Which ICS facility is used to temporary Lee position in account for personnel supplies and equipment awaiting assignment?
Although much of disaster and surge capacity planning focuses on hospital-based care, approximately 89 percent of health care is delivered in outpatient settings. Of an estimated 1.2 billion outpatient visits in 2007, fewer than 17 percent were to emergency departments or hospital-associated clinics (Schappert and Rechtsteiner, 2011); total hospitalizations were 34.4 million in the same year (Hall et al., 2010). Especially during an epidemic, failure to leverage outpatient resources may result in catastrophic overload of inpatient and hospital-affiliated resources (Sills et al., 2011). For this reason, efforts to improve the integration of outpatient care assets into disaster response are critical, not only to improve the provision of crisis care but also to avoid crisis care. Current federal, state, and local disaster planning efforts have focused on integrating the hospital system and public health agencies. Following recent mass evacuations of residential care facilities (for hurricanes and fires), increased attention has been paid to outpatient nursing and long-term care units; however, individual and small-group practice settings have received little attention or integration into broader disaster planning efforts. Show
The value of the outpatient sector—its diversity—is also its challenge; the numbers and types of clinics and providers in a given area (in addition to long-term care, outpatient surgery, and other medical facilities) hamper detailed coordinated planning. Some outpatient facilities may be part of larger health care systems and thus much more able to coordinate information and develop policies that are consistent with a larger community response. Some may be community health centers—publicly funded entities with more than 8,000 sites across the nation. Those that are federally funded through the Department of Health and Human Services (HHS) recently have been required to improve their level of disaster preparedness. Such publicly funded clinics and programs benefit from the fact that they often serve at-risk populations with publicly employed providers, and provide an established mechanism and chain of command for clinical policy development, expertise, and medical direction that can be leveraged in public health emergencies. However, most facilities are independent group and solo private practices that may have no connection to local disaster planning and indeed, may not have a disaster or surge capacity plan at all. The ability of local public health or other government response agencies to engage all of these providers and clinics is compromised by their heterogeneity and the lack of available personnel, time, and funding. This gap in disaster preparedness is a potential barrier that can undermine the delivery of crisis care in mass casualty incidents such as a pandemic. This chapter focuses on the need to include outpatient facilities and providers in disaster response to maximize a community’s available resources. It describes the roles and responsibilities of the outpatient sector in a disaster response and the operational considerations associated with incorporating these facilities and providers into local and regional response. Although the chapter is not designed to be an operational guide for selection or operation of these facilities, it enumerates the functions and tasks required of outpatient facilities and providers to plan for and respond to a disaster. The template at the end of the chapter provides further detail on these functions and tasks for each type of outpatient care entity. While emergency medical services (EMS) may contribute to some of these strategies, their role in disaster response is addressed separately in Chapter 6. ROLES AND RESPONSIBILITIES OF OUT-OF-HOSPITAL AND ALTERNATE CARE SYSTEMSDisaster outpatient care—particularly the use of alternate care systems (hotlines, alternate care sites)—has been a gray area where public health and health care responsibilities frequently overlap. The result often has been less than optimal planning, with public health entities unwilling or unable to take responsibility for coordinating the care of ill or injured patients, and private health care systems unwilling or unable to take responsibility for setting up alternate care sites that would be established in unregulated facilities and therefore not within their current regulatory standards. Preincident discussion and strategizing between the two sectors are critical to a successful disaster response. Public health entities cannot simply “assign” private health care to develop outpatient surge capacity, and private health care cannot assume that public health can provide the clinical leadership or resources (especially medical providers) needed to establish effective alternate care systems. The two have a joint responsibility and distinct but equally necessary roles in efforts to advance planning for outpatient care under crisis standards of care (CSC) conditions to ensure that health care goals during a disaster can be accomplished through coordinated efforts. The coordination of these efforts can be facilitated through public health agencies and health care coalitions. Table 8-1 provides a sampling of the respective responsibilities of the outpatient and public health sectors during a disaster. TABLE 8-1Sample of Responsibilities of the Outpatient and Public Health Sectors During a Disaster. Outpatient Care ResourcesOutpatient care resources include solo and group practices, surgical and procedure centers, long-term care facilities, group home and congregate environments, and home care/durable medical equipment vendors. All of these entities should have a disaster plan. (Facilities that are reviewed by the Joint Commission often are better prepared than solo practices or nonresidential facilities.) These plans should include mechanisms to
Outpatient Providers and FacilitiesProvidersThe roles and responsibilities of outpatient providers fall into two categories:
Integrating outpatient providers into a disaster response requires that they have both an awareness of their role within their facility and system and a way to coordinate their practice with broader community efforts; this includes having a mechanism with which to monitor the common operating picture of the incident. Hospitals and acute care facilities, in coordination with government emergency response entities (including public health agencies), should educate out-of-hospital and alternate care providers on a variety of response topics prior to an incident to support an effective response. Table 8-2 lists disaster planning issues for outpatient providers. TABLE 8-2Disaster Planning Issues for Outpatient Providers. In some communities, providers offer their skill set for disaster response by preregistering with a local MRC (Medical Reserve Corp, 2011) unit or with the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP) (ASPR, 2011b). This facilitates their credentialing and integration into a community response, such as by assisting at shelters. These providers then can serve under the umbrella of the government emergency response entity (e.g., emergency management agency, public health agency) with state and/or federal liability protections. A preregistration system also may help mitigate the convergent volunteerism that results in many providers coming to the site of an incident in an unstructured manner that does not support the response effort (Cone et al., 2003). However, these public health emergency response systems often do not offer providers a mechanism for surging in their own private-practice settings or a means of integrating their practice with the community response. A basic infrastructure of preparedness is a requisite for the delivery of care during a disaster, but is not often considered in a busy practice. Augmentation of simple day-to-day activities and integration into existing disaster communication channels can help providers contribute to the response without imposing large financial or time commitments. ClinicsThis category encompasses a broad array of organizational structures, from multispecialty system-affiliated clinics and federally qualified health clinics to solo independent practitioners. The vast majority of this infrastructure is private, although there are some publicly operated clinics. Additionally, urgent care facilities, clinics based in retail stores, and pharmacies that may provide some medical screening and care should be engaged in disaster response. Finally, contributions from providers of nontraditional care, such as dentists, veterinarians, and others, may be required to support surge requirements during a disaster. Surgical and Procedure CentersThese facilities may be repurposed to provide acute care, nonambulatory hospital overflow care, or elective surgeries not possible at hospitals (during infectious disease incidents), depending on the demands of the incident, the specifics of the facility, and the needs of the community. The need for modified regulatory and licensure standards (e.g., changes in the scope of care) should be addressed in advance in the event that federal, state, or local government entities (such as public health) mandate the delivery of triaged care in these facilities. Long-Term Care FacilitiesMany types of facilities are encompassed by this category. Most long-term care facilities have limited surge capacity to accommodate hospital discharges, although they should not be overlooked as a resource. They may have a role in particular in rural areas, where hospital-associated long-term care facilities may not operate at capacity, and demand in the community may not justify a separate alternate care site. Long-term care facilities should be prepared to shelter in place (including without power) during a major incident, and to modify patient care and referral policies (including when patients are referred to the emergency department) depending on the resources available within the health care system. Long-term care facilities also should plan for a disproportionate impact of certain incidents (e.g., a pandemic involving a novel influenza strain) on their residents (AHRQ, 2007a). Finally, a long-term care facility should have memorandum of understanding (MOU) in place both within its jurisdiction and in a distant jurisdiction to support evacuations or the delivery of CSC during an incident. Group Home and Congregate EnvironmentsThese types of locations (e.g., schools, businesses) with on-site medical personnel may provide dispensing or vaccination/prophylaxis services in conjunction with government disaster response efforts, especially those of public health agencies. They also should be prepared to provide sheltering or isolation for their residents/ students during an incident and adjust referral criteria and care policies to reflect current community practices during a disaster. Home Care/Durable Medical Equipment VendorsHome care/durable medical equipment vendors should have plans to prioritize their services based on the nature of an incident (and adjust them as the incident evolves over time). These plans also should cover clients that are quarantined, isolated, or sheltering in place because of weather or other emergencies (see Box 8-1). Home care and durable medical equipment vendors may play critical roles as well in providing equipment and services to shelters and alternate care sites (AHRQ, 2011; Rebmann et al., 2011). BOX 8-1Home Care Agencies’ Allocation of Scarce Resources. During the 2011 Southern California blackout, home oxygen generators failed and had to be replaced by nonpowered oxygen tanks and systems, which were in short supply. A home care agency determined (more...) Family-Based CareHome care provided by family members can play a critical role in preventing the medical system from being overloaded, whether during a pandemic or an incident such as a blackout. Families should be prepared for expanded responsibilities during an incident. Further, home care agencies should develop mechanisms to communicate issues related to CSC during an incident. Alternate Care SystemsAlthough the previous section addressed outpatient entities whose existence is not tied to disaster response, recent experience (e.g., the H1N1 pandemic, Hurricane Katrina) demonstrates that such entities can serve to reduce patient volume at hospitals and are a crucial response component. When a disaster overwhelms the surge capacity of both hospitals and these traditional outpatient entities, alternate care systems may be established. The common types of alternate care systems and their functions are described in the following sections. Each type provides for the needs of specific patient groups (e.g., ambulatory and nonambulatory, surgical, emergency, shelter based), requires a certain amount of time to set up, and may be more appropriate in certain types of disasters (e.g., an evolving epidemic versus a no-notice mass casualty incident). Figure 8-1 illustrates that as the degree of intervention increases, the number of patients that can receive the intervention decreases. Especially when CSC are in effect, the goal of providing the most benefit to the greatest number of people should influence the types of alternate care systems established. The following