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Transmittal Letter
Pages 1-92

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From page 1...
... Specifically, the committee was asked to identify and describe the key elements that should be included in standards of care protocols, to identify potential triggers, and to develop a template matrix that can be used by state and local public health officials as a framework for developing specific guidance for healthcare provider communities to develop crisis standards of care. The committee was asked to consider the roles and responsibilities of various stakeholders in the implementation of the guidance, and to consider mechanisms for integrating the views of the general public and healthcare providers in the development and implementation of the guidance.
From page 2...
... The committee was tasked to develop national framework guidance on the key elements that should be included in standards of care protocols for disaster situations. Ethical norms in medical care do not change during disasters – health care professionals are always obligated to provide the best care they reasonably can under given circumstances.
From page 3...
... The formal declaration that crisis stan dards of care are in operation enables specific le gal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternate care facility operations. To ensure that the utmost care possible is provided to patients in a catastrophic event, the nation needs a robust system to guide the public, healthcare professionals and institutions, and governmental entities at all levels.
From page 4...
... This guidance includes criteria for determining when crisis standards of care should be implemented, key elements that should be included in the crisis standards of care protocols, and criteria for determining when these standards of care should be implemented. With the intent of assisting the many states that are still in the early stages of developing crisis standards of care, the committee lays out a broad process for developing crisis standards of care protocols that encompasses the full spectrum of the health system, including emergency medical services and dispatch, public health, hospital-based care, home care, primary care, palliative care, mental health, and public health.
From page 5...
... An ethical framework serves as the bedrock for public policy and cannot be added as an afterthought. Hence, ethical principles underlie the committee's vision for crisis planning, outlined above.
From page 6...
... When resource scarcity reaches catastrophic levels, clinicians are ethically justified – and indeed are ethically obligated – to use the available resources to sustain life and well-being to the greatest extent possible. As a result, the committee concluded that ethics permits clinicians to allocate scarce resources so as to provide necessary and available treatments preferentially to those patients most likely to benefit when operating under crisis standards of care.
From page 7...
... Recommendation: Ensure Consistency in Crisis Standards of Care Implementation State departments of health, and other relevant state agencies, in partnership with localities should ensure consistent implementation of crisis standards of care in response to a disaster event. These efforts should include: • Using "clinical care committees," "triage teams," and a state-level "disaster medical advisory committee" that will evaluate evi dence-based, peer-reviewed critical care and other decision tools and recommend and im plement decision-making algorithms to be used when specific life-sustaining resources become scarce; • Providing palliative care services for all pa tients, including the provision of comfort, compassion, and maintenance of dignity; • Mobilizing mental health resources to help communities -- and providers themselves -- to manage the effects of crisis standards of care
From page 8...
... The guidance outlined here is intended to assist federal, tribal, state, and local officials in the development of more uniform crisis standards of care policies and protocols that are applicable in any disaster impacting the public's health. Applying the guidance and principles laid out in the report, the committee developed two brief case studies that may serve to illustrate the implementation crisis standards of care.
From page 9...
... Gostin, J.D., Chair Dan Hanfling, M.D., Vice Chair Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations
From page 10...
... . The Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations brings together a broad spectrum of expertise, including state and local public health, emergency medicine and response, primary care, nursing, palliative care, ethics, the law, behavioral health, and risk communication (Appendix E)
From page 11...
... The letter report will provide guidance on standards of care for use in disaster situations. Specifically, the committee will: • Develop preliminary framework guidance that identifies and describes the key elements that should be included in disaster standards of care protocols; • Identify potential triggers that can be used by state and local public health officials to develop standards of care protocols that will assist healthcare providers; • Develop a template matrix that can be used by state and local public health officials as a framework for developing specific guidance for healthcare providers to develop disaster standards of care; • Consider roles and responsibilities of various stakeholders in the im plementation of the guidance; and • Consider mechanisms for integrating the views of the general public and healthcare providers in the development and implementation of the guidance.
From page 12...
