Mass Medical Care with Scarce Resources: A Community Planning Guide (continued)

Chapter 5. Hospital/Acute Care

By John L. Hick, M.D., Lead Author,a Gabor Kelen, M.D.,b Daniel O'Laughlin, M.D.,c Lewis Rubinson, M.D., Ph.D.,d Richard Waldhorn, M.D.,e Dennis P. Whalenf

a Assistant Professor, Emergency Department, Hennepin County Medical Center
b Director, Office of Critical Event Preparedness and Response, Johns Hopkins University
c Assistant Professor of Emergency Medicine, University of Minnesota/Abbott Northwestern Hospital
d Health Officer, Deschutes County Health Department/Bend Memorial Clinic
e Distinguished Scholar, Center for Biosecurity, University of Pittsburgh Medical Center
f Executive Deputy Commissioner, New York State Department of Health

Some of the most difficult decisions about providing an appropriate standard of medical care when resources are inadequate to meet event-driven demands will be made in hospitals. This section presents an overview of recommended systems and processes for planning and implementing the allocation of scarce hospital and acute care resources during a mass casualty event (MCE). It offers planners recommendations on developing integrated and coordinated response systems and ways to make the operational decisions for stretching and allocating scarce resources during a catastrophic MCE.


Hospital/Acute Care Issues and Recommendations at a Glance

Major Issues and Challenges

  • Hospitals already at or near capacity for emergency and trauma services.
  • Meeting needs for basic and specialized equipment.
  • Coordinating competing health care systems.
  • Incompatibilities in communications systems.
  • Lack of on-call specialists and other essential staff (e.g., nurses).
  • Need for security and protection.
  • Issues regarding professional licensing; verification; and supervision, both intra-and interstate.

Recommendations Prior to an MCE

  • Develop an integrated incident management system.
  • Establish interhospital compacts and mutual aid agreements.
  • Establish a jurisdictional Emergency Operations Center; ensure that the hospital knows how it is represented there.
  • Designate a "trusted source" to serve as the hospital's resource and policy representative at the local or regional emergency response level.
  • Develop a planning framework for allocating scarce resources, ideally based on existing Federal or State guidances, which articulates the integration of response strategies and tactics across facilities/agencies.
  • Regionalize disaster response, through Multi-Agency Coordination (MAC) planning.
  • Establish a Joint Information Center (JIC) or other centralized method to link communications regarding incident and response at the local, regional, and State levels.
  • Use expert panels or planning groups to develop decisionmaking protocols or guidance for allocating scarce resources in the case of an MCE.
  • Put into place an institutional and State position on how scarce resources would be allocated to health care workers.

Responding to an MCE

  • Increase space capacity within the hospital through rapid patient discharge and transfer, addition of beds/cots, facilitation of home-based care, and use of alternative care sites.
  • Increase staff capacity through schedule changes, staff sharing, promotion of home care, and the use of advance registered and credential-verified health professional volunteers.
  • Increase access to supplies through contacts/agreements with commercial vendors.
  • Institute administrative changes to facilitate processes, reimbursements, reassignment of the staff, and schedules.
  • Institute clinical changes to a level appropriate to the available resources. Base triage and allocation decisions on existing guidance, if possible.
  • Ensure security for the staff and supplies.
  • Plan for mass mortuary needs.
  • Develop strategies to identify large numbers of young children who may be separated from parents and cannot give information that would help them to be reunited.

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Hospital and Acute Care in the Context of a Catastrophic MCE

The overall goal of hospital and acute care response in an MCE is to meet the reasonable care needs of as many patients as possible while also meeting at least minimal obligations for comfort to each patient.63

In the case of a catastrophic MCE, however, hospitals will not have access to many needed resources (e.g., manual resuscitation bags to provide ventilation in response to a pandemic influenza, supply of antitoxin in the case of mass botulism poisoning). Thus, difficult decisions will have to be made regarding the allocation of available resources.

During an MCE, Federal and State agencies might be able to offer policy guidance, nationally sanctioned decision tools, and event-specific relief of certain regulatory obligations. However, the operational decisions regarding limited resource allocation (and the liability related to such policies) will be the responsibility of individual hospitals, communities, and regions. Thus, it will be incumbent on these localities and entities before an event occurs to establish and test plans for operational incident management systems that can be applied to respond to an MCE.