discussion expands on foundational work sponsored by the U.S. Soldier Biological and Chemical Command on modular emergency medical systems planning for disasters, including documents on acute care centers and neighborhood emergency help centers (DOD, 2001a,b). FIGURE 8-1Relationship between degree of intervention at an alternate care site and number of patients that can benefit from the intervention. NOTE: FMS = federal medical station. One of the primary benefits of alternate care systems is their flexibility: both government emergency response entities and private health care institutions can establish them to maximize the efficiency of reaching an entire community. For instance, mass prophylaxis and vaccination centers are used in campaigns to inoculate a large population, and thus are generally operated by public health departments in community locations (NACCHO, 2008). However, health care facilities also may have a critical role to play in administering these interventions as closed points of dispensing (NACCHO, 2008) for their own institutions, as may nonhealth facilities (such as businesses or corporations) for their employees. These strategies should be incorporated into local public health dispensing plans and those associated with established health care coalitions. Electronic Alternate Care SystemsBasic interventions can be provided to a large number of people for specific criteria/symptoms using minimal resources via electronic means. Online and telephone assessment and prescribing (implemented successfully in many jurisdictions for early antiviral treatment during the 2009 H1N1 pandemic, for example, through poison control centers) provide a method for treating at-risk individuals rapidly and without face-to-face encounters (Kellermann et al., 2010). Health insurance- and health system-based telephone and web systems, augmented by government emergency response systems as needed, can help meet demand (AHRQ, 2005, 2007c). Referral policies and telephone scripting may have to be adjusted to provide consistency across agencies/entities. Similar systems also can provide psychological assessments for patients with anxiety or depression related to a disaster. In addition, telemedicine may be used to augment specialty care (Nicogossian and Doarn, 2011). Experts from outside the affected area may be used to provide consultation to support overwhelmed local resources; for example, burn experts outside an affected area may provide hotline or telemedicine support to community providers. Emerging social media technologies may also play a role. Ambulatory Care FacilitiesThese facilities (e.g., “flu centers” or casualty collection points) are intended to serve the minimally ill or injured who cannot be accommodated by the usual outpatient infrastructure. The need for such facilities, as well as their staffing and supply, varies greatly depending on the type of incident and the phase of the incident. Acute need for such sites may be seen during a pandemic or after a massive no-notice incident, such as an earthquake or detonation of an improvised nuclear device. Health care facilities may set these units up in nontraditional locations on their premises (CBS News, 2009; Chung et al., 2011; Cruz et al., 2010) or at other sites under their control. Public sites may be initiated if the capacity of the health care system is overwhelmed or if selected populations or areas are disproportionately affected. These public sites also may be in nontraditional locations (e.g., veterinary clinics, dental clinics, schools). Preplanned supplies for infectious and trauma incidents should be considered for ambulatory care facilities. However, it is advisable to work with state Centers for Medicare & Medicaid Services offices to ensure that appropriate waivers are obtained. Shelter-Based CareThe medical care needs of the sheltered population may be extensive, and a high level of medical expertise and materiel may be required at public shelters (e.g., for patients that are oxygen dependent, receive dialysis, or have behavioral health needs). Current recommendations are to avoid special shelters for those with medical or other physical/functional limitations because of the potential for discrimination due to failure to prepare for their needs in general shelters. Thus, the medical community should work with government emergency response entities (and the MRC and other groups) to ensure adequate medical staff and supply support for shelters, depending on demographics and the specifics of an incident. Federal Medical StationsThese 150-bed units are designed to provide basic nonambulatory care to hospital overflow patients with minimal medical needs or to shelter patients with more advanced outpatient needs. Requested by state health or emergency management agencies, they are designed to be moved into “structures of opportunity” in the community, such as schools or convention centers. Although multiple federal medical stations are available, the supply is clearly inadequate for a multistate or national event (e.g., a pandemic, a major earthquake), and the request and setup process requires days. Federal medical stations may be integrated with shelter-based or nonambulatory care or be independent (ASPR, 2012). The federal medical station organization and logistics may be helpful templates for local planning for nonambulatory care centers. Emergency Care Replacement/OverflowUsually provided in a specialty trailer or temporary specialty structure, emergency care replacement or overflow sites provide replacement capacity for damaged emergency departments (particularly in smaller communities). They also can provide temporary increased capacity for a single facility or area during a special event or major incident, particularly one involving health care or transportation infrastructure damage that limits access to emergency care. The level of care provided often can be equal to that provided in a hospital environment. Setup usually takes a matter of hours. The number of patients that can be served is limited by the size of the structure (Blackwell and Bosse, 2007; D’Amore and Hardin, 2005). Surgical/Intensive Care or Inpatient Replacement/OverflowAlso provided in specialty trailers or temporary specialty structures, these care sites provide specialty services in communities whose infrastructure is damaged or inadequate (Bar-Dayan et al., 2005; D’Amore and Hardin, 2005; Rhodas et al., 2005). The infrastructure requirements of such sites are significant (D’Amore and Hardin, 2005; Kreiss et al., 2010). Although these sites often can provide advanced services, at times they can be inserted into situations in which they are the only advanced care