... In addition, the committee will develop guidance that will include information for healthcare providers from primary care, home health, community health centers, and other provider communities not traditionally engaged. two case studies that illustrate the application of the guidance and principles laid out in the report to two different scenarios (Appendix C)
From page 13...
... Scarce Resources, Demand for Healthcare Services, and Standards of Care In preparation for response to any large-scale disaster or public health emergency, healthcare facilities are developing surge plans that include efforts to increase and maximize use of available resources, as well as to manage demand for healthcare services. Facilities can use resource-sharing agreements (e.g., mutual aid agreements)
From page 14...
... Faced with severe shortages of equipment, supplies, and pharmaceuticals, an insufficient number of qualified healthcare providers, overwhelming demand for services, and a lack of suitable space, healthcare practitioners will have to make difficult decisions about how to allocate these limited resources if contingency plans do not accommodate incident demands. Under these circumstances, it may be impossible to provide care according to the conventional standards of care used in non-disaster situations, and, under the most extreme circumstances, it may not even be possible to provide the most basic life-sustaining interventions to all patients who need them.
From page 15...
... State and Local Policies and Protocols The issue of crisis standards of care for use in disaster situations involving scarce resources arose largely since 2004, when the Agency for Healthcare Research and Quality (AHRQ) and the ASPR within HHS convened a meeting of experts.
From page 16...
... These regional meetings on Standards of Care During Mass Casualty Events were designed to describe and demonstrate the current regional, state, and local efforts to establish disaster standards of care policies, and to improve regional efforts by facilitating dialogue and coordination among neighboring jurisdictions.
From page 17...
... It will also provide an opportunity to update and expand the crisis standards of care guidance based on input and feedback from individuals involved in the development and implementation of crisis standards of care.
From page 18...
... The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternate care facility operations. To ensure that the best care possible is provided to patients in a catastrophic event, the nation needs robust and carefully-developed guidance for the public, healthcare professionals and institutions, and governmental entities at all levels.
From page 19...
... , published literature, and
From page 20...
... Recommendation 1: Develop Consistent State Crisis Standards of Care Protocols with Five Key Elements State departments of health, and other relevant state agencies, in partnership with localities should ensure that crisis standards of care protocols include five key elements -- and associated components -- detailed in this report: • A strong ethical grounding; • Integrated and ongoing community and pro vider engagement, education, and communi cation; • Assurances regarding legal authority and en vironment; • Clear indicators, triggers, and lines of re sponsibility; and • Evidence-based clinical processes and opera tions.
From page 21...
... LETTER REPORT 21 TABLE 1 Five Key Elements of Crisis Standards of Care Protocols and Associated Components Key Elements of Crisis Standards of Care Protocols Components Ethical considerations o Fairness o Duty to care o Duty to steward resources o Transparency o Consistency o Proportionality o Accountability Community and provider o Community stakeholder identification engagement, education, and with delineation of roles and involvecommunication ment with attention to vulnerable popu lations o Community trust and assurance of fair ness and transparency in processes developed o Community cultural values and bounda ries o Continuum of community education and trust building o Crisis risk communication strategies and situational awareness o Continuum of resilience building and mental health triage o Palliative care education for stakeholders Legal authority and o Medical and legal standards of care environment o Scope of practice for healthcare profes sionals o Mutual aid agreements to facilitate re source allocation o Federal, state, and local declarations of: o Emergency o Disaster o Public health emergency o Special emergency protections (e.g., PREP Act, Section 1135 waivers of sanctions under EMTALA and HIPAA Privacy Rule) o Licensing and credentialing o Medical malpractice
From page 22...
... o Event specific o Illness and injury -- incidence and severity o Disruption of social and commu nity functioning o Resource availability Triggers for action o Critical infrastructure disruption o Failure of "contingency" surge capacity (resource-sparing strategies over whelmed) o Human resource/staffing avail ability o Material resource availability o Patient care space availability Clinical process and Local/regional and state government processes operations to include: o State-level "disaster medical advisory committee" and local "Clinical care committees" and "triage teams." o Resource-sparing strategies o Incident management (NIMS/HICS)
From page 23...