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Challenges for MCE Planning

Much of the hospital-based response to an MCE will rely on planning, protocols, and actions that should be put into place and tested well ahead of time. In order to address those planning needs, however, planners must take into account the critical challenges that hospitals will face in responding to catastrophic events.64 Those challenges include the following:

Surge Capacity Issues. A recent report on hospital-based emergency care from the Institute of Medicine2 reveals that many hospital emergency and trauma services are already at or near full capacity and thus not equipped to respond to the increased demand and decreased resources that would occur in an MCE. Interhospital agreements have the potential to alleviate overcrowding by transferring existing inpatients to other facilities, for example, but evidence from a Centers for Disease Control and Prevention study indicates that only 46 percent of hospitals have agreements of this type. 65

Inadequate Supplies. Lack of sufficient supplies, particularly of specialized equipment such as personal protective equipment, ventilators, and negative pressure rooms, will be a challenge for most hospitals.

Need for Coordination, Cooperation, and Consistency Between Health Care Systems That Are in Competition With One Another. Public health and State government may have certain authorities to make decisions during an emergency, but the scope of their powers often does not extend into health care facilities. Thought should be given to approaches to facilitating or enhancing cooperation between diverse, and potentially competing, entities.

Communication Barriers. In order to respond at a level appropriate to the incident, critical information must be shared and processed across systems to give an overview of the event, guide the mobilization of necessary resources, and inform the development of strategies and tactics at the hospital and community levels. The fragmented nature of emergency care systems leads to incompatibilities in communications and data systems between EMS systems, hospitals, trauma centers, public safety services and public health agencies.

Lack of Specialists and Other Essential Staff Members. Even in the current emergency and trauma care system, the supply of on-call specialists and other essential staff members (e.g., nurses) is not great enough to meet demand—a gap that will be greatly exacerbated in an MCE.

Need for Security Presence and Protection. Hospital staff members, supplies, and assets will need to be protected in the case of an MCE, which naturally will result in scarcities and the potential for fear, theft, or violence.

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Recommendations Related to Advance Planning

In the event of a catastrophic MCE, decisions and policies regarding resource allocation within hospitals will have to occur at multiple levels, ranging from the State down to local communities and institutions. Ideally, these decisions and policies should be crafted in advance of the event and should reflect nationally sanctioned guidance.

Hospital administrators and local and State elected officials must work to ensure that the framework for such decisionmaking is in place and that a public conversation is held that ensures understanding of the resources and limitations of the health care system.

They must be prepared to defend this planning to State agencies and government and help them to understand the implications of resource allocations. Local and regional legal issues must be raised and defined, and solutions must be determined.

Planning Template for Hospitals

To help stimulate discussion and planning for MCEs within hospital facilities as well as at the local and regional levels, a Mass Casualty Disaster Plan Checklist for Health Care Facilities has been developed by the Center for the Study of Bioterrorism and Emerging Infections and the Association for Professionals in Infection Control and Epidemiology, Inc. It is available at:

Ideally, hospitals should be able to follow guidance and decision support tools to make resource allocation decisions (e.g., who should receive mechanical ventilation) that are sanctioned and approved at the Federal level and are distributed by the State. Even with the support of these tools or policies, however, it is the hospital that will have to take on the role of implementing them.

To plan for addressing the hospital and acute care needs following an MCE prior to an event, hospitals and their partners should do the following:

Develop an Integrated Incident Management System. In order to respond to the demands and scarcity of resources that would be brought on by an MCE, hospitals must have in place a system of coordination with other local hospitals, public health departments, incident commanders, public safety, and EMS systems to provide care.

Thus, integrated incident management is critical to preparing for an MCE and must be developed prior to any catastrophic event.66

Incident Management System Curriculum

The complexity of incident management, coupled with the growing need for multiagency and multifunctional involvement in incidents, has increased the need for a single standard incident management system that can be used by all emergency response disciplines. The Incident Command System, originally designed in California to respond to wildfires, has been adopted as the National Incident Management System, a national training curriculum for public and private sector users that can be applied to multihazard and planned event situations. Information on the training curriculum is available at: .

The Institute of Medicine report on hospital-based emergency care recommends that coordination and incident management require the following components:67


HICS applies the principles of incident management to health care facilities. The system helps coordinate emergency response between hospitals and other emergency responders with a system based on a predictable chain of management, defined responsibilities, prioritized response checklists, clear reporting channels for documentation and accountability, and a common nomenclature to facilitate communications.

