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<table summary="This table gives the layout format of the bread crumb area and the center content area." border="0" cellpadding="0" cellspacing="0" width="100%"><tbody><tr><td height="30px">Mass Medical Care with Scarce Resources: The Essentials </td> </tr> <tr> <td> 4. Prehospital Care
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Key Questions
How can planners maximize the availability of emergency medical services personnel?
How can transport be coordinated and transport capability be maximized?
How can patients be triaged most efficiently?
How can home care be incorporated into emergency planning?
</td> </tr> </tbody></table>
In the event of a catastrophic MCE, it is Emergency Medical Services (EMS) that will be called on to provide first-responder rescue, assessment, care, and transportation to the health care delivery system. EMS in the United States is provided through highly varied organizations. Nearly half of all EMS are delivered through local fire departments. Others fall under municipal or county governments, police departments, health departments, or private companies (e.g., hospital-based, for-profit ambulance services) or are volunteer-based.<sup>48</sup> The variability of EMS response systems and the differences in EMS preparedness training, guidelines, and response capacity pose significant coordination and communications challenges for EMS planners.
Return to Contents
Recommendations for Planners
Planners should take several actions prior to an MCE to help maximize the response capacity of prehospital EMS services. Those actions include the following:
Forge partnerships at all levels. As with all aspects of preparedness, the need to coordinate and allocate scarce prehospital resources in an MCE requires the development, implementation, exercising, and refinement of partnerships between Federal, State, and local government response agencies, as well as between public and private entities.
Improve communication and coordination. Planners must develop integrated and interoperable communications and data systems, with backup strategies and procedures that can link EMS agencies to hospitals, trauma centers, public safety departments, emergency management offices, and public health agencies. In addition, EMS systems must be familiar with the Federal response capability, such as the provisions of the Homeland Security Presidential Directive/HSPD-5, the National Disaster Medical System (NDMS), Disaster Medical Assistance Teams, the Incident Command System (ICS), Occupational Safety and Health Administration (OSHA) personal protective equipment guidelines, and OSHA Hazardous Materials Operations regulations. This awareness will reduce the risk that requests for resources will be misdirected. EMS personnel should be trained in the National Response Framework to learn about its incident command and its tenets for supporting operational requirements. Ideally, EMS systems should be centralized through established ICS channels.
Improve EMS Education. The National Highway Traffic Safety Administration (NHTSA) together with the Health Resources and Services Administration and other members of the Federal Interagency Committee on EMS are involved in ongoing efforts to improve the EMS education system and to provide leadership and coordination of comprehensive, evidence-based and data driven emergency medical services and 9-1-1 systems. NHTSA is supporting implementation of the EMS Education Agenda for the Future: A Systems Approach, and has published the National EMS Scope of Practice Model and the National EMS Education Standards.
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Resources
EMS Education Agenda for the Future: A Systems Approach is available at http://www.nhtsa.gov/people/injury/e...nal/index.html.
National Emergency Medical Services Scope of Practice Model is available at http://www.nhtsa.dot.gov/portal/site...0811060008a0c/.
National Emergency Medical Services Education Standards are available at http://www.nhtsa.gov/staticfiles/DOT...ms/811077a.pdf [PDF Help].
The National EMS Information System (NEMSIS) is an effort to improve the uniformity of EMS data nationally. NEMSIS includes linkages between State and local EMS data systems, as well as a National EMS Database to be housed at NHTSA. More information on NEMSIS is available at http://www.nemsis.org.
EMS Pandemic Influenza Guidelines for Statewide Adoption and Preparing for Pandemic Influenza: Recommendations for Protocol Development for 9-1-1 Personnel and Public Safety Answering Points (PSAPs) are available online under the "Pandemic News" section at http://www.ems.gov.
</td> </tr> </tbody></table>
Continually modify and refine plans. Planning should include concrete implementation steps with training and exercise goals for each step. Each component of the response should be taught, exercised, evaluated, modified, and tested again. Exercises should simulate actual casualties, as well as management of the "worried well"—individuals calling for EMS resources who actually do not need them. Exercises should include response partners from public, private, community, and governmental and nongovernmental agencies. This iterative process allows for continuous modifications and improvements to plans, policies, and procedures.