... This report contains guidance to assist state public health authorities in developing these crisis standards of care in partnership with their regional and local public health authorities, including the key elements that should be included in the crisis standards of care protocols and criteria for determining when crisis standards of care should be implemented. Although the state authority has the responsibility to establish, and ultimately determine, when to implement crisis standards of care, stakeholders should be important partners in this process, including healthcare professionals and institutions, public health and emergency management agencies, and state residents.
From page 24...
... , but should also be ex panded to include comprehensive representation from healthcare practitioners and professional associations in relevant specialties, including but not limited to nurses, physicians, emergency medi cal technicians, a range of specialists from pediatrics to geriat rics, mental health, palliative care, healthcare facilities, and other relevant entities such as the American Red Cross. Although this committee's deliberations will focus on complex medical issues, ethicists and public safety specialists should also be included in
From page 25...
... Although these steps are an integral component of establishing standards of care protocols, few authorities have actively engaged in these efforts. Guidance on this process is provided in the "Community and Provider Engagement" section.
From page 26...
... In addition, as will be described in more detail later in the report, during a disaster the Medical Disaster Advisory Committee will work closely at a lo cal level with "clinical care committees" and "triage teams." Several states and localities have begun to develop scarce resource allocation protocols; however, few have provided guidelines for decision tools that will be needed during an incident (California Department of Public Health, 2008; Virginia Department of Health, 2008; Powell et al., 2008; Colorado Department of Public Health and Environment, 2009; The Commonwealth of Massachusetts Department of Public Health, May 2007; Levin et al., 2009; Minnesota Department of Health, 2008; The Utah Hospitals and Health Systems Association, 2009; Washington State Department of Health's Altered Standards of Care Workgroup, October 2008; Houston/Harris County Committee, 2007)
From page 27...
... These protocols form the basis of much of this committee's deliberations and could serve as useful models for those states that are just beginning the process of developing crisis standards of care protocols. To ensure consistent implementation, states should ensure that protocol development is in accordance with the guidance and key elements outlined in this report, but existing state protocols could be used to avoid unnecessary duplication of effort and as a model for developing and implementing those key elements at the appropriate level of detail.
From page 28...
... The Guideline Development Working Group should determine how best to weigh competing demands given local values, priorities and available resources. Fairness The overarching ethical goal in developing crisis standards of care protocols is for them to be recognized as fair by all affected parties -- even including those who might later be disadvantaged by the protocols.
From page 29...
... The covenant between professional and patient gains rather than loses value in a public health disaster, when members of the community are justifiably frightened and numerous institutions and support systems face great strain. Recognizing that scarce resources may restrict treatment choices, clinicians must not abandon, and patients should not fear abandonment, when an ethical framework informs
From page 30...
... Duty to Steward Resources Healthcare institutions and public health officials also have a duty to steward scarce resources, reflecting the utilitarian goal of saving the greatest possible number of lives. Professionals must balance this duty to the community against that to the individual patient.
From page 31...
... These policies must reflect specific values in choices about contested issues, such as priority setting for access to scarce resources and restrictions on individual choice. A public engagement process is crucial for drafting ethical policies that reflect the communities' values and deserve its trust.
From page 32...
... The public may find that scarce resources have not been allocated fairly if patients at different hospitals in the same affected area receive vastly different levels of care. Consistent policies may also help eliminate unfair local efforts to discriminate against vulnerable groups on the basis of factors such as race or disability.
From page 33...
... Furthermore, ventilators require trained staff to operate them and availability of necessary medications, and thus depend on the additional scarce resources of personnel and drugs. In an influenza pandemic, severe respiratory illness will also increase the need for and scarcity of ventilators.
From page 34...
... The VHA chose to exclude from triage protocols those patients chronically supported by ventilators and living in long-term care facilities or at home, arguing that this choice represented the best available balance between the duty to care and to exercise stewardship of scarce resources. Regarding ventilator allocation as applied to individual patients and healthcare professionals, disaster plans must minimize the need for such painful choices by requiring that all possible steps to augment and substitute for scarce resources precede any reallocation of scarce resources.