Further information is available at:

Develop a Planning Framework for Allocating Scarce Resources. This framework should be transparent and shared with key stakeholders in the health department, attorney general's office, and governor's office as well as with the community, both in advance of and during an MCE. The framework should establish ways to do the following:

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Coordinating Community and Regional Planning of Hospital/Acute Care MCE Responses

Regional Planning

The State health department has the overall responsibility for projecting health resource needs in the event of a major health-related emergency and for allocating scarce resources to meet those needs. Some States have intrastate regional coalitions (clearinghouse hospitals, regional coordinating hospitals), which can assist the State health department in managing resource allocation within their area. This arrangement establishes a more effective span of control for the State, with only a few regions rather than multiple individual facilities, reporting data and resource needs. It also allows for plans to consolidate inventories of supplies, epidemiological data, medical response, communications, and command and control. These intrastate regional coalitions, where they exist, should be incorporated into regional Multi- Agency Coordination (MAC) planning and response (go to Figure 5.2). Planners should expect that there will be issues with communication, coordination, and overlapping responsibilities, and thus it is important to practice all elements of the State, regional, or local interface in advance. Such advance practice would enable planners to find ways to account for and adapt to the variability in relationships among local emergency operations centers, hospitals, regional MACs, and the State.

Interstate regional coordination is another means of managing allocation of scarce resources.  Interstate agreements and cooperation help promote sharing of assets across State lines. These types of agreements also help ensure consistency of response (e.g., National Capital Region) where inconsistencies between State plans could prove problematic. This level of interstate cooperation is difficult to achieve but is one of the most important ways to maximize resource allocation. The development of national-level clinical decision tools to address commonly limited resources (e.g., dialysis, mechanical ventilation) would be very valuable in helping to facilitate greater interstate cooperation.

Planning Resources

The Minnesota Department of Health MAC Plan has been developed to facilitate health-related policy coordination and resource allocation decisions among multiple jurisdictions and health-related entities to provide for the safe, rapid, and coordinated response to a health-related emergency. Information is available at:

A Patient Care Coordination Planning Guide, also developed by the Minnesota Department of Health, is available on CD by request to MDH Office of Emergency Preparedness at:

Coordination and Communication

The State, rather than local jurisdictions, should take responsibility for overall risk communication management. This includes information provided to hospitals and health care systems, as well as the provision of public information releases and information for providers or members of the public that are posted through telephone, the Internet, the media, and other access points. A JIC should be established as well as other ways to link communications at the local, jurisdictional, and State levels to establish mechanisms for media message development.

Communications strategies must be established and practiced ahead of time to ensure that messages will come from accurate sources in a timely and consistent manner. These strategies should include the use of risk communication, regular media releases, and press conferences.

Joint Information Center (JIC)

A JIC is a centralized communication hub for handling emergency events. It serves to gather incident data, analyze public perceptions of the event, and give the public or special targeted audiences accurate and comprehensive incident and response information. Planning for the JIC should be undertaken in advance, including processes, procedures, and staff training. This allows communities to be more proactive in their response to the information needs of the public, industry, and government.

A full description of the JIC model is available from the U.S. National Response Team Web site at:$file/jic.pdf?openelement

Using Expert Panels or Planning Groups

At this time, no current predictive model is sufficient to serve as a decision framework for determining the allocation of critical care resources (e.g., ventilators, intensive care therapies). One valuable strategy for examining the allocation of scarce resources, however, is to convene a balanced expert panel that can bring in multiple viewpoints and establish decisionmaking guidelines. The panel must be inclusive of relevant stakeholders who reflect the jurisdictional area and its demographics, in addition to recognizing border issues with adjoining States. The composition, functions, and operational role of these groups must be carefully considered.

Convening an Expert Panel to Address the Allocation of Scarce Resources: The Example of New York State

In March 2006, the New York State Task Force on Life and the Law (TFLL), in partnership with the State's Department of Health, convened a workgroup to consider clinical and ethical challenges in the allocation of mechanical ventilators in a public health crisis. The group includes experts in the areas of law, medicine, policymaking, and ethics. Its goal is to develop clinical and ethical guidance for local health care systems that will promote the just allocation of ventilators in an influenza pandemic. The panel considered a range of policy options necessary to support such an allocation system, including the development of recommendations for laws or regulations in areas including liability and appropriate standards of care.

Further information on the TFLL is available at:

Issues of resource allocation ideally would be addressed by expert panels or groups as part of MCE planning. An ad hoc expert panel may be called on to address an unexpected event to determine which factors will be used for decisionmaking based on a particular situation and the specific resource in short supply. The community member panels that allocated scarce hemodialysis resources in the city of Seattle during the 1960s can serve as an historic example of this process.

Using Community Panels to Help Allocate Scarce Resources: The Example of Hemodialysis in Seattle

When hemodialysis was first introduced in 1960, it was available only in limited supply. In order to decide which patients would receive this life-prolonging treatment, the city of Seattle established a two-committee decisionmaking process. The first committee was comprised of physicians and the second made up of a cross-section of community representatives. The physician committee took into account medical and psychiatric criteria, while the community group weighed factors such as age, future potential, and other intangible measures of personal and community value.