infrastructure, which can lead to both capacity and capability issues with respect to supplies and specialty providers (Bar-On et al., 2011; Burnweit and Stylianos, 2011; Kreiss et al., 2010; Merin et al., 2010). Mass MortuaryAlthough not a matter of clinical care per se, structured planning for mortuary services during a major incident is critical to maintaining the dignity and timely and orderly processing of the deceased, as well as social order. Plans for surge capacity mass mortuary sites should be planned in coordination with the jurisdiction’s coroner and office of emergency management for possible logistical support. In addition, plans should include options for staffing (incorporating a National Disaster Medical System [NDMS] disaster mortuary operational response team when possible, as well as state-based resources to support a mass fatality or mortuary incident) (ASPR, 2011A), equipment, identification, family support/viewing, processing, and holding/ storage. Such sites are an important part of disaster planning, but are not addressed further in this report. In developing mass mortuary plans, coordination with EMS and hospitals is essential. OPERATIONAL CONSIDERATIONSIn many communities, public health agencies are the only entities capable of harnessing the vast array of outpatient resources for disaster care for the community’s benefit. In other communities, public health agencies have a role that involves coordination or is secondary to efforts being led by health care entities themselves. Given the variability in both structure and relationships among entities engaged in health-related activities in communities nationwide, it is not possible to identify which entity should take the lead in all cases in harnessing resources for disaster care. Regardless, it is important that this entity be able to monitor, communicate about, and coordinate public and private resources across a region. Such entities will have to leverage the resources and expertise of health care, health care coalitions, and private-sector partners, as well as other public emergency response agencies, to accomplish these goals. This section describes how such entities can coordinate the expansion of outpatient care and summarizes a framework for maximizing the utility of outpatient disaster medical care. Expansion of CareAs demand exceeds existing outpatient resources, it becomes necessary to maximize the ability of hospitals and acute care facilities and systems to expand capacity. Every response coordination entity, especially departments of public health, should monitor this situation and work with health care entities to determine the next steps to be taken if private capacity and capabilities become overwhelmed or demand forecasting predicts that this will occur. Proactive planning for the next steps is critical to avoid falling behind the demand curve. Close coordination is required, and each incident will demand different utilization of the resources of outpatient facilities and alternate care systems. This is perhaps the most difficult aspect of planning as, given the variations across facilities and systems in the resources needed and available, no single strategy applies, and the success of the response depends on the commitments and coordination of the stakeholder entities in responding to incident-driven needs in a flexible, scalable fashion. Hospitals and acute care facilities should work closely with local public health agencies to determine priorities for therapies and services. Emergency response entities should ensure that appropriate regulatory and logistical issues of care are addressed in coordination with other public and private agencies. Hospitals and acute care facilities should ensure that a clinical care committee (in some cases, a very small command group/staff) determines what services can be offered and how these services fit with community priorities. In some cases, this decision making may occur at the health system level. The goal for independent facilities is that, although these decisions are made by a small group, they are informed by broad information sources channeled through emergency response coordination entities and are consistent with a common response strategy. Box 8-2 provides an example of the difficulties that can arise in making decisions about the allocation of outpatient resources even when high-level guidance is available. Table 8-3 illustrates how the emphasis of the outpatient response shifts according to the incident type, duration, and phase. BOX 8-2Allocation of Outpatient Resources. During the 2009 H1N1 pandemic, the Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on Immunization Practices (ACIP) provided recommendations on priority groups for influenza vaccine (more...) TABLE 8-3Out-of-Hospital Response Emphasis According to Incident Type, Duration, and Phase. Local Emergency Response Planning to Incorporate Outpatient CareLocal emergency response planning for outpatient disaster medical care entails the following five elements:
Reimbursement and Financing IssuesReimbursement of hospitals and acute care facilities for disaster-related expenditures often is difficult even with proper documentation given the private nature of most facilities and the reimbursement requirements of the Federal Emergency Management Agency (FEMA). Time and material expenses should be carefully tracked and, when possible, purchases and authorization of personnel time should be public actions (that is, ordered by public health or emergency management agencies rather than by a private health care facility) to enhance the prospects for reimbursement. Reimbursement by insurance companies for care provided in nontraditional settings (e.g., “flu centers") is an area that requires further clarification. If the site is staffed by usual health care providers and meets usual regulatory and other requirements, billing and reimbursement may be pursued in the normal manner (CMS, 2009). If, however, public sites, personnel, or supplies are used, private reimbursement usually is not possible (or necessarily permissible). Discussion of different scenarios with public and private payers prior to an incident is advisable. TEMPLATE DESCRIPTIONMany of the functions and tasks required of the various outpatient care entities to plan for and implement CSC are similar in nature. Thus, the following descriptions of the general functions of outpatient care facilities are meant to serve as a broad guide; specific functions and tasks for outpatient care facilities, long-term care facilities, home care/medical equipment vendors, and alternate care systems are enumerated in Template 8.1 at the end of this chapter. The functions presented in this section should be regarded as optimal, not minimal, and are unlikely to be implemented without significant time and funding commitments that are not priorities in current preparedness programs. Nonetheless, they offer concrete goals for outpatient sector preparedness. The term “facility” often is used below, but the principles apply equally to the other types of outpatient entities cited above. Following these general descriptions for outpatient care entities is a section describing the function and tasks of outpatient providers; these functions and tasks make up the final section of Template 8.1. General Functions of Outpatient Care Facilities
