Mass Medical Care with Scarce Resources: The Essentials - Hospital/Acute Care

[sharon sanders]

<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> 5. Hospital/Acute Care

<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Key Questions
What is the National Incident Management System and what are its components?
What guidance should be included in a plan for allocating scarce resources?
How can staff and space capacity be increased during an emergency?
What factors should be included in patient assessments when resources are scarce?
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In the event of an MCE, decisions and policies regarding resource allocation in hospitals will have to be developed in advance at multiple levels, ranging from the State to local communities and institutions. Hospitals should be able to follow guidance and decision support tools available through a clearinghouse to make resource allocation decisions (e.g., who should receive mechanical ventilation). 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 hospital and acute care needs following an MCE, hospitals and their partners need to prepare.
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Developing an Integrated Incident Management System

Hospitals must have in place a system of coordination with other local hospitals, public health departments, incident commands, public safety, and EMS systems to provide care. Integrated incident management is critical to preparing for an MCE and must be developed prior to any catastrophic event.⁵⁰
The ICS 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.
<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Resource
Information on the National Incident Management System training curriculum is available at http://www.fema.gov/emergency/nims/N...ngCourses.shtm.
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An Institute of Medicine report on hospital-based emergency care recommends that coordination and incident management require the following components:⁵¹

• The establishment of hospital coalitions, compacts, and mutual aid agreements to create a common platform for planning and response. This may be facilitated by the use of an existing program, such as the Hospital Incident Command System (HICS). HICS is a nationally recognized approach to disaster management (go to box).
• The establishment of a jurisdictional Emergency Operations Center. Hospitals should be familiar with its local office of emergency preparedness and know how it is represented there.
• The designation of a particular hospital or local public health agency as a 'trusted source' to serve as the hospital's resource and policy gateway within the region during a major multijurisdictional event.

<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>The Hospital Incident Command System
The Hospital Incident Command System (HICS) was developed in California to provide an emergency management system for hospitals for use during a medical disaster. The system helps coordinate emergency response between hospitals and other emergency responders and is based on a clear chain of management, clearly defined responsibilities, prioritized response checklists, clear reporting channels for documentation and accountability, and a common nomenclature. HICS is compliant with the National Incident Management System. More information on HICS is available at http://www.hicscenter.org/pages/index.php.
The Incident Command Section provides overall coordination of the response and is the central communications point.
The Operations Section conducts tactical medical operations to carry out the incident action plan. Activities will include basic medical services, behavioral/mental health support, ancillary medical services, and preventive medicine.
The Planning Section prepares and documents the Incident Action Plan (IAP) by collecting and evaluating information, maintaining resource status and documentation for incident records.
The Logistics Section provides support, resources, and other services, including personnel, needed to meet operational objectives.
Finance and Administration is responsible for time-recording, procurement, accounting, and cost analysis.
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Developing a Planning Framework for Allocating Scarce Resources

The planning framework should be transparent and shared with key stakeholders in the health department, attorney general's office, and governor's office and with the community, both in advance of and during an MCE. The framework should establish ways to:

• Define or project the resource shortfalls and the impact on clinical care.
• Request additional resources, facilitate the transfer of patients out of the affected area, or facilitate alternative strategies for patient care (e.g., alternative care sites, home care).
• Develop and disseminate supportive policy and clinical guidance (e.g., triage and treatment recommendations, decision tools)?ideally ones that have been nationally sanctioned or federally approved and disseminated. Clinical guidance or decision aids should reflect any available Federal guidance and ideally be flexible enough to allow hospital and clinician discretion in making resource allocation decisions, as deemed medically justified.
• Provide guidance for liability relief for providers.
• Provide guidance on the equitable management and allocation of scarce resources.
• Integrate response strategies and tactics across facilities and agencies at the local, regional, State, and Federal levels (Figure 1). The six-tier construct depicts public health and medical asset management levels during response to mass casualty or mass effect incidents. The tiers range from individual health care organizations or other healthcare assets and their integration into a local healthcare coalition to coordination of Federal assistance. Each tier must be managed internally to integrate externally with other tiers.