Some questions that States should consider when developing an expert panel include:

The recommendations of the expert panel should be vetted and shared with larger, more diverse groups to allow feedback and further modifications. Those groups might include physicians or other health care professionals, palliative care providers, ethicists, State health officers, representatives from the Office of Emergency Preparedness, community leaders, and others. Any guidelines or decisionmaking framework developed should be circulated between facilities and jurisdictions prior to an event.

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Increasing System Capacity During an MCE

During an MCE, the capacity of the health care system should be expanded according to an incident management system-directed mobilization of physical space, personnel, and material resources—sometimes referred to as "space, staff, and stuff." For example, in advance of an MCE, hospitals should establish a preference list of supplemental providers to expand staff capacity. These providers might include local hospital staff, clinic staff, and health professional volunteers who have registered with and had their credentials verified by one of the State Emergency Systems for Advance Registration of Volunteer Healthcare Professionals (ESAR-VHP), Medical Reserve Corps, National Disaster Medical System teams, trainees, patient family members, military members, Community Emergency Response Teams, and lay volunteers. Policies should be in place in advance to credential staff members and manage deployment of nonhospital personnel at community and hospital levels, and there should be a plan for managing spontaneous volunteers.

Another critical component of increasing system capacity during an MCE is informing the public. It is important to provide the public with information on two fronts: information about ongoing events and how to care for themselves, as well as information that will enable them to make appropriate decisions about their own personal health care situation. This information process will help limit or slow the spread of disease while engaging the public in the allocation of scarce resources.

The goal of informing the public can be achieved through a two-pronged approach: the use of effective media campaigns to educate and inform most of the public, supported by enlisting the assistance of established community health call centers (poison centers, nurse advice lines, public health hotlines) to help address the public's additional concerns and questions. This approach should enable most people to care for themselves, and at the same time, will help to lessen demands on the healthcare system.

Short-term Strategies

Short-term strategies may be applied to increase healthcare facility capacity in cases where resource shortages can be expected to be resolved relatively quickly (within hours or days). These strategies usually do not require a systematic assessment of the standard of care being provided. They may include the following:

Increase space capacity with:

Expand staff capacity with:

State Coordination of Volunteer Resources: Emergency Systems for Advance Registration of Volunteer Health Professionals

State Emergency Systems for Advance Registration of Volunteer Health Professionals (ESAR-VHP) systems are statewide mechanisms for recruiting, registering, and verifying credential information of potential health volunteers in a State. These systems should support and include information about volunteers involved in organized efforts at the local level (such as MRC units) and the State level (such as National Disaster Medical System [NDMS] teams). The ESAR-VHP systems also will coordinate broader Statewide recruitment and registration of health professionals who would be willing to serve in an emergency, but are not interested in being a part of a trained, organized unit structure such as MRC or NDMS. State ESAR-VHP systems provide a single, centralized source of volunteer information to facilitate intrastate, State-to-State, and State-to-Federal transfer and mobilization of volunteer health professionals.

More information about the national effort to develop State ESAR-VHP systems, including information about the legal protections offered to volunteers in each State and Territory, and links to State systems is available at:

Increase access to supplies by:

If these strategies are not sufficient to meet the demands of the incident and no immediate relief is available, then a systematic evaluation of the level of care being provided must be conducted. These surge strategies should be reviewed and revised based on the available resources.

The Medical Reserve Corps (MRC)

The mission of the MRC is to organize medical, public health, and other volunteers in support of existing programs and resources to improve the health and safety of communities and the Nation. MRC units provide personnel to support and supplement the existing emergency and public health agencies in the community. MRC leaders are encouraged to adopt an all-hazards approach and more broad-based public health initiatives, including a focus on increasing disease prevention efforts, and enhancing emergency preparedness. Medical Reserve Corps volunteers include medical and public health professionals such as physicians, nurses, pharmacists, dentists, veterinarians, and epidemiologists.

During the 2005 Hurricane Season, MRC members provided support for American Red Cross health services, mental health and shelter operations. MRC members also supported Federal response efforts by staffing special needs shelters, Community Health Centers and health clinics, and assisting health assessment teams in the Gulf Coast region. For example, The Southside (Boydton, VA) MRC organized, conducted, and supervised a local food relief and water collection site for Hurricane Katrina victims. In all, 53,000 pounds of food and water were shipped to Lamar County, Mississippi. The Rhode Island MRC, along with the Rhode Island DMAT team, was largely responsible for staffing a weeklong clinic that received 105 evacuees from Louisiana. The clinic averaged 26 visits per day with daily blood pressure checks provided.

Further information on MRC is available at :

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