TABLE 8-4Sample Logistical Considerations for Alternate Care Sites. Functions of Outpatient Providers
Template 8.1. Core Functions of the Out-of-Hospital and Alternate Care Systems in CSC and Planning ImplementationOutpatient Care Facilities Function 1. AlertingNotes and Resources Institution should at least annually test notification systems and ensure that up-to-date contact information is available. Task 1Health care facility is able to receive and manage alerts from partner facilities (corporate, health care coalitions, hospital, or other facility partners), public health agencies (health alert network), and the National Weather Service. Task 2Emergency response plan provides triggers and process for incident command to activate the CSC plan and indicators (if applicable) to prompt consideration of activation. Function 2. NotificationTask 1Institution is able to alert staff within and external to the facility, including
Notification mechanisms account for redundancy in case a disaster affects usual means of contact/consultation. Task 2Facility identifies technical experts that can work with the administration to determine issues/policies related to infection control, infectious diseases, pediatric care, mental health care, and other specialties as required by the role of the facility. (These may be identified regionally.) Function 3. CommandTask 1A hospital incident command system (HICS) (or other modified National Incident Management System [NIMS]- and community-compliant system) appropriate to the institution’s size and role is utilized. Includes
Function 4. ControlTask 1Command staff/leadership understand, to the degree necessary for the size/scope of the facility’s engagement, the interface for resource requests and the acquisition process (as well as any existing plans for resource triage/allocation) with
Task 2Command and other appropriate staff understand transfer and diversion policies in the area and their function during disaster situations (including any agreements to receive ambulances or referral patients and what to do when emergency medical services [EMS] cannot rapidly transfer a patient from the facility to the hospital). Task 3Command staff understand the processes for sheltering, relocation, and evacuation in response to threats to the facility. Task 4Command staff understand options for security/access controls and community law enforcement support during a disaster. Task 5Facility plan reflects a phased expansion of surge capacity/capabilities for conventional, contingency, and crisis care situations. Task 6Command staff understand the process for rapid facility and response assessment in the immediate aftermath of an incident to gain situational awareness. Task 7Command staff/administrators understand the process for determining facility shut-down procedures (if required) and notification/diversion of patients. Task 8Command staff/administrators understand their authorities relative to the facility and its role in any larger system (e.g., authority to change staffing, hours, policy). Function 5. CommunicationsTask 1Facility has policies and procedures in place for sharing situational updates with staff, patients, and other facilities and agencies as necessary (ideally via multiple methods, potentially including):
Task 2Facility has the ability to communicate with
Function 6. CoordinationTask 1Command staff understand the interface between the institution and local public health and emergency management agencies and any local/regional health care coalitions during a disaster. Task 2Institution understands the function of the state disaster medical advisory committee and any regional medical coordination center or regional disaster medical advisory committees, as well as the means by which information is received from or communicated to these bodies. Task 3If facility is part of a health care system, plans document the integration of facility response with the corporate response structure and processes. Task 4If facility has a limited patient population (Department of Veterans Affairs [VA], pediatric, or other specialty facility), there is guidance/a plan for how that facility contributes to the response when an incident affects either its usual target population or other groups disproportionately. Function 7. Public InformationTask 1Facility coordinates information with other agencies and facilities and participates in jurisdictional joint information system (JIS) activities as appropriate. Function 8. OperationsNotes and Resources The mental health section of Chapter 4 provides a more detailed discussion and examples. The palliative care section of Chapter 4 provides a more detailed discussion. Conventional, Contingency, and Crisis Care ConditionsTask 1Under conventional care conditions, command/supervisory staff know how to maximize capacity, including postponing elective appointments, adjusting staffing and hours, and other changes. Task 2Under contingency care conditions, command/supervisory staff can implement plans for repurposing patient care areas (e.g., changes to waiting areas to segregate infectious patients, space expansion) and understand the decision process for changes to clinical practice. Task 3Under CSC conditions, same as under contingency care conditions, but options are expanded to include
