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1. Community-Wide Planning
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Key Questions
What is a mass casualty event?
What are the two types of mass casualty events?
What are the basic steps planners must take to prepare for a mass casualty event?
</td> </tr> </tbody></table>
In the event of a catastrophic public health or terrorism-related event, such as an influenza pandemic or the detonation of a nuclear device, the needs of tens of thousands of victims may overwhelm the resources of a community's health care system. Indeed, if the event incapacitates health care workers, damages facilities, or destroys supplies, the capacity of the health care system to respond may be severely compromised. If other communities are faced with similar demands (as would be the case in an influenza pandemic or a nuclear detonation, for example), the arrival of additional health care resources, including assistance from the Federal Government, likely would be significantly delayed. Additional resources may not arrive at all.
In this dire scenario, referred to as a mass casualty event (MCE), if the health care system is to remain functioning and save as many lives as possible, it will be necessary to allocate scarce resources in ways that are different from normal circumstances but are appropriate for the situation. For the purposes of this report, scarce resources broadly include physical items (e.g., medical supplies, drugs, beds, equipment), services (e.g., medical treatments, nursing care, palliative care), and health care personnel (e.g., physicians, nurses, laboratory technicians, other essential workers in health care settings).
In general, MCEs can be organized into two categories: those that result in a sudden impact and those that result in a developing impact.
The "sudden-impact" MCE includes events such as detonation of bombs, airplane or train crashes, and natural disasters such as earthquakes. This category is characterized by many casualties at the outset of the event that generally taper off. In some cases there may be a second wave of casualties because of depleted resources or such factors as exposure to natural elements, unclean water, and contagious diseases. In this category of MCE, planners need to consider that the event may destroy essential infrastructure, requiring a mass migration of survivors.
The "developing-impact" MCE features events such as a mass exposure to anthrax or smallpox or an influenza pandemic. The number of people affected by the event increases gradually to a catastrophic number. In this category, the number of cases may decline due to treatment and prophylactic efforts, for example, only to increase as a result of additional waves of the disease. A "developing-impact" MCE necessitates a more sustained response, since the impact is felt over a much longer period than that of the "sudden-impact" MCE.
Levels of preparedness differ for the two types of MCEs. The "sudden-impact" MCE is unpredictable and requires immediate response in terms of the need to triage and temporize until the necessary resources arrive. In a "developing" MCE, such as an influenza pandemic, the impact is considered more predictable, and preparedness efforts most likely will mitigate its impact.
In the event of an MCE, whether "sudden impact" or "developing impact", community planners will face the challenge of allocating scarce resources quickly enough to prevent undue illness and death. To prepare, planners need to take several steps.
Be proactive. Planners should anticipate to the degree possible the types of health care needs and resource shortfalls that will occur and identify policy and operational adjustments that will be needed in response.
Build and maintain relationships. Planners should forge partnerships, memoranda of understanding, interhospital agreements, and other relationships with key stakeholders from:
These relationships need to clearly define the roles, responsibilities, capabilities, oversight, communications, logistics, and response resources each partner will contribute in an MCE. All partners must have a common vision for how they will function during a disaster. Multiagency coordination provides a mechanism for cooperative coordination of activities, resources, and policies across multiple agencies and jurisdictions. The involvement of senior leadership from all response agencies is essential.
Devise, model, and exercise MCE response plans. Stakeholders should understand and practice the processes that responders and health facilities will use to request resources from each other, supply vendors, special stockpiles, and emergency management contacts. Plans should be modified and refined continually based on input from response partners, lessons learned from exercises, and changing conditions. Modeling responses to a catastrophic MCE may take the form of tabletop exercises, actual but smaller events, or computer simulations. Such modeling efforts should begin by using small numbers of casualties as a starting point and then use rising victim number scalability models; i.e., plan for 100 casualties, then 1,000, then 10,000, and then 100,000. Possible useful models include:
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Resources
Information on the LaSER program is available at http://www.nyu.edu/ccpr/laser/planc.html.
The Hospital Surge Model is available at http://www.ahrq.gov/prep/hospsurgemodel/.
The Mass Evacuation Transportation Model is available at http://www.ahrq.gov/prep/massevac/.
</td> </tr> </tbody></table>
Establish clear channels of communication. The State, rather than local jurisdictions, should assume responsibility for overall risk communication management. This includes information provided to hospitals, health care systems, providers, or the public via telephone, the Internet, media campaigns, 9-1-1 dispatchers, established community health call centers (poison centers, nurse advice lines, public health hotlines), and other communications mechanisms.