Source: Barbera JA, Macintyre AG. Medical Surge Capacity and Capability Handbook. Prepared for the U.S. Department of Health and Human Services by CNA Corporation under contract. September 2007). Accessed July 21, 2009 at http://www.hhs.gov/disasters/discuss...pter1/1.2.html.
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Coordinating Community and Regional Response Planning for Hospital/Acute Care

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) that can help the State health department in managing resource allocation in their area. This arrangement allows for plans to consolidate 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.
Interstate agreements and cooperation help promote sharing of assets across State lines. This level of interstate cooperation is difficult to achieve but is one of the most important ways to maximize resource allocation.
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Increasing System Capacity

In advance of an MCE, hospitals should establish a preference list of supplemental providers to expand staff capacity. These providers might include:

• State Emergency Systems for Advanced Registration of Volunteer Healthcare Professionals (ESAR-VHP). Local hospital staff, clinic staff, and health professional volunteers registered with an ESAR-VHP have had their credentials verified.
• The Medical Reserve Corps (MRC). Local MRC units of volunteers may include medical and public health professionals, such as physicians, nurses, pharmacists, dentists, veterinarians, epidemiologists, and paramedics.
• Federal public health and medical teams. (e.g., National Disaster Medical System, Public Health Service).
• Trainees.
• Patient family members.
• Military members.
• CERTs.
• Lay volunteers.

<table class="bluebox" border="1" cellpadding="8" cellspacing="0" width="80%"> <tbody><tr valign="top"> <td>Resources
More information on MRC and ESAR-VHP is available at http://www.medicalreservecorps.gov.
</td> </tr> </tbody></table> Policies should be in place in advance for credentialing staff members and managing deployment of nonhospital personnel in the hospital. A plan also should be in place for managing volunteers.
An important staffing issue 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 possible harm to themselves or their family members. Some States have provisions to delicense or otherwise sanction providers who do not report for duty during a declared disaster. Nevertheless, there are real concerns for providers about duty to family and child care issues that may not be solved easily.
Careful determination of priority groups and essential personnel, facilitation of child care, providing adequate personal protective equipment, and providing housing apart from family for workers who request it, all can help ensure that health care workers are willing and able to work (and work safely) during a disaster.
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Applying Short-Term Strategies

Short-term strategies may be applied to increase healthcare facility capacity in cases in which 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.
Planners can increase space capacity by:

• Employing rapid discharge of emergency department and other outpatients who can continue their care at home safely.
• Employing rapid discharge of inpatients who can safely continue their care at home or at alternate facilities if they are available.
• Canceling elective surgeries and procedures, with reassignment of surgical staff members and space. 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.
• Reducing the usual use of imaging, laboratory testing, and other ancillary services.
• Expanding critical care capacity by placing select ventilated patients on monitored or step-down beds; using pulse oximetry (with high/low rate alarms) in lieu of cardiac monitors; or relying on ventilator alarms (which should alert for disconnect, high pressure, and apnea) for ventilated patients, with spot oximetry checks.
• Converting single rooms to double rooms or double rooms to triple rooms if possible.
• Designating wards or areas of the facility that can be converted to negative pressure or isolated from the rest of the ventilation system for cohorting contagious patients; or use of these areas to cohort health care providers caring for contagious patients to minimize disease transmission.
• Using cots and beds in flat space areas (e.g., classrooms, gymnasiums, lobbies) within the hospital for noncritical patient care.
• Transferring patients to other institutions in and out of the State.
• Facilitating home-based care for patients in cooperation with public health and home care agencies.
• Establishing mobile or temporary evaluation and treatment facilities in the community. These locations also may be used to screen patients with mild symptoms when medications are available and must be taken early in the course of illness to be effective.

Planners can expand staff capacity by:

• Calling in staff members.
• Changing staff scheduling (e.g., duration of shifts, staffing ratios, staff assignments).
• Requesting supplemental staff members.
• Sharing small numbers of specialized staff members (e.g., burn nurses, pediatric critical care staff members) with hospitals in need.
• Activating memoranda of understanding (MOU) with regional and distant hospitals, health systems, or State disaster medical assistance teams. Planners can increase access to supplies by activating MOUs with commercial companies.

