Chapter 5 (continued)

The Spectrum of Adaptation: From Administrative to Clinical Change

In the case of a longer-term resource shortage, strategies for meeting the event-generated demands of an mass casualty event (MCE) can be classified along a spectrum that includes two categories of changes: administrative adaptations and clinical adaptations, as shown in  Figure 5.3.

Administrative adaptations are designed to increase provider availability for patient care. Though their effect on clinical care should be minimal, it must be recognized that changes in shift length or staffing patterns will increase the risk for complications such as infections.

Administrative changes generally can be implemented with minimal discussion by hospital administration or nursing personnel, but such changes require preplanning. Examples of administrative changes may include the following:

• Changes to reduce provider documentation, billing and coding, registration, and other administrative policy burdens. These should be discussed in advance with the State and Federal agencies that oversee public health insurance programs and with private payers.
• Cancellation of elective procedures. The definition of "elective" may vary with the severity and duration of the situation and requires daily review; a surgery to remove a neoplasm, for example, may be elective for 24 hours but not for weeks.
• Reassignment of qualified administrative nursing staff members to clinical roles or use of nonhospital staff members, potentially including family members, to provide basic patient care.
• Adoption of Continuity of Operations (COOP) strategies within each department as needed to cope with the impact of the event. A good COOP plan details the critical functions and staffing within each department and lists ways for these functions to be carried out when the staff or infrastructure is inadequate to carry on daily operations.

Surge Capacity Resources The Joint Commission on Accreditation of Healthcare Facilities Report Surge Hospitals: Providing Safe Care in Emergencies is available online at: http://www.jointcommission.org/PublicPolicy/surge_hospitals.htm. Seamless Emergency Medical Logistics Expansion System (SEMLES) promotes the development of collaborative relationships between public and private entities and between local and regional partners to expand surge capacity. Information on SEMLES is available at: http://www.disasterhelp.net/resources.

One important staffing issue to consider in the context of MCE planning is the concern that a significant proportion of health care providers will fail to report to work if they perceive a threat to themselves or their family members from contamination by biological or radiological agents. Certain States have provisions to de-license or otherwise sanction (or even arrest, in the State of Maryland) providers who do not report for duty during a declared disaster. It is important, to remember, however, that although health care providers have a duty to act and may have been supported in their training by Federal dollars, there are real concerns about the "duty to family" and issues of child care, among others, which may not be solved easily.

Careful determination of priority groups and essential personnel as well as facilitation of child care, providing adequate PPE, providing housing apart from family for workers who request it, and other "carrots" need to accompany the regulatory "sticks" designed to ensure that health care workers are able to work (and work safely) during a disaster.

Clinical adaptations represent the allocation of scarce resources or services based on the ethical principles outlined in Chapter 2.

Examples of clinical adaptations include the following:

• Triage of patients to home care, acute care sites, or other offsite locals who would otherwise be treated as inpatients.
• Assignment of limited resources (e.g., ventilators, radiographs, laboratory testing) to those most expected to benefit.
• Provision of specialty care (e.g., burn or intensive care) by nonspecialty trained staff members (ideally with supervision by appropriately trained staff members).

Implementing Clinical Changes to Respond to an MCE Examples of Possible Response Processes The incident commander recognizes the need for systematic clinical changes. The planning chief gathers any guidelines, information, and resources. A clinical care committee (predetermined members and designees for toxic, infectious, and trauma situations) is convened. Members may include a hospital administrator, a hospital attorney, nursing supervisor, a respiratory care supervisor, a hospital ethicist, a community representative, and representatives from clinical departments. The clinical care committee reviews existing strategies/protocols and determines: Methods to meet patient care needs, location of care, assignment of resources. Additional changes in staff responsibilities to redistribute specialized staff and incorporate other health care providers, lay providers, or family members. A mechanism to reassess local/regional hospital efforts and needs and recommend changes on a regular basis. Information is disseminated to inpatient services, outpatient services, the regional hospital coordination point, and State and local health departments. Security and behavioral health response plans are implemented. Triage plan is implemented to determine ED/outpatient screening of patients, patient discharge, removal from therapy, and bed assignments. Just-in-time training or education is implemented for health care workers, patients, and family members.

