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2: Indicators and Triggers
Pages 41-74

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From page 41...
... The tornado seems to be a perfect indicator (providing discrete information that is certain, and can be easily acted on) to trigger emergency medical services (EMS)
From page 42...
... (Examples include disaster declaration, establishment of an emergency operations center [EOC] and multiagency coordination, establishment of alternate care sites, and surge capacity expansion.)
From page 43...
... . Crisis care trigger: The point at which the scarcity of resources requires a tran sition from contingency care to crisis care, implemented within and across the emergency response system.
From page 44...
... Scripted triggers may appropri ately lead to scripted tactics and a rapid, predefined response. Predicting every disaster scenario (and related key response strategies, actions, and tactics)
From page 45...
... Key response strategies and actions are determined by community plans: • Agency/facility triggers into contingency care generally involve activation of facility or agency disaster plans, which produces additional surge capacity that cannot be achieved in conventional response (Barbisch and Koenig, 2006; Hick et al., 2008; Kaji et al., 2006)
From page 46...
... Predictive indicators can be monitored, but cannot be directly impacted through actions taken within an organization or component of the emergency response system. Examples include monitoring of weather, epidemiologic data, or other such information.
From page 47...
... . •  ndicators that are actionable typically involve certain data that can lead to scripted triggers that staff can initiate without further analysis (e.g., if a I mass casualty incident involves >20 victims, the mass casualty incident [MCI]
From page 48...
... For example, an indicator of gastroenteritis in a community that achieves a threshold may require significant epidemiological investigation just to determine whether the presence of disease in the community is a valid indicator of a sentinel event, or simply represents a coincidence or normal variant. For no-notice disaster incidents, the initial indicator is often a 911 call reporting a mass casualty incident, and all that remains is determining a threshold for the dispatcher to trigger the mass casualty plan for the agency.
From page 49...
... involving more than 10 victims = activate EMS MCI plan • Health alert involving novel illness = notify emergency management group The disadvantage of scripted triggers is that they sometimes will not match the resources to the incident well. Scripted triggers should be designed in a conservative fashion so that they are more likely to over­ commit, rather than undercommit, resources relative to the scope of the incident.
From page 50...
... . Box 2-2 provides an example of how a medium-sized health care coalition region might approach determining a dispatch-based scripted trigger threshold for activation of disaster plans.
From page 51...
... For example, EMS agencies during nighttime hours may be operating under contingency or even conventional response conditions, but during daytime peak hours they are consistently applying crisis care tactics. Another example in hospitals or the outpatient setting INDICATORS AND TRIGGERS 51
From page 52...
... Education and Training Key point: Implementation of actions depends on the level of training and authority and requires appropriate education. All of the following groups must be integrated into CSC planning and response: • Frontline employees: Awareness -- actions should be scripted at specific thresholds and be made as concrete as possible (e.g., activate EMS disaster plan for MCI involving >10 victims)
From page 53...
... So, even certain numbers based on actionable data do not necessarily yield scripted triggers for crisis care (though for both of these examples, reaching such a threshold should still prompt action to assess and address the situation, as these are still relevant predictive indicators of system capacity problems, and proactive management decisions are strongly preferred to reactive ones made when there is no option left but crisis care)
From page 54...
... In each of these systems, there is a time lag between acquiring primary data points, verification of the data received, and reporting that information. Many emergency operations centers and health care coalitions are maturing to the point of developing an information clearinghouse function that can serve to collect and collate such information, but the reporting must be recognized as representing static data points in what is very often a very dynamic environment.
From page 55...
... This section outlines system-level considerations for indicators and triggers; Chapter 1 provides additional discussion of the systems approach to catastrophic disaster response. Use of Indicators and Data at Different Levels of the Emergency Response System Key points: Data that may be very actionable at the agency or facility level may be only of limited use in regional aggregate.
From page 56...
... . It is recognized that the use of the term surge capacity in mass casualty incidents is not equated with daily variations in ED volume, although there may be some relationship (Davidson et al., 2006; Handler et al., 2006; Jenkins et al., 2006)
From page 57...