If these strategies are not sufficient to meet the demands of the incident and no immediate relief is available, then an evaluation of the level of care being provided must be conducted. Surge strategies should be reviewed and revised based on available resources.
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Applying the Spectrum of Adaptation: From Administrative to Clinical Change

In the case of a long-term resource shortage, strategies for meeting the demands of an MCE can be classified along a spectrum that includes two categories of changes: administrative adaptations and clinical adaptations.
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, but they require planning. Examples of administrative changes may include the following:

• Changes to reduce provider documentation, billing and coding, registration, and other administrative policy burdens. These changes 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.
• 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 in 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.

Clinical adaptations represent the allocation of scarce resources or services based on preestablished ethical principles as discussed earlier. Examples of clinical adaptations include the following:

• Triage of patients who would otherwise be treated as inpatients to home care, acute care sites, or other alternative care sites.
• 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 trained staff members).

The hospital should be able to follow State guidance regarding clinical triage decisions. If no guidance exists, the hospital will need a plan for bringing together the appropriate personnel who can make the critical decisions and reevaluate the situation during each planning cycle (e.g., each shift per day). When there is little advance evidence to guide allocation decisions (for example, not knowing how different age groups of patients in an influenza pandemic respond to mechanical ventilation), good clinical judgment by experienced clinicians will be the final common denominator to justify resource allocation decisions. The decisionmaking process should be shared openly with staff members, patients, and the public and should be as consistent as possible across facilities.
There are no clear trip points to indicate when the shift from reactive, mostly administrative changes to proactive, clinical changes must occur. 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 Hospital Resources

Patient assessment. When resources are scarce, at a minimum patient assessment should include the following factors:

• Patient's need for the resource.
• Potential to return to the baseline state.
• Overall acute resource needs of the patient.
• Health and prognosis related to an underlying disease or diseases.
• Event-specific or injury-specific prognostic factors.

If there is no differentiation in criteria between patients, then resources should be allocated on a first-come, first-served basis.
Patient triage. The four levels of priority for triage discussed earlier?green, yellow, red, and black?can be used in assigning patient acuity levels. An experienced health care provider should be involved in any decision to classify a patient as "black" during a disaster.
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Addressing Select Operational Considerations

In addition to allocating scarce resources, an MCE will require that hospitals address many operational considerations, including security and mass mortuary.
Security. A patient surge that results in scarce resources may increase the potential for violence against health care facilities and providers. Hospitals should work with their community law enforcement agencies and hospital security staff to develop a security assessment and vulnerability analysis and a plan for increasing hospital security during a widespread disaster. This plan should prioritize hospital assets for protection and rely, when possible, on physical and technological solutions rather than human solutions.
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.
• Limiting visitors to one or none per patient.
• Metal detectors and security screening at entry points.
• Increased law enforcement presence (mutual aid agreements must be in place ahead of an event. Hospitals could consider using uniformed peace officers or National Guard personnel).
• Equipping and training hospital security personnel with nonlethal methods of behavioral control with appropriate policies and oversight (e.g., batons or pepper spray).
• Other deterrents at entrances (e.g., canine officers, increased uniformed security).

Mass Mortuary. Hospitals should understand the community plan for management of the deceased. In some cases, hospital responsibilities for record-keeping and reporting will change in a disaster. Temporary facility morgue facilities may be required, and regional processing sites may be needed.
Provisions should be made for appropriate solutions to barriers presented by culturally based funeral and burial practices. Every effort should be made to plan 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 as little disruption as possible to cultural practices and that the maximum level of dignity is afforded the deceased and their families.
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1. Barbera J, Macintyre A. Medical and Health Incident Management System: A Comprehensive Functional System Description for Mass Casualty Medical and Health Incident Management. Washington: George Washington University Institute for Crisis, Disaster, and Risk Management; December 2002. Available at: http://www.gwu.edu/~icdrm. Accessed May 20, 2009.
2. Institute of Medicine. Hospital-based Emergency Care: At the Breaking Point. Washington: National Academies Press, 2006.

http://www.ahrq.gov/prep/mmcessentials/mcc5.htm

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