medication availability

•   Implement BH patient evacuation to out-of-state hospitals (SO)

•   Recommend triage strategies and dosing strategies to address critical shortages

Indicators:

•   Demand for psychiatric medications and medications used to treat substance abuse disorders and is returning toward baseline

•   Supply of psychiatric medications and medications used to treat substance abuse disorders increases

•   Self-medication becomes a declining factor in law enforcement, HCO encounters

•   HCOs see a declining number of patients experiencing/exhibiting withdrawal symptoms

Triggers:

•   Demand for psychiatric medications and medications used to treat substance abuse disorders returns to baseline

•   Supply of psychiatric medications and medications used to treat substance abuse disorders adequate to meet community needs

•   HCOs see a return to baseline in the number of patients experiencing/exhibiting withdrawal symptoms

Tactics:

•   Continue/improve monitoring of supply and demand for BH-related medications

•   Evaluate efficacy of strategies to optimize efficiency of supply lines/processes

•   Review and revise recommendations for medication use/triage

Suggested Citation:"6: Toolkit Part 2: Behavioral 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
Other categories: Fatality management

Indicators:

•   Hospital and civic morgues approach capacity

•   Community distress over visible disinterment in local cemeteries (NN)

•   Death becomes an increasing topic in conversation, media, and public meetings

•   Recovered remains are partial, creating increased stress on workers, families (NN)

•   It becomes increasingly clear that body recovery will be a protracted process, increasing stress on workers and families (NN)

•   Citizens are increasingly agitated because of delays in issuance of death certificates and resulting inability to obtain survivor benefits and services

Triggers:

•   Community experiences mass fatalities in a very short period of time

•   Death-related supplies are increasingly difficult to obtain (e.g., body bags, caskets, etc.)

•   Burials are delayed

Tactics:

•   Review mass fatality plans

•   Seek advice from BH bereavement specialists, disaster mortuary operational response teams (DMORTs), faith community, other experienced sources

•   Review and provide risk/crisis communication training

•   Convene stakeholders on a regular basis to monitor and assess trends/issues

Indicators:

•   Death rate continues unabated or increases

•   The population is unable to gather for support and ceremonies because of contagion

•   Hospital and civic morgues are at or over capacity

•   Death dominates conversation, media, and public meetings

•   Delayed recovery, including decomposition of remains, increases stress for workers and families (NN)

Crisis triggers:

•   Temporary interment and “unofficial” burials occurring or considered

•   Death-related supplies cannot be obtained (e.g., body bags, caskets, etc.)

•   Storage of remains becomes a problem and temporary solutions are employed

Tactics:

•   Implement and adapt mass fatality plans

•   Open family assistance center (NN)

•   Seek advice from BH bereavement specialists, DMORTs, faith community, other experienced sources

•   Expand risk/crisis communication training

•   Continue to convene stakeholders on a regular basis to monitor and assess trends/ issues

•   Implement mutual aid (including temporary morgues)

•   Coordinate with faith-based and cultural advocacy groups to address concerns and manage expectations about burial options, processes, risks

Indicators:

•   Death rate declines

•   The population is increasingly able to gather for support and ceremonies

•   Death becomes less dominant in conversation, media, and public meeting

•   Burials are resuming; issues of storage of remains become less acute

•   Death certificate processing times are becoming shorter

•   Media sensational and provocative stories about bodies decline and are replaced with stories of survival, resilience, and moving forward

Triggers:

•   Hospital and civic morgues can accommodate demand

•   Death-related supplies are more available (e.g., body bags, caskets, etc.)

Tactics:

•   Evaluate and modify mass fatality plans

•   Update roster of BH bereavement specialists, DMORTS, faith community, other experienced sources

•   Enlist those who can help the community memorialize the event and its aftermath as a way of individual and collective healing

•   Expand and institutionalize risk/ crisis communication training

•   Continue to convene stakeholders on a regular basis to monitor and assess trends/issues

•   Demobilize family assistance centers and other resources as appropriate

Suggested Citation:"6: Toolkit Part 2: Behavioral 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.
×
Other categories: Risk/crisis communications

Indicators:

•   Key government officials refuse to make public statements

•   “Experts” in media are increasing community fear/confusion/anger

•   Racial and ethnic groups in the community are differentially affected or obtaining and understanding different information