Mental HealthTask 1Facility has a plan for triage-driven management of psychological casualties, including participation in local/regional plans for disaster mental health incident management. Task 2Facility has all personnel trained in basic “neighbor-to-neighbor, family- to-family” psychological first aid that includes psychological triage. Task 3Facility has a health care worker personal resilience plan with inoculation, self-triage, and evidence-based care elements. Palliative CareTask 1Facility has anticipated the need for adequate symptomatic management (analgesia, antiemetics, anxiolytics) for its patients (including those that will not receive other treatments). These medications may be in short supply in community pharmacies. Task 2Palliative care is addressed in the emergency operations plan, including palliative care principles, triage tools if applicable, home care and medical equipment referrals, counseling referrals, and family support resources. Task 3Palliative care training (including just-in-time training) can be made available to facility staff. Function 9. LogisticsStaffingTask 1Call-back criteria and policies are in place and include maintenance of current and accurate employee contact information. Task 2Facility assesses the number of staff potentially available during whole-community incidents, including situations that limit access to the facility, affect staff families, or result in provider illness/injury. Task 3Facility has planned for on-site accommodation of staff and family members as appropriate. SuppliesTask 1Identify key potential scarce resources based on types of incidents and stockpiles or identify alternative sources for these supplies if possible (e.g., N95 masks, selected medications). Task 2For highly vulnerable supplies, identify strategies for appropriate substitution, conservation, adaptation, reuse, and reallocation. Task 3For local or state cached supplies (such as a local pharmaceutical cache) or Strategic National Stockpile (SNS) supplies, facility understands the process for request, receipt, and distribution of these supplies through public health agencies. SpaceTask 1Facility has examined available patient care space and conversion of non-patient care areas to patient care, as possible. Special ConsiderationsTask 1Patient groups requiring special consideration are identified, and, to the degree possible, equipment and supplies to address the needs of these groups are purchased and/or stockpiled in relation to the facility’s size and role in the community. Considerations include (but are not limited to)
Task 2Facility understands any regional plans or resources for specific groups (e.g., regional pediatric or dialysis networks) and its role in such plans. Function 10. PlanningTask 1Facility understands how to access appropriate technical specialists and how they interface with the facility’s (or corporate) command and planning functions (may be a regionally shared function—for example, a regional disaster medical advisory committee). Task 2Facility and/or system uses an action planning process and can modify the strategies, tools, or process based on evolving incident information. Task 3Facility and/or corporate bylaws and credentialing policies and procedures account for the use of outside staff during a disaster, including the use of local/regional staff in accordance with coalition agreements, and for the integration of outside staff, including orientation, mentoring, and supervision. Task 4Policies for altered staffing ratios, shift lengths, and staff roles are examined, and any collective bargaining issues are identified, if not addressed. Task 5Facility understands the process and supporting agreements (e.g., related to worker’s compensation, liability) for sharing staff with other facilities in need, including staffing of alternate care sites. Function 11. Administration/Legal IssuesNotes and Resources See Chapter 3 for a more detailed discussion. Task 1Administration (including corporate administration outside of the facility) examines its delegation-of-authority processes and makes any changes necessary to ensure that CSC decisions are supported (i.e., that facility decision makers are acting with the support of administration). Task 2Administration understands relevant changes to facility authorities and protections when state declarations of emergency/public health emergency are made, including legal protections or obligations for medical providers (e.g., duty to serve). Task 3Facility and/or corporate legal counsel are aware of surge capacity plans and implications for patient care. Task 4State and local laws and regulations that would constrain the institution’s ability to implement CSC plans and possible solutions are identified (may be a regional effort—see Chapter 3 for a detailed discussion of functions). Core Functions of the Outpatient Sector in CSC Planning and ImplementationLong-Term Care Facilities Function 1. AlertingTask 1Long-term care facility is able to receive and manage alerts from partner facilities (corporate, hospital, or other facility partners), public health agencies (health alert network), and the National Weather Service. Task 2Emergency response plan provides triggers and the process for incident command activation. Function 2. NotificationTask 1Institution is able to alert staff within and external to the facility, including
Notification mechanisms should account for redundancy in case a disaster affects usual means of contact/consultation. Task 2Facility identifies technical experts (may be shared regionally) that can work with administration to determine issues/policies for infection control, infectious diseases, palliative care, and other specialty considerations. Function 3. CommandTask 1An HICS system (or other modified NIMS- and community-compliant system) is in place. Includes
Function 4. ControlTask 1Command staff understand the interface for resource requests and the acquisition process (as well as any existing plans for resource triage/ allocation) with their local partners (regional medical coalitions and public health and emergency management agencies as applicable). Task 2Command and other appropriate staff understand the interface with EMS and what services EMS will provide during evacuation and other events associated with an incident. Task 3Command staff understand the processes for sheltering, relocation, and evacuation in response to threats to the facility. Task 4Command staff understand options for security/access controls and community law enforcement support at their facility during a disaster. Task 5Command staff/administrators understand the process for determining facility shut-down procedures (if required). Function 5. CommunicationsNotes and Resources Task 1Facility has policies and procedures in place for providing situational updates to staff, patients, and their families. Ideally, these mechanisms have redundancy in case of failure of the primary system. Task 2Facility has the ability to communicate with
