Executive Summary

Background

In the event of a catastrophic public health- or terrorism-related event, such as an influenza pandemic or the detonation of improvised nuclear devices, the resulting tens of thousands of victims will be likely to overwhelm the resources of a community's health care system. In this dire scenario, which we refer to as a mass casualty event (MCE), it will be necessary to allocate scarce resources in a manner that is different from usual circumstances but appropriate to the situation. Making optimal decisions concerning the allocation of scarce resources could make a big difference in the degree to which health care systems continue to function; ultimately it could mean saving many thousands of lives.

Purpose of the Guide

The purpose of this guide is to provide community planners–as well as planners at the facility/community, State, and Federal levels–with valuable insights and information that will help them in their efforts to plan for and respond to an MCE. The guide aims to present planners with approaches and strategies that would enable them to provide the most appropriate standards of care possible under the circumstances of an MCE.

This document is intended not to reflect Department of Health and Human Services policy but to provide State and local planners with options to consider when planning their response to an MCE.

Development of the Guide

This guide builds and expands on an earlier document published by the Agency for Healthcare Research and Quality (AHRQ). Altered Standards of Care in Mass Casualty Events (available on the AHRQ Web site at http://www.ahrq.gov/research/altstand/) explored the issues and outlined the principles associated with the provision of medical care in the face of overwhelming numbers of casualties.

This planning guide is the product of a collaborative effort between AHRQ and the Office of the Assistant Secretary for Preparedness and Response (formerly the Office of Public Health Emergency Preparedness).

Organization of the Guide

This planning guide looks at issues and challenges in MCE response and preparedness issues across the spectrum of health care settings and provides recommendations for planners specific to each area. The planning guide begins with a discussion of the ethical and legal considerations and then discusses issues related to MCE planning in three care settings: prehospital, hospital and acute care, and alternative care sites (ACSs). This is followed by a discussion of palliative care issues, which must be integrated throughout the planning for and response to an MCE. The planning guide concludes with a presentation of a case study: an influenza pandemic.

Ethical Considerations

We live in a world where a whole range of manmade and natural disasters are of increasing concern to communities across the Nation. Terrorism, epidemics, hurricanes, earthquakes, floods, and fires are all too possible in an industrialized and increasingly interdependent world. For this reason, serious and systematic disaster planning and preparedness at the community level are absolutely essential. If or when a disaster occurs, communities must be prepared for the possibility that the arrival of government assistance may be delayed. Indeed, potentially significant interruptions in the deployment of medical assistance may occur in certain kinds of events (e.g., pandemic influenza) or in situations in which several events occur simultaneously. Government agencies at all levels may be overstretched by multiple challenges and competing demands or have their ability to function degraded by catastrophic events.

Hurricane Katrina, for example, demonstrated that communications systems may be damaged or temporarily severed at the outset of a disaster. While such systems are being reestablished or put in place, local communities that have planned for such a possibility will have a head start on meeting community care needs.

Indeed, one reality is clear: communities that have not planned and prepared for such an eventuality will be less equipped to face the complexities of such an event than communities that have planned. Moreover, once a planning process is undertaken, it will become clear that serious ethical decisions are central to shaping any community's disaster response. It is important to realize that once a disaster strikes, difficult choices will have to be made, and the more fully the ethical issues raised by such choices are discussed prior to making them, the greater the potential for the choices to be ethically sound. The ethical issues and considerations in MCE planning are discussed in Chapter 2.

Legal Issues

Laws at all levels of government are a critical part of emergency responses and allocation decisions involving scarce resources in an MCE. Legal issues that need to be considered in the context of MCE planning include understanding the changing legal landscape during emergencies, the balance of individual and communal interests, the suspension of existing legal requirements, interjurisdictional legal coordination issues, medical licensure reciprocity, liability and other protections for health care workers and volunteers, property management and control, and legal triage.

Chapter 3 contains a detailed discussion of relevant laws and their potential impact on the ability of planners to allocate scarce resources during an MCE.

Prehospital Care

In the event of an MCE, the emergency medical services (EMS) systems will be called on to provide first-responder rescue, assessment, care, and transportation and access to the emergency medical health care system. The bulk of EMS in this country is provided through a complex system of highly variable organizational structures. While efforts are ongoing to standardize EMS disaster training, no single oversight agency is responsible for ensuring consistency in training, certification, or guidelines for disaster response; the use of personal protective equipment; or the coordination of EMS response and operations.

The unique context in which EMS systems operate in this country serves to amplify the challenges of providing emergency medical services in the context of an MCE. The issues and challenges of providing such services are discussed in Chapter 4.

Hospital and Acute Care

The overall goal of hospital and acute care response to an MCE is to maximize care across the greatest number of people while meeting at least minimal obligations for care to all who are in need. In the case of an MCE, however, hospitals will not have access to many needed resources. Thus, some of the most difficult decisions about providing an appropriate standard of medical care in an environment of scarce resources will be made in hospitals.

The major challenges that hospitals will face in an MCE include surge capacity issues, the fact that they are already at or near capacity for emergency and trauma services, a lack of on-call specialists and nurses, the need to coordinate between competing health care systems, incompatibilities in communications systems, and the need for security and protection, to name just a few. The issues related to MCE planning and response in the hospital sector are discussed in detail in Chapter 5.

ACSs

The impact of an MCE of any significant magnitude likely will overwhelm hospitals and other traditional venues for health care services. Indeed, it may render them inoperable, necessitating the establishment of ACSs for the provision of care that normally would be provided in an inpatient facility. Advance planning is critical to the establishment and operation of ACSs; this planning must be coordinated with existing health care facilities as well as home care entities. Planners must delineate the specific medical functions and treatment objectives of the ACS. The principle of managing patients under relatively austere conditions, with only limited supplies, equipment, and access to pharmaceuticals and a minimal staffing arrangement, is the starting point for ACS planning.