From page 35...
... Despite removing a vital treatment, a clinician must continue to provide compassionate care. In stewarding resources, palliative care will be prioritized to those critically ill patients who do not meet allocation criteria for scarce resources.
From page 36...
... Proportionality requires that this drastic infringement on the autonomous choice of patients or the professional judgment of clinicians is not invoked unless all other reasonable surge strategies have been implemented. Finally, accountability demands that professionals follow triage guidelines for assigning scarce resources and can support their decisions based on good-faith efforts to adhere to disaster policies.
From page 37...
... Both groups are part of the same community, but specific engagement efforts aimed at both types of community stakeholders, across all phases of disaster planning and response, are necessary to ensure effective engagement and engender trust in the processes and systems put in place (Table 2)
From page 38...
... . In partnership, these entities should then work with healthcare providers and their institutions to communicate with and engage community stakeholders in the disaster-planning phase, explaining that crisis standards of care will be applied in disasters during unresolvable circumstances of resource scarcity.
From page 39...
... The reasoning behind the decision to implement crisis standards of care in emergency situations must be explained with a high degree of transparency to all stakeholders involved. This engagement dialogue should be inclusive of the opportunity for community stakeholders to articulate underlying community values and ethical principles of fairness and social justice to ensure that healthcare providers apply these principles appropriately during times of crisis (Houston/Harris County Committee, 2007; Powell et al., 2008; LiVollmer, 2009)
From page 40...
... Building on the trust and credibility that were established during the predisaster phase, governmental entities in partnership with healthcare professionals and institutions will need to provide clear, timely, effective, and appropriate crisis risk communication so that community stakeholders will receive needed ongoing situational awareness of the disaster's impact on precious health system resources as the situation unfolds. Although a number of crisis risk communication tools are available, evaluation of such tools is beyond the scope of this committee's work.
From page 41...
... Customized, event-specific risk communications, emergency public health information linked with resilience enhancing psychoeducational coping information, and coping strategies that use social networks to cope with fears and loss may serve to "inoculate" the population and the healthcare workforce from the effects of a mass casualty event requiring crisis standards of care. For example, in a pandemic incident, a key resilience component could be a "Coping with scarce resources/mass casualty events" module disseminated through emergency public information and messaging.
From page 42...
... Concerns for other vulnerable populations such as children, older adults, persons with disabilities, and individuals with medical special needs must also be considered during disaster planning and response because these factors may also impact morbidity and mortality. The needs, challenges, and barriers to caring for these specific community stakeholders must also be considered for integration into the overall disaster response effort prior to the implementation of crisis standards of care.
From page 43...
... Particular attention should be given to mental health triage and needs, especially bereavement, as individuals begin the process of recovery from the dual impacts of both the crisis medical care environment and other non-medical impacts of the incident. Health education, risk communication, community outreach, and other wellestablished strategies should be incorporated in the recovery phase to ensure that the needs of the community -- particularly those from populations that may have been disproportionately impacted during the crisis -- are attended to as the medical system returns back toward normalcy (Schoch-Spana et al., 2007)
From page 44...
... Distinguishing Medical and Legal Standards of Care and Scope of Practice Modern studies and assessments improve our understanding of how healthcare services change during emergencies to ensure optimal health outcomes (AHRQ, 2005b; GAO, 2008; AMA, 2007; Romig, 2009; Christian et al., 2006; Kanter, 2007)
From page 45...
... among types of medical facilities such as hospitals, clinics, and alternate care facilities, and (2) based on prevailing circumstances, including during emergencies.
From page 46...
... . Emergency declarations trigger an array of non-traditional powers that are designed to facilitate response efforts through public and private sectors.
From page 47...