Function 6. CoordinationTask 1Command staff understand how they are expected to interface with local public health and emergency management agencies and/or existing health care coalitions during an incident. Task 2Institution understands the function of the state disaster medical advisory committee and any regional medical coordination center or regional disaster medical advisory committees, as well as the means by which information is received from or shared with these bodies. Task 3If facility is part of a health care system, plans document the integration of facility response with the corporate response structure and processes. Function 7. Public InformationTask 1Facility contributes to jurisdictional JIS activities as appropriate. Function 8. OperationsNotes and Resources See Chapter 4 for a more detailed discussion. See Chapter 4 for a more detailed discussion. Conventional, Contingency, and Crisis Care ConditionsTask 1Under contingency care conditions, command and unit staff are aware of how to adjust staff hours and responsibilities and resident locations to maximize capacity. Task 2Under CSC conditions, same as under contingency care conditions, but options are expanded to include
Mental HealthTask 1Facility has a plan for triage-driven management of psychological casualties, including participation in local/regional plans for disaster mental health incident management. Task 2Facility has all personnel trained in basic psychological first aid (PFA) that includes psychological triage. Task 3Facility has a health care worker personal resilience plan with triage and referral elements. Palliative CareTask 1Facility has planned for adequate symptomatic management (e.g., analgesia, antiemetics, anxiolytics) for patients (including those that will not receive other treatments). Task 2Palliative care is addressed in the emergency operations plan, including palliative care principles and resources, incorporation of incident-specific triage criteria when applicable, and patient/family support resources. Task 3Palliative care awareness training is provided to staff, and just-in-time training can be made available. Function 9. LogisticsStaffTask 1Call-back policies are in place, including maintenance of current and accurate employee contact information. Task 2Facility considers alternative staffing plans during incidents that limit access to the facility or result in provider illness/family illness. Task 3Facility has planned for on-site accommodation of staff and family members as appropriate. SuppliesTask 1Identify key potential scarce resources based on types of incidents and, to the degree possible, stockpiles or identify alternative sources for these supplies (e.g., N95 masks, antivirals, vaccines). Task 2For highly vulnerable supplies, identify strategies for appropriate substitution, conservation, adaptation, reuse, and reallocation as appropriate. Task 3For local or state cached supplies (such as a local pharmaceutical cache) or SNS supplies, facility understands the process for request, receipt, and distribution of these supplies. SpaceTask 1Facility has examined available patient care space and conversion of non-patient care areas to patient care, as possible. Function 10. PlanningTask 1Facility and/or corporate bylaws and credentialing policies and procedures account for the use of outside staff during a disaster, including use of the Medical Reserve Corps or staff from partner facilities. Task 2Need for orientation, mentoring, education, and supervision of outside staff is anticipated. Task 3Policies for altered staffing ratios, shift lengths, and staff roles are examined, and any collective bargaining issues are identified, if not addressed. Task 4Facility understands the process and supporting agreements (e.g., related to worker’s compensation, liability) for sharing staff with other facilities in need, including staffing of alternate care sites. Function 11. Administration/Legal IssuesNotes and Resources See Chapter 3 for a more detailed discussion. Task 1Administration (including corporate administration outside of the facility) examines its delegation-of-authority processes and makes any changes necessary to ensure that CSC decisions are supported (i.e., that facility decision makers are acting with the support of administration). Task 2Administration understands relevant changes to facility authorities and protections when state declarations of emergency/public health emergency are made, including legal protections or obligations for medical providers (e.g., duty to serve). Task 3Laws and regulations that would constrain the institution’s ability to implement CSC plans and possible solutions are discussed/identified. (This may be a regional process.) Core Functions of the Outpatient Sector in CSC Planning and ImplementationHome Care/Medical Equipment Vendors (referred to as “Home Care”) Function 1. AlertingTask 1Home care agencies are able to receive and manage alerts from public safety, corporate administration, public health agencies (health alert network), and the National Weather Service as appropriate. Task 2Emergency response plan provides triggers and process for supervisor (incident commander if ICS used) to activate the surge capacity/ CSC plan and indicators (if applicable) to prompt consideration of activation. Function 2. NotificationTask 1Able to alert staff within and external to the agency, including health care system partners as appropriate. Task 2Staff understand what they are to do in a disaster, and appropriate notification policies are in place. Function 3. CommandTask 1Emergency response plan accounts for
Function 4. ControlTask 1Command staff understand the interface for resource requests (as well as any existing plans for resource triage/allocation) with local public health/emergency management agencies and/or local health coalitions as applicable. Task 2Command staff understand the processes for sheltering, relocation, and evacuation in response to threats to the agency, including facility assessment (includes suspension of services because of unsafe delivery conditions). Task 3Command staff understand options for community law enforcement support for their personnel during a disaster if required. Task 4Agency plan reflects a phased expansion of surge capacity/capabilities for conventional, contingency, and crisis care conditions. Function 5. CommunicationsTask 1Agency has policies and procedures in place for sharing situational updates with staff and clients (optimally redundant strategies in case of power or other system failures). Task 2Agency has the ability to communicate with (as appropriate)