Provide leadership. Leadership training should be provided for mid- and upper-level EMS supervisory staff members to ensure that in case of major illness, injuries, or deaths, there will be individuals who can take on the role of EMS medical director or leadership. A staff member or members should be designated in advance who can adjust standard operating procedures and the scope of practice of EMS personnel to accommodate the needs of the situation.
Return to Contents
Approaches to the Allocation of Scarce Resources
In the case of an MCE, there likely will be scarcities of emergency medical technicians (EMT), transport capacity, and destinations for patient treatment. As a result, plans should be in place for coordinating and maximizing the use of available staff members and resources. These plans should be tested and refined prior to the MCE. Legal and ethical advisors should be included in planning discussions. Allocation of scarce resources should include the following:
Make sure as many EMS personnel as possible are available through use of modified or extended shifts, deployment of no more than two providers per vehicle, and use of one-person response vehicles for "patient evaluation" prior to dispatch of transport resources. Staff members also may be shifted so that non-EMTs can serve as drivers; fire, police, or volunteer EMTs can provide assistance during transport; and other medical personnel (e.g., physicians, nurses, nurse's aides) can help staff casualty treatment sites to permit EMS personnel to provide transport services. "Just-in-time" programs that train nonmedical volunteers to provide basic medical care such as applying direct pressure for hemorrhage control also should be developed.
Make best use of available EMS personnel. Some medical protocols may be suspended to allow greater efficiency and flexibility in patient management. EMS personnel may be used in nontraditional settings (e.g., alternative care sites (ACSs), hospitals, pharmaceutical distribution centers) for field triage, treatment, or transport. Their scope of practice may be extended to provide vaccinations or medications or to deliver nontraditional medical care at the scene.
Maximize transport capability. Public and private ambulance services should be coordinated and steps should be taken to ensure that they do not self-dispatch to MCEs. Paramedic-initiated alternative transportation (e.g., buses, taxis, privately owned vehicles) also should be used. Mutual aid agreements should be in place to deploy available transportation assets, staff members, and staging locations. Transportation assets should be loaded to full capacity and patients taken to the closest appropriate hospital or care site. Air transport should be used to take patients to distant facilities (unless the incident presents contamination risks). Noncritical calls should be batched by geographic area. Bypass, diversion, or closure rules can be suspended to best distribute patients and to avoid overloading any one hospital.
Use the Community Emergency Response Team (CERT). The CERT program trains people in basic disaster response skills, such as fire safety, light search and rescue, team organization, and disaster medical operations. CERT members can assist others following an event when professional responders are not immediately available.
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Resources
Information about CERT is available at http://www.citizencorps.gov/cert/about.shtm.
</td> </tr> </tbody></table>
Screen calls and dispatch efficiently. Call screening strategies should be in place to determine the level of urgency required to respond to calls. Response strategies involving multiple responders (e.g., engine company, ambulance, law enforcement) used in standard EMS response should be avoided. Prearrival instructions should be scripted and tailored to the incident with formal recommendations on use of alternative transport and ACSs.
Provide personal protection for personnel. Universal precautions should be used for every patient encounter, if possible. To reduce the number of responders exposed to pathogens or chemicals, specialized protections should be used to the extent possible and adjusted to the nature of the incident (e.g., distribution of antibiotics, vaccines, or antidotes to staff and family members). In the case of chemical incidents, decontamination needs must be evaluated and addressed before transportation to preserve transport capability. Similarly, security personnel should be assigned to protect EMS response operations, logistics centers, and stockpile depots.
Triage and evaluate patients efficiently. Specific triage systems should be in place before an incident, and personnel should be trained and exercised in their use. Simple triage methods include rapid separation of critical patients from noncritical patients (i.e., "Everyone who can walk should get on this bus."). The overarching principle for triage is "to do the most good for the most people."
There are three basic types of triage. Primary triage is the first triage of patients into the medical system (possibly occurring 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.<sup>49</sup> This may occur at the hospital following EMS interventions or after initial interventions in the emergency department. Tertiary triage is the reevaluation of the patients' response to treatment after further interventions. This continues for the duration of the patient's hospital stay. Historically, triage has involved four levels of priority for traumatic injuries:
An experienced health care provider, such as the EMS Medical Director or designee, should be involved in any decision to classify a patient as "black" during a disaster. Although such patients may be designated as low priorities for transport, they should have access to palliative care (e.g., analgesia, sedation, physical and behavioral care) to the extent possible under the circumstances. Expectant patients should be reassessed regularly for comfort, improvements in their situation, or in case resources become available unexpectedly.