... Recommendation 4: Provide Necessary Legal Protec tions for Healthcare Practitioners and Institutions Implementing Crisis Standards of Care In disaster situations, tribal or state governments should authorize appropriate agencies to institute crisis standards of care in affected areas, adjust scopes of practice for licensed or certified healthcare practitioners, and alter licensure and credentialing practices as needed in declared emergencies to create incentives to provide care needed for the health of individuals and the public. Legal Challenges Concerning Standards of Care in Declared Emergencies Healthcare providers responding to public health emergencies involving scarce resources may confront numerous legal challenges, as summarized below.
From page 48...
... . There are no comprehensive national liability protections for healthcare providers or entities in all settings.
From page 49...
... This existing patchwork of liability protections can complicate planning and response efforts and deter emergency response participation. Emergency liability protections often have limitations.
From page 50...
... Individual privacy must also be assessed against the need for government or others to provide adequate care or review identifiable health data in health emergencies (Hodge et al., 2004)
From page 51...
... This will result in a healthcaresector response that requires implementation of a variety of "surge capacity" strategies that include steps taken to reduce demand for care (e.g., the implementation of community-based triage capabilities and risk communication about when to seek care) and the augmentation of ambulatory care capacity in addition to better described inpatient care strategies (Hick et al., 2004; Kaji et al., 2006; Barbisch and Koenig, 2006; Davis et al., 2005; Kelen et al., 2006, 2009; California Department of Public Health, 2008 ; Hanfling, 2006)
From page 52...
... These spaces and practices are used during a major mass casualty incident that triggers activation of the facility emergency operations plan. Contingency capacity -- The spaces, staff, and supplies used are not consis tent with daily practices, but provide care that is functionally equivalent to usual patient care practices.
From page 53...
... Along the span from conventional to crisis care, healthcare facilities should attempt to minimize changes that significantly impact patient outcomes by changing work practices in order to focus resources on patient care (Phillips and Knebel, 2007; ANA, 2008; Gebbie et al., 2009) (Figure 1)
From page 54...
... . TABLE 3 Sample Strategies to Address Resource Shortages Conventional Contingency Crisis Capacity Capacity Capacity Prepare Stockpile supplies used Substitute Equivalent medica tions used (narcotic substitution)
From page 55...
... , diac arrest calls, decline closest hospital destina- service to noncritical, tion nonvulnerable patients and to critical patients with little to no chance of survival Broadening surge capacity must incorporate the full spectrum of patient care delivery capabilities in a disaster-impacted community. This includes planning for extension of hospital-like services in an unregulated, non-healthcare setting.
From page 56...
... In such conditions, a decision to relocate most care from hospital emergency departments to alternate care facilities would comprise a change in the usual standard of care, but superior quality compared to attempting to maintain ordinary use of the usual facilities. Disaster Mental Health Crisis Standards of Care In major disaster and emergencies, there will also be a surge of psychological casualties among those directly affected, including responders, healthcare practitioners, and members of the population who have not experienced direct impact.
From page 57...
... . Palliative Care Planning for Crisis Standards of Care The provision of palliative care in the context of a disaster with scarce resources is a relatively new component of disaster planning.
From page 58...
... Planners should: • Develop evacuation plans for existing and new palliative care patients; • Develop a community response plan, staffing plans, and training programs for first responders and other relevant medical person nel;
From page 59...
... . BOX 3 Palliative Care Triage Tools Flacker Mortality Score: Flacker and Kiely developed a model for identifying factors associated with one-year mortality (the probability of death within the next year)
From page 60...
... • Vasopressors/inotropes • Medical transportation Implementation of crisis standards of care first requires recognition of a resource shortfall or impending resource shortfall. However, good situational awareness and incident management can often forestall any requirement to adjust standards of care as patients can either be moved to areas with resources or resources can be brought in to ameliorate the shortage prior to significant consequences for the patient(s)
From page 61...
... The members did feel strongly, however, that waiting for hard "trigger" evidence of crisis care was inappropriate, and that the goal should be anticipation of resource shortages based on situational awareness (including tracking of indicators) , with correction of the problem prior to crisis when possible.
From page 62...
