Altered Standards of Care in Mass Casualty Events

Chapter 5. Recommended Action Steps

Several recommendations for action related to planning a health and medical care response to a mass casualty event are identified below. The list of recommendations is not meant to be comprehensive, but it provides a starting point for discussion. These ideas suggest that a collaborative approach should be taken when developing next steps; both government and private organizations have unique roles and important contributions to make in moving forward.

Step 1: Develop general and event-specific guidance for allocating scarce health and medical care resources during a mass casualty event.

Public and private organizations, including professional societies, should develop guidance in specific areas related to allocating scarce clinical resources. Examples include but are not limited to the following:

• Triage guidelines and measures for specific types of events.
• Allocation guidelines for scarce resources, such as ventilators, burn beds, or surgical suites.
• Guidance for the triaging and treatment of children, specifically the ways in which altered standards of care might differ for a pediatric population.

Step 2: Develop and implement a process to address nonclinical issues related to the delivery of health and medical care during a mass casualty event.

Examples of nonclinical issues include but are not limited to the following:

• Alternative ways to establish authority to move to altered standards of health and medical care in a mass casualty situation.
• Alternative ways to ensure an adequate legal framework, including liability, certification and licensing, and mutual aid agreements for the provision of health and medical care in a mass casualty event.
• Alternative ways to resolve issues of finance and reimbursement issues related to the provision of health and medical care in a mass casualty event.

Step 3: Develop a comprehensive strategy for risk communication with the public before, during, and after a mass casualty event.

Experts agreed that a unified strategy and tools for public communication around mass casualty risk and health and medical care response are indicated. Part of the challenge is to craft credible messages that the public will perceive as immediately relevant and important to their daily lives without causing undue alarm. Such a strategy should take the form of anticipatory guidance. Messages should be developed collaboratively with various stakeholders (such as the American Hospital Association, the Joint Commission on the Accreditation of Health Care Organizations, and others), that should also participate in their dissemination.

Specific ideas and suggestions made regarding public communication include but are not limited to the following:

• Continue and expand CDC training of journalists to cover health events as a means to partner effectively with the media in reaching the public.
• Find effective ways to communicate clinical information to lay audiences.
• Utilize primary care providers and local public health departments, especially nurses, in getting out agreed-upon messages in local communities on a one to one basis.
• Provide a communications capability at the level of the individual facility as well as through joint information centers.
• Include communications internal to health care facilities and among system components, such as hospitals and alternate care sites, in communications strategies.
• Build on the HANS (Health Alert Network System), part of CDC's emergency alert system, to develop an overall communication strategy.

Step 4: Identify, analyze, and consider modification of Federal, State, and local laws and regulations that may affect the delivery of health and medical care during a mass casualty event.

As part of an effort to develop a legal framework for providing health and medical care in a mass casualty situation, an effort should be made to create a compendium of laws and regulations at the Federal, State and local levels that affect the delivery of health and medical care. This compendium of laws and regulations would facilitate the creation of an adequate legal framework for moving to altered standards of care when necessary. It would identify the following:

• The responsible parties for each law or regulation (local, State or Federal government).
• Circumstances when each law or regulation can be modified.
• Specific ways each law or regulation could be modified on a temporary basis.

Step 5: Develop means for verifying credentials of medical and other health personnel prior to and on-site during a mass casualty event.

In disaster situations, individuals who claim to be qualified providers and who want to volunteer their services typically approach health care facilities. In order to be able to make use of such resources, facility and incident managers need to have tools and methods, such as searchable databases, for verifying credentials. Efforts are underway at both the State and Federal levels to address this need. Emergency Systems for Advance Registration of Volunteer Health Care Personnel (ESAR-VHP), as outlined in the Public Health Security and Bioterrorism Preparedness and Response Act of 2002 (Public Law 107-188), as well as the Medical Reserve Corps credentialing efforts, and other State-developed systems are examples of tools that could be useful in this regard.

Step 6: Create strategies to ensure health and medical leadership and coordination for the health and medical aspects of system response during a mass casualty event.