Coordinate destination choices. A centralized coordination of patient transport should be in place for minimal hospital overloading and best use of other available resources, such as primary care providers, ACSs, medical evaluation centers, or triage centers.
The vast majority of victims of an MCE may end up being most appropriately managed at home, either because their illness or injury is not severe enough to warrant institutionalized care or because, given scarce resources, inpatient treatment may be considered futile or wasteful.
Use local, regional, State, and national information services systems that provide updates of hospital bed status and capabilities to inform EMS about destination choices and to help coordinate patient distribution.
Establish casualty treatment areas on or near the disaster site or at ACSs (depending on the nature of the incident) to address the volume of casualties, provide triage, assess transport, and serve as treatment sites. Home health care should be used according to predetermined triage protocols to prevent unnecessary use of EMS transport and hospital resources.
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Resources
Home Health Care During an Influenza Pandemic, available at http://www.flu.gov/professional/hosp...omehealth.html.
</td> </tr> </tbody></table>
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Incorporating Home Health Care Into Emergency Planning: Issues to Consider
Register patients being cared for in the home setting with a local emergency management agency and the public health department to ensure access to relevant information.
Ensure adequate stock of routine chronic care medications.
Ensure adequate stock of basic first aid supplies, including bandages, antipyretic medications (e.g., acetaminophen, ibuprofen), oral electrolyte solutions, and thermometers.
Ensure that backup utility support is in place if warranted (particularly for those patients requiring electricity for medical devices).
Establish a "sick room" in the home for managing ill household members, particularly in the event of a transmissible infectious disease.
In caring for patients with advanced symptoms who are too sick for hospital care, coordinate symptom palliation with a home care team coordinated by local public health authorities.
Ensure the availability of a bedside commode or bedpan.
</td> </tr> </tbody></table>
<hr>
</td></tr></tbody></table>
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Key Questions
How can planners maximize the availability of emergency medical services personnel?
How can transport be coordinated and transport capability be maximized?
How can patients be triaged most efficiently?
How can home care be incorporated into emergency planning?
</td> </tr> </tbody></table>
In the event of a catastrophic MCE, it is Emergency Medical Services (EMS) that will be called on to provide first-responder rescue, assessment, care, and transportation to the health care delivery system. EMS in the United States is provided through highly varied organizations. Nearly half of all EMS are delivered through local fire departments. Others fall under municipal or county governments, police departments, health departments, or private companies (e.g., hospital-based, for-profit ambulance services) or are volunteer-based.<sup>48</sup> The variability of EMS response systems and the differences in EMS preparedness training, guidelines, and response capacity pose significant coordination and communications challenges for EMS planners.
Return to Contents
Recommendations for Planners
Planners should take several actions prior to an MCE to help maximize the response capacity of prehospital EMS services. Those actions include the following:
Forge partnerships at all levels. As with all aspects of preparedness, the need to coordinate and allocate scarce prehospital resources in an MCE requires the development, implementation, exercising, and refinement of partnerships between Federal, State, and local government response agencies, as well as between public and private entities.
Improve communication and coordination. Planners must develop integrated and interoperable communications and data systems, with backup strategies and procedures that can link EMS agencies to hospitals, trauma centers, public safety departments, emergency management offices, and public health agencies. In addition, EMS systems must be familiar with the Federal response capability, such as the provisions of the Homeland Security Presidential Directive/HSPD-5, the National Disaster Medical System (NDMS), Disaster Medical Assistance Teams, the Incident Command System (ICS), Occupational Safety and Health Administration (OSHA) personal protective equipment guidelines, and OSHA Hazardous Materials Operations regulations. This awareness will reduce the risk that requests for resources will be misdirected. EMS personnel should be trained in the National Response Framework to learn about its incident command and its tenets for supporting operational requirements. Ideally, EMS systems should be centralized through established ICS channels.
Improve EMS Education. The National Highway Traffic Safety Administration (NHTSA) together with the Health Resources and Services Administration and other members of the Federal Interagency Committee on EMS are involved in ongoing efforts to improve the EMS education system and to provide leadership and coordination of comprehensive, evidence-based and data driven emergency medical services and 9-1-1 systems. NHTSA is supporting implementation of the EMS Education Agenda for the Future: A Systems Approach, and has published the National EMS Scope of Practice Model and the National EMS Education Standards.