... for addi­ional information on Israel's system for hospital surge capacity and for notifying t hospitals about the approximate number and type of casualties to anticipate. Some relevant time-phase work has been done with data from bombings and other no-notice mass casualty incidents, where 50 percent of the victims presented to hos pitals within the first hour and the vast majority within 3 hours (CDC, 2003, 2010)
From page 58...
... It allows for the visualization of special data, with inputs and data point assessments determined by the user of the system, tailoring information inputs to those that are most likely to help inform decision making during large-scale incidents. The most prominent Web data mining effort is Google Flu Trends (GFT)
From page 59...
... Additional modeling work found that Telehealth Ontario call volume data can be used to estimate future ED visits for respiratory illness at the health unit level, of which there are 36 in Ontario (Perry et al., 2010)
From page 60...
... and thus support response with available resources and early mobilization of mutual aid. Goals at Different Levels of the Emergency Response System Key point: Different types of indicators may be most valuable at different levels of the system.
From page 61...
... Efforts to synthesize the available information, using the emergency management–led jurisdictional EOC, along with the use of a medical information clearinghouse concept, will be of significant value. For example, stressors emanating from one single incident may be seen across the entirety of the emergency response system.
From page 62...
... Many more states have developed, or are developing, similar efforts, particularly as federal grant guidance highlights the importance of establishing situational awareness, including data sharing and analysis. At the federal level, HAvBED was created under a contract from the Agency for Healthcare Research and Quality to help develop a national hospital bed reporting system that could be used to provide situational awareness of hospital bed availability during times of surge demand in care (AHRQ, 2005)
From page 63...
... The Michigan Syndromic Surveillance System 2  Unpublished work; information from committee co-chair Dan Hanfling.
From page 64...
... . The committee searched for and com piled 18 available jurisdictional plans that discussed triggers for crisis care or pandemic influenza.1-18 Six of these discussed lab or World Health Organization criteria-based trig gers for pandemic influenza and not relevant to crisis care.6-8,11-12,16 A few states included state declarations of emergency as the trigger for increased information sharing and coordination, but not for triage.1,4 One state referenced "unusual events" rather than triggers, which prompt enhanced information exchange within the system.2 These were defined as events that significantly impact or threaten public health, environmental health, or medical services; are projected to require resources from outside the region; are politically sensitive or of high visibility; or otherwise require enhanced information exchange between partners or the state.
From page 65...
... Available plans tended to list indicators, for the most part without specific thresh olds.2-5,7,9,10,13-14,19 This is actually consistent with the fact that most of the plans were state level, and thus unlikely to identify indicators of sufficient certainty to establish triggers, aiming primarily to identify the key resources expected to be in shortage and potential indicators from available systems data or functional thresholds (alternate care site use, etc.) marking the transition to crisis care.
From page 66...
... In 2013, the MSSS will be able to receive data from health care professionals in settings other than hospital emergency departments, in support of Meaningful Use, which involves using electronic health record technology to ensure complete and accurate information, better access to information, and patient empowerment (CMS, 2013; HealthIT.gov, 2013)
From page 67...
... Therefore, they will be expected to use similar indicators, triggers, and tactics as those used by their public- and private-sector counterparts. In the case of mature health care coalitions that have included these facilities within their membership, the use of situational awareness tools in place across the community are likely to provide this information to all member hospitals, including those in the Department of Veterans Affairs (VA)
From page 68...
... SUMMARY In planning, facilities and agencies should first identify the key response strategies they will use. Second, data sources and information that inform these thresholds should be examined and optimized.
From page 69...
... 2011. Disaster metrics: Quantitative benchmarking of hospital surge capacity in trauma-related multiple casualty incidents.
From page 70...
... 2007. An integrated information system for all-hazards health preparedness and response: New York State Health Emergency Response Data System.
From page 71...
... 2006. Inpatient disposition classification for the creation of hospital surge capacity: A multiphase study.
From page 72...
... 2009. Enhancing hospital surge capacity for mass casualty events.
From page 73...
... 2013. Michigan Emergency Department Syndromic Surveillance System.
From page 74...
... 2008. Can Telehealth Ontario respiratory call volume be used as a proxy for emergency department respiratory visit surveillance by public health?


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