The hospital should be able to follow State guidance regarding clinical triage decisions. If no guidance exists, it will be incumbent on the hospital to have a plan or strategy for bringing together the appropriate personnel who can make the best decisions possible and reevaluate the situation during each planning cycle (e.g., each shift a day). When there is little advance evidence to guide allocation decisions (for example, not knowing how different age groups with pandemic influenza respond to mechanical ventilation), good clinical judgment by experienced clinicians will be the final common denominator to justify resource allocation decisions. The decisionmaking process, based on ethical judgments that include maximizing good consequences across the many while meeting at least minimal duties and obligations to all, should be shared openly with staff members, patients, and the public and should be as consistent as possible across facilities.

The goal is to adjust clinical care to a level appropriate to the resources available and to do so in as smooth, transparent, consistent, and incremental a fashion as possible. There are no clear "trigger" or "trip" points to indicate when the shift from reactive, mostly administrative changes to proactive, clinical changes must occur. Communities and regions should coordinate as much as possible. Situational awareness by the Incident Commander and Planning Section Chief can help anticipate or recognize resource bottlenecks that may require intervention.

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Allocating Scarce Resources

Patient Assessment

The American Medical Association (AMA) has identified five important criteria to consider when the allocation of scarce resources is required: likelihood of benefit, change in quality of life, duration of benefit, urgency of need, and amount of resources required. According to the AMA guidance, all five of these criteria must be considered. If there is no differentiation in the criteria between patients, then resources should be allocated on a "first come, first served" basis.

At a minimum, patient assessment should include the following factors:

• The patient's need for the resource.
• Potential to return to the baseline state.
• Overall acute resource needs of the patient.
• Age and functional assessment (e.g., Quality Adjusted Life Years or other tools when significant functional differences are present between patients).
• Underlying health and prognosis related to an underlying disease(s).
• Event-specific or injury-specific prognostic factors.

Patient Triage

There are three basic types of triage. Primary triage is the first triage of patients into the medical system (it may occur prehospital), at which point patients are assigned an acuity level based on the severity of their illness/disease. Secondary triage is the reevaluation of the patient's condition after initial medical care (go to Box).⁶⁹ This may occur at the hospital following EMS interventions or after initial interventions in the ED. Tertiary triage is the reevaluation of the patients' response to treatment after further interventions and is ongoing during their hospital stay. This is the least practiced and least well-defined type of triage.

Historically, triage has involved four levels of priority for traumatic injuries:

• Green—delayed treatment—has minor injuries or illness and should not pose a threat to life or limb.
• Yellow—intermediate—has injuries or illness that may result in death or disability but pose no immediate threat to life or limb.
• Red—critical—has injuries or illness that will result in death within the hour unless interventions occur.
• Black—expectant or deceased—is expected to die because of severity of illness or injuries or has died.

It is important to note that criteria such as gender, race, ability to pay, social worth, perceived obstacles to treatment, patient contribution to illness, or past use of resources are not appropriate criteria for determining the allocation of scarce resources. Age may be considered only as it relates to underlying organ function and prognosis.

An experienced health care provider should be involved in any decision to classify a patient as "black" during a disaster. As described in Chapter 7, all such patients should have access to palliative care (analgesia, sedation, physical and behavioral cares) to the extent possible under the circumstances. Expectant patients should be reassessed regularly for comfort, for improvements in their situation, or in case resources become available unexpectedly.

Studies have shown that experienced health care providers are generally very accurate at assigning triage levels in the ED on a daily basis,⁷⁰ though there are no studies to determine to what degree this is true in disasters.

An example of an existing triage tool is the Emergency Severity Index (ESI), perhaps the best-studied hospital ED approach to triage. While highly predictive of resource use within the ED, the ESI was not designed, however, for disaster situations per se. Simple Triage and Rapid Treatment triage may be used for traumatic injuries, but it is perhaps too simplistic for application in the ED setting and has not been validated.

The Emergency Severity Index (ESI) The ESI is a five-level ED triage algorithm that provides clinically relevant stratification of patients into five groups, from 1 (most urgent) to 5 (least urgent), on the basis of acuity and resource needs. The ESI Implementation Handbook is available at: http://www.ahrq.gov/research/esi/esi1.htm.