A Joint Information Center (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. The JIC serves to gather incident data, analyze public perceptions, and provide the public or targeted audiences with accurate and comprehensive incident and response information. Communication strategies must be established and practiced ahead of time and can include risk communication, regular media releases, and press conferences.
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Resources
A description of a virtual joint information center, The Virtual Joint Information Center: A Technological Tool for Emergency Communication, is available at http://www.cdc.gov/about/pah/pages/p...Practices2.htm.
</td> </tr> </tbody></table>
Establish clear public messages. The public will need information on the status of the MCE and information that can help them make appropriate decisions about their own and their family's health care. Messages can tell community members how to protect themselves and others, when it is safe to stay home, how to provide the best possible care at home, where to go for particular services, and when to call 9-1-1 or go to the emergency room. This information will help address the strain on health system resources and, in the case of infectious diseases, slow the spread of disease, while engaging the public in the allocation of scarce resources.
Clarify the process for leadership and coordination. It is critical to identify leaders, alternates, and the decisionmaking process for resource allocation and policy guidance.
Emphasize prevention. In MCEs such as an influenza pandemic, prevention of transmission is critical to minimizing the burden of disease.
Identify existing national and State tools, protocols, and processes for phases of the MCE. Many products and resources have been developed to help plan for catastrophic events. Numerous examples of these are presented in this report.
Consider the financial implications of responding to an MCE and the potential need to enact administrative or policy changes to facilitate reimbursement and recordkeeping. It is important to take into account any funding from HHS's Centers for Disease Control and Prevention's Public Health Emergency Preparedness Cooperative Agreement Program and HHS's ASPR Hospital Preparedness Cooperative Agreement Program.
Consider vulnerable populations. Explicit planning must occur at all levels for vulnerable populations including infants, children, frail elderly people, pregnant women, people with disabilities, people with mental illness, and those with chronic medical conditions (e.g., cardiac, dialysis, HIV, and oncology patients).
Develop robust security plans. Security is especially important in the case of a large-scale MCE because of the chaos such an event 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.
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Key Questions
What is a mass casualty event?
What are the two types of mass casualty events?
What are the basic steps planners must take to prepare for a mass casualty event?
</td> </tr> </tbody></table>
In the event of a catastrophic public health or terrorism-related event, such as an influenza pandemic or the detonation of a nuclear device, the needs of tens of thousands of victims may overwhelm the resources of a community's health care system. Indeed, if the event incapacitates health care workers, damages facilities, or destroys supplies, the capacity of the health care system to respond may be severely compromised. If other communities are faced with similar demands (as would be the case in an influenza pandemic or a nuclear detonation, for example), the arrival of additional health care resources, including assistance from the Federal Government, likely would be significantly delayed. Additional resources may not arrive at all.
In this dire scenario, referred to as a mass casualty event (MCE), if the health care system is to remain functioning and save as many lives as possible, it will be necessary to allocate scarce resources in ways that are different from normal circumstances but are appropriate for the situation. For the purposes of this report, scarce resources broadly include physical items (e.g., medical supplies, drugs, beds, equipment), services (e.g., medical treatments, nursing care, palliative care), and health care personnel (e.g., physicians, nurses, laboratory technicians, other essential workers in health care settings).
In general, MCEs can be organized into two categories: those that result in a sudden impact and those that result in a developing impact.
The "sudden-impact" MCE includes events such as detonation of bombs, airplane or train crashes, and natural disasters such as earthquakes. This category is characterized by many casualties at the outset of the event that generally taper off. In some cases there may be a second wave of casualties because of depleted resources or such factors as exposure to natural elements, unclean water, and contagious diseases. In this category of MCE, planners need to consider that the event may destroy essential infrastructure, requiring a mass migration of survivors.
The "developing-impact" MCE features events such as a mass exposure to anthrax or smallpox or an influenza pandemic. The number of people affected by the event increases gradually to a catastrophic number. In this category, the number of cases may decline due to treatment and prophylactic efforts, for example, only to increase as a result of additional waves of the disease. A "developing-impact" MCE necessitates a more sustained response, since the impact is felt over a much longer period than that of the "sudden-impact" MCE.
Levels of preparedness differ for the two types of MCEs. The "sudden-impact" MCE is unpredictable and requires immediate response in terms of the need to triage and temporize until the necessary resources arrive. In a "developing" MCE, such as an influenza pandemic, the impact is considered more predictable, and preparedness efforts most likely will mitigate its impact.