... Outpatient care Marked increase in appointment demand or unable to reach clinic due to call volume Staff illness rate > 10% > 10% > 10% School Not applicable > 20% > 20% absenteeism
From page 63...
... Therefore, this issue needs to be considered when formulating crisis standards of care protocols for use in disaster situations. Trigger events revolve around changes to staff, space, and supplies that constitute a change in standard practices such that morbidity and mortality risks to the patient increase (i.e., to crisis standards of care)
From page 64...
... Staff Specialty staff unavailable in timely manner to provide or adequately supervise care (pediatric, burn, surgery, critical care) even after call back procedures have been imple mented Supply Supplies absent or unable to substitute, leading to risk to patient of morbidity (including untreated pain)
From page 65...
... Crisis Standards of Care Triage Triage occurs routinely in medicine, when resources are not evenly distributed or temporarily overwhelmed. Examples include transfer of a patient to a trauma or burn center because most hospitals do not specialize in these types of care, or a mass casualty incident when priority must be assigned for diagnostic imaging or surgery.
From page 66...
... is transition point to pro active) Situational awareness Poor Good Resource availability Extremely dynamic (over Relatively static
From page 67...
... Decision making Unstructured, ad hoc Structured Regional and state No Yes guidance and legal protections Regional partner Available Unavailable (usually) assistance Proactive triage involves systematic decisions made by clinical or administrative personnel to a situation requiring resource triage where situational awareness is available and the decision-making is accountable to the incident management process.
From page 68...
... . Situational Awareness Situational awareness will improve the ability to predict and recognize resource shortages and allocate fairly to minimize disparities.
From page 69...
... . All healthcare facilities and entities must have a well-practiced incident management system and understand their plans for notification, activation, mobilization of resources, and continuity of operations.
From page 70...
... 70 CRISIS STANDARDS OF CARE GUIDANCE FIGURE 2 Overview of relationships among agencies, committees, and groups NOTE: Depending on the organization of the state, the functional layout, details, and relationships among the units might vary.
From page 71...
... Healthcare coalitions should be designed to provide added administrative and logistical support to the many components of the health system that need to share limited resources or to transfer patients due to disaster situations. Notably, during a catastrophic disaster, reliance on the state or adjacent regions may become greater.
From page 72...
... The coalition must be integrated with key stakeholder agencies within ESF-8, including the broader "health system" (which may include clinics, long-term care facilities, behavioral health, and specialty resources, e.g., dialysis) as well as local and regional public health entities, emergency management entities, and emergency medical services.
From page 73...
... These facilities have assigned staff to attend to the emergency management requirements of their healthcare facilities, and most recently have designated a public health emergency officer on each of its bases to assist in the coordination of planning for a major public health emergency (Hachey, 2009)
From page 74...
... The state EOC is also the means for relaying information to the local level from neighboring states and the federal partners regarding situational awareness related to resource availability and conditions of medical practice in other regions. Coordination of care in a disaster event is of paramount importance to the successful mitigation and response effort.
From page 75...
... If these strategies cannot be carried out, or if partner facilities are in the same situation (e.g., a pandemic influenza scenario) , then systematic implementation of crisis standards of care at the state level may become necessary in order to codify and provide guidance for triage of life-sustaining interventions as well as to authorize care provided in non-traditional locations (alternate care facilities)
From page 76...
... Thus, the state, through its emergency powers, resource allocation, and provision of clinical guidance, attempts to "level the playing field" at the state level, as well as provide legal protections for providers making difficult triage decisions and provide relief from usual regulations that might impede coping strategies such as alternate care facilities. Regional healthcare coalition data on the status of patient care delivery and access to key resources should be reflected to the state level, where the state EOC synthesizes information.
From page 77...
... A sample institutional process is outlined in Box 5 below. Clinical Care Committee The individual healthcare institution surge capacity plan should incorporate the use of a "clinical care committee" that is composed of clinical and administrative leaders who can focus a hospital or hospital system approach to the allocation of scarce, life-saving resources (Phillips and Knebel, 2007; Hick and O'Laughlin, 2006; O'Laughlin and Hick, 2008)
From page 78...