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Resources
EMS Education Agenda for the Future: A Systems Approach is available at http://www.nhtsa.gov/people/injury/e...nal/index.html.
National Emergency Medical Services Scope of Practice Model is available at http://www.nhtsa.dot.gov/portal/site...0811060008a0c/.
National Emergency Medical Services Education Standards are available at http://www.nhtsa.gov/staticfiles/DOT...ms/811077a.pdf [PDF Help].
The National EMS Information System (NEMSIS) is an effort to improve the uniformity of EMS data nationally. NEMSIS includes linkages between State and local EMS data systems, as well as a National EMS Database to be housed at NHTSA. More information on NEMSIS is available at http://www.nemsis.org.
EMS Pandemic Influenza Guidelines for Statewide Adoption and Preparing for Pandemic Influenza: Recommendations for Protocol Development for 9-1-1 Personnel and Public Safety Answering Points (PSAPs) are available online under the "Pandemic News" section at http://www.ems.gov.
</td> </tr> </tbody></table>
Continually modify and refine plans. Planning should include concrete implementation steps with training and exercise goals for each step. Each component of the response should be taught, exercised, evaluated, modified, and tested again. Exercises should simulate actual casualties, as well as management of the "worried well"—individuals calling for EMS resources who actually do not need them. Exercises should include response partners from public, private, community, and governmental and nongovernmental agencies. This iterative process allows for continuous modifications and improvements to plans, policies, and procedures.
Provide leadership. Leadership training should be provided for mid- and upper-level EMS supervisory staff members to ensure that in case of major illness, injuries, or deaths, there will be individuals who can take on the role of EMS medical director or leadership. A staff member or members should be designated in advance who can adjust standard operating procedures and the scope of practice of EMS personnel to accommodate the needs of the situation.
Return to Contents
Approaches to the Allocation of Scarce Resources
In the case of an MCE, there likely will be scarcities of emergency medical technicians (EMT), transport capacity, and destinations for patient treatment. As a result, plans should be in place for coordinating and maximizing the use of available staff members and resources. These plans should be tested and refined prior to the MCE. Legal and ethical advisors should be included in planning discussions. Allocation of scarce resources should include the following:
Make sure as many EMS personnel as possible are available through use of modified or extended shifts, deployment of no more than two providers per vehicle, and use of one-person response vehicles for "patient evaluation" prior to dispatch of transport resources. Staff members also may be shifted so that non-EMTs can serve as drivers; fire, police, or volunteer EMTs can provide assistance during transport; and other medical personnel (e.g., physicians, nurses, nurse's aides) can help staff casualty treatment sites to permit EMS personnel to provide transport services. "Just-in-time" programs that train nonmedical volunteers to provide basic medical care such as applying direct pressure for hemorrhage control also should be developed.
Make best use of available EMS personnel. Some medical protocols may be suspended to allow greater efficiency and flexibility in patient management. EMS personnel may be used in nontraditional settings (e.g., alternative care sites (ACSs), hospitals, pharmaceutical distribution centers) for field triage, treatment, or transport. Their scope of practice may be extended to provide vaccinations or medications or to deliver nontraditional medical care at the scene.
Maximize transport capability. Public and private ambulance services should be coordinated and steps should be taken to ensure that they do not self-dispatch to MCEs. Paramedic-initiated alternative transportation (e.g., buses, taxis, privately owned vehicles) also should be used. Mutual aid agreements should be in place to deploy available transportation assets, staff members, and staging locations. Transportation assets should be loaded to full capacity and patients taken to the closest appropriate hospital or care site. Air transport should be used to take patients to distant facilities (unless the incident presents contamination risks). Noncritical calls should be batched by geographic area. Bypass, diversion, or closure rules can be suspended to best distribute patients and to avoid overloading any one hospital.
Use the Community Emergency Response Team (CERT). The CERT program trains people in basic disaster response skills, such as fire safety, light search and rescue, team organization, and disaster medical operations. CERT members can assist others following an event when professional responders are not immediately available.
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Resources
Information about CERT is available at http://www.citizencorps.gov/cert/about.shtm.