In the event of an MCE, whether "sudden impact" or "developing impact", community planners will face the challenge of allocating scarce resources quickly enough to prevent undue illness and death. To prepare, planners need to take several steps.
Be proactive. Planners should anticipate to the degree possible the types of health care needs and resource shortfalls that will occur and identify policy and operational adjustments that will be needed in response.
Build and maintain relationships. Planners should 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; and
- Other public and private partners at State, local, Tribal, regional, and Federal levels.
These relationships need to clearly define the roles, responsibilities, capabilities, oversight, communications, logistics, and response resources each partner will contribute in an MCE. All partners must have a common vision for how they will function during a disaster. Multiagency coordination provides a mechanism for cooperative coordination of activities, resources, and policies across multiple agencies and jurisdictions. The involvement of senior leadership from all response agencies is essential.
Devise, model, and exercise MCE response plans. Stakeholders should understand and practice the processes that responders and health facilities will use to request resources from each other, supply vendors, special stockpiles, and emergency management contacts. Plans should be modified and refined continually based on input from response partners, lessons learned from exercises, and changing conditions. Modeling responses to a catastrophic MCE may take the form of tabletop exercises, actual but smaller events, or computer simulations. Such modeling efforts should begin by using small numbers of casualties as a starting point and then use rising victim number scalability models; i.e., plan for 100 casualties, then 1,000, then 10,000, and then 100,000. Possible useful models include:
- The Large Scale Emergency Response (LaSER) Program at New York University, which includes computer modeling of large-scale events, risk communication, legal aspects, workforce support, and community-based response issues.
- The Hospital Surge Model and Mass Evacuation Transportation Model, developed through collaboration between the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ) and the Office of the Assistant Secretary for Preparedness and Response (ASPR). The Surge Model estimates the amount of hospital resources needed to treat casualties of major disasters and the Evacuation Transportation model estimates the time required to evacuate patients from health care facilities.
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Resources
Information on the LaSER program is available at http://www.nyu.edu/ccpr/laser/planc.html.
The Hospital Surge Model is available at http://www.ahrq.gov/prep/hospsurgemodel/.
The Mass Evacuation Transportation Model is available at http://www.ahrq.gov/prep/massevac/.
</td> </tr> </tbody></table>
Establish clear channels of communication. The State, rather than local jurisdictions, should assume responsibility for overall risk communication management. This includes information provided to hospitals, health care systems, providers, or the public via telephone, the Internet, media campaigns, 9-1-1 dispatchers, established community health call centers (poison centers, nurse advice lines, public health hotlines), and other communications mechanisms.
A Joint Information Center (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. The JIC serves to gather incident data, analyze public perceptions, and provide the public or targeted audiences with accurate and comprehensive incident and response information. Communication strategies must be established and practiced ahead of time and can include risk communication, regular media releases, and press conferences.
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Resources
A description of a virtual joint information center, The Virtual Joint Information Center: A Technological Tool for Emergency Communication, is available at http://www.cdc.gov/about/pah/pages/p...Practices2.htm.
</td> </tr> </tbody></table>
Establish clear public messages. The public will need information on the status of the MCE and information that can help them make appropriate decisions about their own and their family's health care. Messages can tell community members how to protect themselves and others, when it is safe to stay home, how to provide the best possible care at home, where to go for particular services, and when to call 9-1-1 or go to the emergency room. This information will help address the strain on health system resources and, in the case of infectious diseases, slow the spread of disease, while engaging the public in the allocation of scarce resources.
Clarify the process for leadership and coordination. It is critical to identify leaders, alternates, and the decisionmaking process for resource allocation and policy guidance.
Emphasize prevention. In MCEs such as an influenza pandemic, prevention of transmission is critical to minimizing the burden of disease.
Identify existing national and State tools, protocols, and processes for phases of the MCE. Many products and resources have been developed to help plan for catastrophic events. Numerous examples of these are presented in this report.
Consider the financial implications of responding to an MCE and the potential need to enact administrative or policy changes to facilitate reimbursement and recordkeeping. It is important to take into account any funding from HHS's Centers for Disease Control and Prevention's Public Health Emergency Preparedness Cooperative Agreement Program and HHS's ASPR Hospital Preparedness Cooperative Agreement Program.
Consider vulnerable populations. Explicit planning must occur at all levels for vulnerable populations including infants, children, frail elderly people, pregnant women, people with disabilities, people with mental illness, and those with chronic medical conditions (e.g., cardiac, dialysis, HIV, and oncology patients).
Develop robust security plans. Security is especially important in the case of a large-scale MCE because of the chaos such an event 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.