... c. Changes in staff responsibilities -- to allow specialized staff to redis tribute workload (e.g., floor nurses provide basic patient care in the intensive care unit while critical care nurses "float" and trouble shoot)
From page 79...
... . A clinical care committee is activated by the facility incident commander when the facility is practicing contingency or crisis care due to factors that are not readily reversible.
From page 80...
... In this case, the clinical care committee should appoint or ensure access to a triage team, which will use decision tools appropriate to the event and resource being triaged to make allocation decisions (Devereaux et al., 2008b; AHRQ, 2005b; Hick et al., 2007; Hick et al., 2004; O'Laughlin and Hick, 2008)
From page 81...
... . Decision Tools and Resource Use Guidance Decision tools are used by the triage team as a basis for, or to at least inform, triage decisions.
From page 82...
... Though much of the core component guidance does apply, agencies and entities should examine potential scarce resources and outline coping strategies using base principles similar to those for hospital environments (Rubinson et al., 2008; ANA, 2008)
From page 83...
... However, these may be inex pensively and easily stockpiled. In mass casualty events, an age/percentage burn table has been published as an adjunct for triage decisions (Saffle et al., 2005)
From page 84...
... In situations of resource shortages where the resource is titrated or dosed (medications, IV fluids, blood products, but not ventilators) , the clinical care committee may wish to establish a ceiling on the amount of resources required in addition to changes to indications for treatment (Propper et al., 2009; Beekley et al., 2007; Eastridge et al., 2006; AMA, 2007)
From page 85...
... to predict outcome by assessing degree of organ system dysfunction and is one of the least complex and most predictive available metrics for prognosis prediction in critical care. Some systems consider other factors such as expected duration of ventilation, underlying diseases, or duration of benefit (Minnesota Department of Health, August 2008; Devereaux et al., 2008b)
From page 86...
... Adopters of decision tools should understand their limitations and scope and communicate issues of uncertainty to the triage team members. The only process and triage system that is the output of an expert, specialty society working group with broad stakeholder input at this time is that of the American College of Chest Physicians (ACCP)
From page 87...
... . If triage of mechanical ventilation/critical care becomes necessary assess existing critical care patients according to: • SOFA score • Expected duration of mechanical ventilation • Any severe, life-limiting underlying disease states • Other disease-specific factors Order patients from most sick to least sick and reassess daily or as conditions warrant New patient requires mechanical ventilation - Assess patient SOFA score, expected duration (rough)
From page 88...
... (2008b) Critical care and ventilator allocation decision tools should be consistent with currently available evi dence-based expert panel and national critical care guidelines, although modifications may be made to meet the specific needs of the state.
From page 89...
... These efforts should include: • Using "clinical care committees," "triage teams," and a state-level "disaster medical advisory committee(s) " that will evaluate evi dence-based, peer-reviewed critical care and other decision tools and recommend and im plement decision- making algorithms to be used when specific life-sustaining resources become scarce.
From page 90...
... These populations -- as described in the committee's report -- should be given particular attention to make sure their unique needs are considered in disaster planning and response efforts. As such, the Committee supports the efforts of the World Health Organization and similar agencies in affirming the importance of addressing health inequities and the social determinants of health because those most vulnerable in communities prior to a disaster are those most likely to be impacted adversely by the disaster itself (WHO, 2008)
From page 91...
... • Planning for the health and medical response to a catastrophic, mass casualty event must take a regional, systems approach, and involve a broad array of public and private community stake holders. • Adequate ethical and legal frameworks must be in place that pro tect both the rights of patients and the rights of those providing care to patients, despite the austere conditions under which such care is being delivered.
From page 92...
... o Uncertain expectations for completion of diminished documentation o Uncertain process for deescalation from crisis care to conventional care (return to "normalcy") o Uncertain processes for developing constructive after action reports documenting crisis care responses o Uncertain strategy for using community-based assets of the health system (i.e., private practices, ambulatory care clinics)


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