•   Rumors are growing

•   There is inconsistency in health messages from various official sources

•   Messaging is increasingly inconsistent with current standards of care and status of health system elements

•   Issues of social justice, historical animosities, incapable leadership, etc., begin to increase in the media and at public events

Triggers:

•   Event involves high degree of risk or concern (contagion, contamination, delayed effects)

•   Public is demanding answers/reassurance/ direction

•   Media are providing inconsistent messaging

Tactics:

•   Community leaders promoted as credible sources of information

•   Review, update, and implement crisis communication plans

•   Implement Joint Information System—develop, vet, and circulate press and information releases

•   Proactively schedule briefings and make credible experts available

•   Provide just-in-time crisis communication training for formal and informal leaders

•   Seek specialized consultation and advice regarding risk/crisis communication

•   Increase content monitoring and analysis of media (including social media) for tone, accuracy, usability, consistency

•   Obtain information from nontraditional sources to determine how information is being provided/interpreted in vulnerable or specific cultural groups

Indicators:

•   Public is increasingly insistent and angry at lack of direction and answers

•   Media continue to provide inconsistent messaging even when provided with credible information

•   Some community leaders are discredited as sources of information; they are marginalized and/or removed

•   Key government officials continue to refuse to make public statements

•   “Experts” in media are increasing community fear/confusion/anger; some come to the community and create increased disruption

•   Racial and ethnic groups in the community are differentially affected or obtaining and understanding different information; talk of demonstrations and civil protest increases

•   Rumors are growing

•   There continues to be inconsistency in health messages from various official sources

•   Messaging is increasingly inconsistent with current standards of care and status of health system elements

•   Information is inaccurate and changing about locations for vaccinations, causing anger among the general population

Crisis triggers:

•   Issues of social justice, historical animosities, incapable leadership, etc., dominate the media and public events

•   Civil unrest occurs

Tactics:

•   Aggressive implementation of crisis communication plans—additional resources for rumor control, specific population targeted messages, social media responses

•   Provide just-in-time crisis communication training for formal and informal leaders

•   Seek specialized consultation and advice regarding risk/crisis communication

•   Increase content monitoring and analysis of media for tone, accuracy, usability, consistency

Indicators:

•   Public is increasingly satisfied with information they are receiving; less public anger and frustration

•   Emerging community leaders are solidified in their roles as credible sources of information

•   Discredited leaders are seen and heard from less

•   Key government officials increase public visibility and apply risk/communications training in their public statements

•   The media are moving on to other stories and outside “experts” are seen less frequently; the community is increasingly perceived as able to handle challenges

•   Different racial and ethnic groups in the community are increasingly getting the same credible information; talk of demonstrations and civil protest decreases

•   Rumors are identified early and accurate information is effectively communicated

Triggers:

•   Media are providing more consistent messaging and increasingly use credible information

•   Consistency in health messages from various official sources increases

•   Messaging more accurately reflects current standards of care and status of health system

Tactics:

•   Evaluate and revise crisis communication plans

•   Institutionalize crisis communication training for formal and informal leaders

•   Update roster of specialized consultants/advisers in risk/crisis communication

Suggested Citation:"6: Toolkit Part 2: Behavioral 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
Other categories: Risk/crisis communications (continued)

•   Deploy crisis counseling teams to health resource lines to address social unrest

•   Convene stakeholders regarding issues of, and strategies for, crisis communication

•   Focus on positive accomplishment or developments in communications

•   Meet with major media to emphasize gravity of situation and attempt to address conflicts in messaging

•   Continue and enhance content monitoring and analysis of media for tone, accuracy, usability, consistency

•   Continue to convene stakeholders regarding issues of, and strategies for, crisis communication

•   Focus on positive accomplishments/developments

•   Continue to aggressively address rumors and monitor new developments

Suggested Citation:"6: Toolkit Part 2: Behavioral 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.4

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 behavioral 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, and (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.

____________________

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

Suggested Citation:"6: Toolkit Part 2: Behavioral 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:"6: Toolkit Part 2: Behavioral 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:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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Suggested Citation:"6: Toolkit Part 2: Behavioral 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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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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