Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations A Letter Report (2009) / Chapter Skim
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C Crisis Standards of Care Implementation Guidance Scenarios
C Crisis Standards of Care Implementation Guidance Scenarios
Pages 119-132
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From page 119... ...
For each scenario specific activities are indicated in italics and mapped by number to key elements and core components from the committee's guidance. Major Influenza Pandemic Scenario Key elements/core components Scenario Description: An influenza pandemic was selected to demonstrate a response to the need to implement crisis standards of care as a result of a gradual-onset disaster event.
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From page 120... ...
The Disaster Medical Advisory Committee was tasked with obtaining quarterly data from this system and determining thresholds that would prompt an alert to the regional hospital coalition that patient care demand for services was increasing. State preparation also included planning for the establishment of alternate care facilities, if necessary, for acute, palliative, and behavioral health care.
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From page 121... ...
A few of the in-state regional hospital coalitions convened 10Incident management – State Agency Role their own regional advisory committees10 to modify and customize this guidance to make it applicable for their local needs. At the hospital level, pandemic planning included members of the 11Clinical Process and Operations: Clinical care in crisis predesignated disaster clinical care committees11, situations who approved and/or modified these tools and guidance for institutional use.
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From page 122... ...
care operations: Use of the Area hospitals moved from conventional care to Regional Medical Coordinating contingency care as the pandemic worsened, with Center (RMCC) many reducing elective surgeries, boarding ICU patients in stepdown units, boarding floor patients 14State Public Authorities in procedure and postanesthesia care areas, and Process: Public health setting up rapid screening and treatment areas14 emergency for the mildly ill apart from the emergency department, where volumes had escalated to nearly double usual daily volumes.
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From page 123... ...
committee As demand increased, hospital incident 25Legal Authorities: Executive commanders convened their clinical care order committees26 in order to prioritize available hospital resources toward patient care, as well as 26Clinical Process and anticipating those resources that may soon be in Operations: Intrastate regional short supply. Many of these committees used prior consistencies guidance for scarce resource situations from the state DOH and other "evidence-based" sources in 27Clinical Process and their recommendations at each operational period Operations: Communications to the incident commander27.
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From page 124... ...
"Triage teams34" were thus activated to assist with these clinical allocation decisions by their institutional clinical care committees. Rural hospitals used a phone-in metropolitan hospital triage team (three were set up in the state via the RMCC in coordination with state DOH)
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From page 125... ...
38Clinical Process and Patients with mental health needs38 continued to Operations: Mental health needs stress many elements of the healthcare delivery system and required significant resources. Alternate care sites that were once used as "flu centers" or to help decompress overwhelmed hospitals were now being used to provide mental health screening and therapeutics, when indicated.
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From page 126... ...
However, it highlights many of the basic key elements and core components required to implement crisis standards of care in a disaster. Scenario: It is a relatively quiet afternoon in the emergency department of Hillendale Hospital in Southern California, a 232-bed Level 2 trauma center, when without warning, the shaking begins.
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From page 127... ...
Due to the power outage, no elective Operations: Resource-sparing cases are being performed5. strategies A few staff are able to make it in to the hospital, including an administrator who takes over the role 6Clinical Process and of incident commander and requests that the Operations: Coordination of nursing supervisor pull together members of the resource management, use of predetermined clinical care committee in order to clinical care committee take stock of available resources6 and, in conjunction with the planning chief, determine 7Clinical Process and Operations: Resource-sparing ways to conserve7 blood products, intravenous strategies; Ethical Elements: fluids, narcotics, antibiotics, and surgical supplies.
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From page 128... ...
The hospital Engagement: Provider roles and "clinical care committee" has included burn and involvement trauma triage information19 with its daily recommendations to the incident commander because of this anticipated surge in demand for care. Given that staff surgeons will perform triage 20Clinical Process and based on their clinical judgment, there is no need to Operations: Resource-sparing activate the plan for a hospital "triage team".
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From page 129... ...
Reports continue to come in to the state EOC that hospitals that are functioning in the affected disaster zone are being inundated with patients seeking care. Hillendale Hospital reports that complete reliance on back-up generator power has limited the number of critical care medical devices that can be supported, while the number of patients requiring critical care interventions continues to 28Indicators and Triggers: Illness rise.
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From page 130... ...
That afternoon, members of an internal state disaster response team arrive to begin relieving surgeons and emergency department (ED) physicians.
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From page 131... ...
APPENDIX C 131 The State Health Department has also issued interim guidance33 for tetanus vaccine 33Legal Authority and administration in response to this common Environment: Scope of practice complaint and is monitoring the daily conference calls and RMCC web-based messaging to identify other issues for the state DOH and the State Disaster Medical Advisory Committee. Fortunately, despite huge demands on the hospital, Hillendale was never forced to appoint a "triage team" or restrict access to critical care resources.
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