Experience in developing preparedness strategies suggests there is a need to assure high-level health and medical leadership at the system and regional levels. For some systems and regions, this may involve creating a designated Medical Disaster Specialist or a role with comparable responsibilities to coordinate the health and medical aspects of system response. The expertise required ensuring appropriate health and medical leadership in a mass casualty event includes the following:

• Knowledge about how and when to initiate altered standards of care.
• Knowledge and skill to facilitate communication and provide the link between the medical care system and overall incident response.
• Knowledge and skill to provide disaster-related medical leadership in a system of community or region, including all aspects of medical preparedness and response.
• Knowledge and skill to provide leadership for training.
• Knowledge of and the ability to match hospital and system-specific resources to interventions in a crisis.
• Knowledge of surge plans, resources, and techniques for that particular region/city.
• Knowledge and skill in developing resource-sharing agreements, such as regional travel teams and memoranda of understanding, with adjacent areas.

Step 7: Continue and expand efforts to train providers and others to respond effectively in a mass casualty event.

A wide range of provider training is needed to ensure an effective health and medical response to a mass casualty event. Training needs include, but are not limited to:

• General disaster response, including an introduction to altered standards of care and how the move to such standards may affect triage and treatment decisions as well as facility conditions.
• Legal and ethical basis for allocating scarce resources in a mass casualty event.
• Orientation to how an incident management system would work in a mass casualty event.
• How to treat children and other groups who may need special equipment or modified approaches to care.
• How to recognize the signs and symptoms of specific hazards.
• How to treat specific conditions.
• How to recognize and manage of the effects of stress on themselves and their patients.

General principles to guide the design of effective training programs are included in Chapter 4.

Step 8: Develop and support a research agenda specific to health and medical care standards for mass casualty events.

Ideas for research related to health and medical care standards for mass casualty events are listed below. The focus of these suggested studies should be on practical application, testing, and sharing of promising practices.

• Examine how different combinations of resources, signs/symptoms, and response to treatment may affect the numbers of lives that can be saved. A better understanding of survivability is especially important in developing criteria for the allocation of scarce treatment resources.
• Analyze or develop models to predict how much injury or illness can be prevented under different kinds of mass casualty scenarios. A better understanding of achievable reductions in injury and illness is important to setting goals for a system under stress.
• Examine international models and other real-world experiences of health and medical care delivery for evidence of what happens when "usual" rules are suspended or impossible to maintain. Other models and experiences may include specific disaster experiences (e.g., the Madrid train bombing and suicide bombings in Israel), as well as countries whose health systems operate daily with mildly, moderately, or severely constrained resources compared with the U.S. health care system. The focus of the research might be on methods for and outcomes of rationing scarce resources under different conditions.
• Evaluate all aspects of demonstrations and mock mass casualty events, such as "TOPOFF 3" and other drills, to find and address weak points in the system.
• Conduct research on effective risk communication with the public.
• Identify ways to share promising and tested practices in resource sharing (e.g., mutual aid agreements in St. Louis, Louisiana, New York City, and New Jersey).

Step 9: Develop a Community-Based Planning Guide for Mass Casualty Care.

Experts agree that local and regional planners need a resource to assist them in enhancing surge capacity plans so that they include situations involving mass casualty events. A Community-Based Planning Guide for Mass Casualty Care could be developed that includes guidelines, principles, templates, and examples of promising or tested practices for addressing the many and varied aspects of this task, whether the focus is site-specific, local, regional, or statewide. Although some tools and resources exist that could be incorporated into a Planning Guide, others—including guidelines for the allocation of scarce resources during a mass casualty event—have yet to be fully developed or evaluated. It is important that the Planning Guide not be prescriptive, but rather offer suggestions and identify tools and resources that may be useful in guiding triage and the allocation of scarce resources.

Step 10: Identify and support States, health systems, and regions to develop mass casualty and health and medical care response plans based on the Planning Guide and to share their results widely.

A number of practice-oriented "centers of excellence" could be supported in their efforts to build on surge capacity planning to prepare for a health and medical response to mass casualty events. The goal would be to move beyond specific elements of a plan limited to facilities, such as hospitals, to create a health and medical care response plan that is coordinated among its participants and with the overall emergency response system for the system or region. A central expectation of this approach is that the supported centers would develop and implement plans based on the Planning Guide and serve as demonstrations whose results would be widely shared with peers around the country.

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