</td> </tr> </tbody></table>
Screen calls and dispatch efficiently. Call screening strategies should be in place to determine the level of urgency required to respond to calls. Response strategies involving multiple responders (e.g., engine company, ambulance, law enforcement) used in standard EMS response should be avoided. Prearrival instructions should be scripted and tailored to the incident with formal recommendations on use of alternative transport and ACSs.
Provide personal protection for personnel. Universal precautions should be used for every patient encounter, if possible. To reduce the number of responders exposed to pathogens or chemicals, specialized protections should be used to the extent possible and adjusted to the nature of the incident (e.g., distribution of antibiotics, vaccines, or antidotes to staff and family members). In the case of chemical incidents, decontamination needs must be evaluated and addressed before transportation to preserve transport capability. Similarly, security personnel should be assigned to protect EMS response operations, logistics centers, and stockpile depots.
Triage and evaluate patients efficiently. Specific triage systems should be in place before an incident, and personnel should be trained and exercised in their use. Simple triage methods include rapid separation of critical patients from noncritical patients (i.e., "Everyone who can walk should get on this bus."). The overarching principle for triage is "to do the most good for the most people."
There are three basic types of triage. Primary triage is the first triage of patients into the medical system (possibly occurring 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.<sup>49</sup> This may occur at the hospital following EMS interventions or after initial interventions in the emergency department. Tertiary triage is the reevaluation of the patients' response to treatment after further interventions. This continues for the duration of the patient's hospital stay. Historically, triage has involved four levels of priority for traumatic injuries:
- Green—delayed treatment—patient has minor injuries or illness that should not pose a threat to life or limb.
- Yellow—intermediate—patient has injuries or illness that may result in death or disability but pose no immediate threat to life or limb.
- Red—critical—patient has injuries or illness that will result in death within the hour unless interventions occur.
- Black—expectant or deceased—patient is expected to die because of severity of illness or injuries or has died. Comfort measures, including pharmacologic treatment, should be provided as available.
An experienced health care provider, such as the EMS Medical Director or designee, should be involved in any decision to classify a patient as "black" during a disaster. Although such patients may be designated as low priorities for transport, they should have access to palliative care (e.g., analgesia, sedation, physical and behavioral care) to the extent possible under the circumstances. Expectant patients should be reassessed regularly for comfort, improvements in their situation, or in case resources become available unexpectedly.
Coordinate destination choices. A centralized coordination of patient transport should be in place for minimal hospital overloading and best use of other available resources, such as primary care providers, ACSs, medical evaluation centers, or triage centers.
The vast majority of victims of an MCE may end up being most appropriately managed at home, either because their illness or injury is not severe enough to warrant institutionalized care or because, given scarce resources, inpatient treatment may be considered futile or wasteful.
Use local, regional, State, and national information services systems that provide updates of hospital bed status and capabilities to inform EMS about destination choices and to help coordinate patient distribution.
Establish casualty treatment areas on or near the disaster site or at ACSs (depending on the nature of the incident) to address the volume of casualties, provide triage, assess transport, and serve as treatment sites. Home health care should be used according to predetermined triage protocols to prevent unnecessary use of EMS transport and hospital resources.
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Resources
Home Health Care During an Influenza Pandemic, available at http://www.flu.gov/professional/hosp...omehealth.html.
</td> </tr> </tbody></table>
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Incorporating Home Health Care Into Emergency Planning: Issues to Consider
Register patients being cared for in the home setting with a local emergency management agency and the public health department to ensure access to relevant information.
Ensure adequate stock of routine chronic care medications.
Ensure adequate stock of basic first aid supplies, including bandages, antipyretic medications (e.g., acetaminophen, ibuprofen), oral electrolyte solutions, and thermometers.
Ensure that backup utility support is in place if warranted (particularly for those patients requiring electricity for medical devices).
Establish a "sick room" in the home for managing ill household members, particularly in the event of a transmissible infectious disease.
In caring for patients with advanced symptoms who are too sick for hospital care, coordinate symptom palliation with a home care team coordinated by local public health authorities.
Ensure the availability of a bedside commode or bedpan.
</td> </tr> </tbody></table>
<hr>
- Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Emergency Medical Services: At the Crossroads. Washington: National Academies Press; 2006.
- Saffle JR, Gibran N, and Jordan M. Defining the ratio of outcomes to resources for triage of burn patients in mass casualties. Journal of Burn Care & Rehabilitation November/December 2005;26(6):478-482.
</td></tr></tbody></table>