Altered Standards of Care in Mass Casualty Events

Chapter 3. Framework and Guiding Principles When Planning for Health and Medical Care in a Mass Casualty Event

Framework

The expert panel suggested that a framework for planning should take into account the ways in which response to a mass casualty event is both similar to and different from responses to current surge capacity issues in health care facilities. The goal is to devise a framework that is applicable to both ordinary ("daily routine") and extraordinary situations. To this end, they recommended that plans for a medical care response to a mass casualty event should:

• Be compatible with or capable of being integrated with day-to-day operations.
• Be applicable to a broad spectrum of event types and severities.
• Be flexible, to permit graded responses based on changing circumstances.
• Be tested, to determine where gaps in the framework exist.

A model reflecting the concept of a graded response that is sensitive to changing circumstances was shared with the panel and is depicted in Exhibit 4. This matrix illustrates how the release of a biological agent resulting in mass casualties would require that health and medical care standards be altered over time as the disease progresses within the population and demands on the health system grow. The disease progresses from a pre-release state (upper left) through death, at each stage placing greater demands on the system, and thus requiring increasing alterations in standards. This staged model approach allows for the development of care guidelines for each stage that are consistent with the overall goal of maximizing the number of lives saved.

Although Exhibit 4 is based on a disease model, this graded response could be adapted easily to other types of mass casualty events (e.g., chemical releases or explosions) by compressing the stages according to the magnitude and velocity of the event. High magnitude, high velocity events will require the system to adopt altered standards more quickly than smaller or slower-developing events. However, it is also important to recognize that as the impact of the event wanes and resources become more available, it may be possible to return to established standards of care used in normal situations.

Exhibit 4. How Health and Medical Care Standards May Have to Be Modified in a Mass Casualty Event by Stage of Disease in the Population

Source: Dr. Michael Allswede, University of Pittsburgh, UPMC Health System

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Guiding Principles for Developing Altered Standards of Care

In addition to offering suggestions for a framework for the development of plans to respond to a mass casualty event, the expert panel also articulated five principles that should steer the development of such guidelines. Incorporating these five principles will ensure that standards of care are altered sufficiently to respond to issues arising from a mass casualty event.

Principle 1: In planning for a mass casualty event, the aim should be to keep the health care system functioning and to deliver acceptable quality of care to preserve as many lives as possible.

Adhering to this principle will involve:

• Allocating scarce resources in order to save the most lives.
• Developing a basis for the allocation of resources that is fair, open, transparent, accountable, and well understood by both professionals and the public.
• Ensuring, to the possible extent, a safe environment for the provision of care, and placing a high priority on infection control measures, and other containment processes.

Principle 2: Planning a health and medical response to a mass casualty event must be comprehensive, community-based, and coordinated at the regional level.

Effective planning should:

• Be done at the facility level. However, facility-level planning alone is not sufficient.
• Integrate facility-level planning into a regional systems approach.
• Involve a broad array of public and private community stakeholders.³
• Begin with the agreement on shared responsibility among all partners in the planning process. It is not adequate for individual institutions and systems to have emergency response plans unless those plans are coordinated into a single unified response system.
• Be consistent. Planning also should be integrated with Federal, State and local emergency plans.

Principle 3: There must be an adequate legal framework for providing health and medical care in a mass casualty event.

An adequate legal framework for providing health and medical care in a mass casualty event would do the following:

• Include a designation of the authority to declare an emergency and implement temporary alterations in standards of care.
• Define the conditions for temporary modification of laws and regulations that govern medical care under normal conditions.
• Be simple, clear, and easy to communicate to providers and the public.
• Be flexible enough to accommodate the demands of events that vary in size and velocity, such as an explosive or biological event.

Principle 4: The rights of individuals must be protected to the extent possible and reasonable under the circumstances.

The rights of individuals must be protected to the extent possible and reasonable:

• In establishing and operationalizing an adequate legal framework for the delivery of care.
• In determining the basis on which scarce resources will be allocated.
• When considering limiting personal freedom through quarantine or isolation as well as the conditions for release.
• When privacy and confidentiality may have to be breached.

Principle 5: Clear communication with the public is essential before, during, and after a mass casualty event.

To manage expectations and educate the public about the impact of an event, whom to call for information, where to go for care, and what to expect, the following points should be kept in mind:

• The public should be brought into the discussion during the early stages of planning so that citizens develop a clear understanding of concepts such as rationing of resources.
• Public understanding and acceptance of plans are essential to success.
• Messages should be consistent and timely at all stages.
• Official health and medical care messages should be delivered through public media by a local physician whom the public perceives to have knowledge of the event and the area, a representative of the Centers for Disease Control and Prevention (CDC), or the Surgeon General, depending on the level of communication necessary.
• Spokespersons at all levels—local, State, regional, and Federal—should coordinate their messages.
• It may be necessary to vary the modes of communication according to the type of information to be communicated, the target audience for which it is intended, and the operating condition of media outlets, which may be directly affected. Variations that illustrate this point but that do not reflect expert discussion include the need to use languages other than English and the need to use alternatives to usual media outlets in the affected area. Also, national audience messages would be less detailed and specific than messages to the affected area.

³ These stakeholders include: emergency management agencies, police and fire departments, emergency medical services, ambulance and other transport providers, health departments and community health centers, hospitals, ambulatory care centers, private physician offices, medical examiners, nursing homes, health centers, mental health services, morticians, and others. They also may include schools, churches, hotels, businesses, and other organizations that can provide space for alternate care facilities and cooperate in the preplanning required to activate such sites.

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