Overall illness severity and mortality prediction scores (Mortality Probability Model II, Sequential Organ Failure Assessment) and organ system-specific mortality predictors (oxygenation index—FiO2 x mean airway pressure / pO2 has predictive value in pediatric patients, for example) may be used to provide quantitative estimates of survival or severity. These prediction scores present limitations, however, in that they are validated on cohorts, not individuals, and generally require data obtained from laboratory or other invasive measures.^71,72

An example of a secondary triage decision tool is the American Burn Association table of mortality graphed against age and percent body surface area burns, which allows a burn surgeon to make immediate rough determinations of the resource needs and projected mortality of a given patent and allocate, when needed, limited resources available.

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Select Operational Considerations

In addition to allocating scarce resources, an MCE will require that hospitals also address many operational considerations, including security and mass mortuary.

Security

Disasters that require systematic changes in the provision of health care are likely to have had similar pronounced effects on the community at large. Civil unrest due to supply line disruptions, infrastructure damage, and resource scarcity are not uncommon in such situations. Resources in short supply may be subject to hoarding or internal pilfering (e.g., of vaccine, of antibiotics). Any changes in usual clinical care that result in resources not being available to all patients who may need them may increase the potential for violence against health care facilities and providers.

Hospitals should work with their community law enforcement agencies and security staff members to develop a security assessment and vulnerability analysis and a plan for augmenting hospital security during a widespread disaster, when demands on law enforcement may be extreme. This plan should prioritize hospital assets for protection and rely, when possible, on physical and technological, rather than human solutions. Proactive communication with the public can reduce the potential for civil unrest and should be part of community and institutional strategies.

Security measures that hospitals may wish to consider in an MCE include:

• Increased security personnel.
• Increased monitoring of hospital premises and surroundings.
• A lockdown plan that can be rapidly implemented (including campus buildings that may be used in nontraditional capacities as part of the facility response plan).
• Single or few designated entrances.
• The limit of a single visitor (or no visitors) per patient.
• Metal detectors and security screening at entry points.
• Augmented law enforcement presence (must have mutual aid agreements in place ahead of an event; consider uniformed peace officers or National Guard personnel).
• Equipping and training hospital security personnel with less-than-lethal methods of behavioral control (if not already so equipped) with appropriate policies and oversight (e.g., batons, pepper spray, TASER electroshock guns or similar electric-current immobilizer devices).
• Other deterrents at entrances (presence of canine officers, increased uniformed security presence).

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Mass Mortuary

Hospitals should understand clearly the community plan for management of excess casualties. In some cases, hospital responsibilities for record keeping and reporting will change in a disaster. Temporary facility morgue locations may be required, and regional processing sites may be needed. The role of the medical examiner's office versus that of public health should be clearly defined. This should include situations such as pandemic influenza, which normally would not involve the medical examiner's office.

Provisions should be made for appropriate solutions to barriers presented by culturally based funeral and burial practices. Every effort should be made to preplan for adjusting standards of care as appropriate to the situation, to advise and involve the public and faith-based communities in these decisions, and to ensure that the minimum level of disruption to usual cultural practices and the maximum level of dignity are afforded the deceased and their families.

Conducting Patient Triage New Orleans International Airport—Hurricane Katrina Three Disaster Medical Assistance Teams (DMATs) were faced with the task of providing medical care to tens of thousands of patients at New Orleans International Airport who had been evacuated or rescued from their homes, nursing homes, and hospitals. Approximately 300 of these patients were stretcher bound. Few had acute injuries, but many had complex medical problems exacerbated by dehydration, infections, and lack of medications. There was essentially no ability to communicate externally, nor was there an identified command element to request additional resources and evacuation assistance in the first 24 hours of the operation. Standard triage tags were used for nonambulatory patients, and they were prioritized for care and evacuation. Approximately 50 extremely sick patients were tagged as "expectant" due to the lack of clinical resources and transferred to a separate area of the airport. Many of these were elderly with complex underlying health problems and unstable vital signs, coma, or other poor prognostic signs—and were expected by the clinician to die within the next 24 hours. As staff members and resources became available, some of these individuals were reclassified as "red" and provided care. Ultimately, only 26 of these patients died, thanks to the efforts of the DMATs, who also treated hundreds of other critical and serious patients. A Herculean evacuation effort over the subsequent several days and the arrival of additional staff members and resources prevented further deaths.

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