The issues and challenges of establishing and operating ACSs during an MCE, as well as specific case study examples of ACSs in operation during the response to Hurricane Katrina, are discussed in detail in Chapter 6.

Palliative Care

In the event of an MCE, it will be assumed that some people may survive the onset of the disaster but will have sustained such serious illness or injury that they will live only for a relatively short period of time. In addition, there will be vulnerable individuals (e.g., the elderly, those sick in hospitals, nursing homes, the disabled, children) who may be negatively impacted by the resulting scarcity of resources. In some instances, decisions will need to be made to withdraw resources from those not likely to survive and shunt those resources to others.

The goal of an organized and coordinated response to an MCE should be to maximize the number of lives saved. At the same time, there should be a goal to provide the greatest comfort and minimize the psychological suffering of those whose lives may be shortened as a result of an MCE. These issues fall under the broad rubric of palliative care, which refers to the aggressive management of symptoms and relief of suffering.

The overarching issue of how to provide optimal support for the dying, those facing life-limiting illness or injury, and those caring for them must be integrated into initial planning efforts as well as addressed throughout the response to an MCE, as discussed in Chapter 7.

Case Study: Influenza Pandemic

The concepts, strategies, and approaches that planners need to consider in the context of an MCE highlighted in the chapters of the planning guide are applied to a specific case study scenario. The case study selected involves a potential influenza pandemic. The key issues that planners need to consider when faced with the challenges of allocating scarce resources in the context of a pandemic are presented in Chapter 8.

MCE Advance Planning Themes and Recommendations

In the event of a catastrophic MCE, community planners will face the challenge of allocating scarce resources in a timely enough fashion to prevent undue illness and death. As the chapters of this guide indicate, in order to prepare for such an eventuality, planners need to focus on the following:

• Be Proactive. Good planning must be undertaken ahead of time. Planners should anticipate to the degree possible the types of health care needs and resource shortfalls that will occur, and they must identify policy and operational adjustments that will need to take place in response.
• Build and Maintain Relationships. It is important to forge partnerships, memoranda of understanding, interhospital agreements, and other relationships with key stakeholders from the health care system, emergency management system, State and local public health systems, local emergency responders, emergency medical services, home health care, and other medical providers; volunteer agencies; public safety; and other public and private partners at all levels (State, local, regional, and Federal).
• Establish Regional and Local Multiagency Coordination. Public and private health agencies, facilities, and responders must have a common vision within their cooperative regional area for how they will function during a disaster. Regional coordination may involve regions within a State or between States, particularly when a metropolitan area is situated in more than one State. Multiagency coordination may take the form of a planning committee, an extension of a Metropolitan Medical Response System, or something else. Regardless of the form it takes, the key is to provide a mechanism for cooperative coordination of activities, resources, and policy across multiple agencies and jurisdictions.
• Devise, Model, and Exercise MCE Response Plans. Plans must include ways to increase surge capacity in anticipation of large numbers of patients needing care in the face of scarce resources. Stakeholders should understand and practice the processes that responders and health facilities will use to request resources from each other, from supply vendors, from special stockpiles, and from emergency management contacts. Opportunities such as special events (e.g., major sporting events, political conventions) can be used to test disaster planning.
• Establish Clear Channels of Communication to link the public health community, diverse health care entities, and emergency response systems. A process must be in place for sharing accurate, real-time situational information with involved stakeholders across multiple jurisdictions.
• Establish Clear Messages and Communications Strategies to inform the public about the status of the event and what actions they should take. It is important to work with the media, 9-1-1 dispatchers, special information phone lines, and other communications mechanisms to share clear and accurate messages.
• Emphasize Prevention. Planners should recognize the preeminent value of prevention. This is particularly true in MCEs such as an influenza pandemic, where a focus on prevention of transmission is critical to minimizing the burden of disease.
• Clarify the Process for Leadership and Coordination. It is critical to identify leaders, alternates, and the decisionmaking process for resource allocation and policy guidance.
• Identify Existing National and State Tools, Protocols, and Processes for each phase of the MCE. Many products and resources have been developed to help plan for catastrophic events. Numerous examples of these are presented within the chapters of this guide.
• Consider the Legal and Ethical Issues Related to Planning and Responding to an MCE. Planners must be familiar with State emergency powers and have a solid understanding of what types of events or circumstances would trigger their implementation. Planners also must be familiar with the ethical principles that underlie decisionmaking for the allocation of scarce resources.
• Integrate Palliative Care Strategies Across the Planning Process. Plans should be made for how to care for individuals who are not expected to survive the MCE and how to support the family members and others who are caring for them.
• Consider the Financial Implications of Responding to an MCE and the potential need to enact administrative or policy changes to facilitate reimbursement and recordkeeping obligations.
• Consider Vulnerable Populations. Explicit planning must occur at all levels for vulnerable populations including infants, children, the frail elderly, pregnant women, the disabled, the mentally ill, and special needs groups with chronic medical conditions (e.g., cardiac, dialysis, HIV and oncology patients). Prior experience has demonstrated that without explicit planning, the needs of these populations will not be adequately met.
• Develop Robust Security Plans. Security is especially important in the case of a large-scale MCE due to the chaos and confusion that it engenders. Having a uniformed presence (e.g., hospital security personnel, off-duty police officers, National Guard members, volunteers) helps maintain order as do clear identification tags; visiting rules; and procedures for accessing supplies, service sites, and patients.

Clearly, the optimal allocation of scarce resources in response to an MCE is unlikely to occur without proper advance planning at the health care facility, community, State, and Federal levels. Simply put, the goal of this planning guide is to promote and assist in those efforts.

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