Function 6. CoordinationTask 1Command staff understand the policy interface between the agency and local public health and emergency management agencies and local/regional hospital coalitions. Task 2If agency is part of a health care system, plans document the integration of agency response with the corporate response structure and processes. Task 3Agency has a plan for coordinating the scope of home care services provided with other home care agencies to avoid significant inconsistencies. Function 7. Public InformationTask 1Agency provides information to the JIS for public dissemination as appropriate to its services. Function 8. OperationsNotes and Resources The mental health section of Chapter 4 provides a more detailed discussion. The palliative care section in Chapter 4 provides a more detailed discussion. Conventional, Contingency, and Crisis Care ConditionsTask 1Under contingency care conditions, command and unit staff can implement strategies for supply substitution, conservation, and adaption; extension of staff responsibilities; and patient care strategies (which patients will receive services depending on demand). Task 2Under CSC conditions, same as under contingency care conditions, but expanded options to include
Mental Health CareTask 1Understand how to access local mental health system resources. Task 2A mental health triage system for at-risk patients, co-workers, and selftriage (for example, PsySTART) is in place. Task 3Staff are trained in psychological first aid to support at-risk patients, co-workers, and themselves. Palliative CareTask 1Agency has planned for adequate symptomatic management (analgesia, antiemetics, anxiolytics) for clients (including those that will not receive other treatment modalities). Task 2Palliative care is addressed in the emergency operations plan, including palliative care resources, the physician decision-making process, education, and any agency-specific procedures. Task 3Palliative care training (including just-in-time training) is developed and performed according to the agency plan. Function 9. LogisticsStaffingTask 1Call-back criteria and policies are in place, including maintenance of current employee contact information. Task 2Agency assesses the number of staff potentially available for large- scale incidents, anticipating limits due to community access problems (e.g., flooded roads), family obligations, or employee illness. SuppliesTask 1Identify key potential scarce resources based on types of incidents and to the degree possible stockpiles or identify alternative sources for these supplies (e.g., home oxygen concentrators, oxygen tanks for use during power failures). Task 2For highly vulnerable supplies, identify strategies for appropriate substitution, conservation, adaptation, reuse, and reallocation. Task 3For local or state cached supplies (such as a local pharmaceutical cache) or SNS supplies, agency understands the process for request, receipt, and distribution of these supplies. Special ConsiderationsTask 1Patient groups requiring special consideration are identified and, to the degree possible, equipment and supplies to address the needs of these groups are purchased and/or stockpiled in relation to the agency’s size and role in the community. Includes (but is not limited to)
Task 2Agency understands any regional plans or resources for specific groups (e.g., pediatric-specific disaster supplies, regional pediatric or dialysis networks) and its role in such plans. Function 10. PlanningTask 1Agency is aware of the role of the state or regional disaster medical advisory committees and understands how to receive information from those bodies (or communicate with them if applicable). Task 2Agency (or partner) has a plan for the clinical care committee or technical experts to review current response strategies and make modifications based on evolving information during a long-term incident. Task 3Policies for altered shift lengths and staff roles are examined, and any collective bargaining issues are identified, if not addressed. Task 4Use of nontraditional assistance (family members, volunteers, Medical Reserve Corps providers) to provide care is addressed as needed within the emergency operations plan. Task 5Orientation, mentoring, education, and clinical care policies for nonagency supplemental staff are anticipated (e.g., Medical Reserve Corps). Task 6Agency understands the process and supporting agreements (e.g., related to worker’s compensation, liability) for sharing staff with other agencies or facilities in need, including staffing of alternate care sites. Function 11. Administration/Legal IssuesNotes and Resources See Chapter 3 for more detailed discussion. Task 1Administration (including corporate administration outside of the facility) examines its delegation of authority to incident commanders during a disaster and makes any changes necessary to ensure that CSC decisions are supported (i.e., that the incident commander is acting with the authority of the agency). During a crisis, administration may require additional communications and coordination with the incident commander. Task 2Administration understands relevant changes to agency authorities and protections when state declarations of emergency/public health emergency are made, including legal protections or obligations for medical providers (e.g., duty to serve). Task 3Agency and/or corporate legal counsel are aware of surge capacity/ CSC plans and implications for patient care (e.g., plans to triage the provision of home care or of medical resources). Task 4Legal counsel identifies state and local laws and regulations that would constrain CSC plans and possible solutions (this may be a regional analysis). Core Functions of the Outpatient Sector in CSC Planning and ImplementationAlternate Care Systems (ACS) Function 1. AlertingTask 1Public health and health care coalitions (at a minimum—likely also includes emergency management and EMS) identify a multiagency coordination (MAC) group prior to an incident that can assess and address the need for alternate care sites. Task 2Process (and triggers and indicators, as applicable) for alerting the medical advisory committee is defined in emergency operations plans at the agency, coalition, and jurisdiction levels according to local plans. Function 2. NotificationNotes and Resources Institution should at least annually test notification systems and ensure that up-to-date contact information is available. Task 1MAC group has a notification mechanism (including a redundant mechanism in case of failure of the primary mechanism) for informing stakeholders of activation/demobilization of Alternate Care Systems (ACS), including
Task 2Expectations of involved agencies and technical experts are understood prior to an incident, and appropriate activation/notification policies are in place. Function 3. CommandTask 1Public health takes a leadership role in ESF-8 (Health and Medical) at the local and state levels to assess available resources vs. actual or potential demand, and to implement public alternate care systems as required to supplement the usual health care system and any private (health care organized) alternate care sites. Task 2A NIMS-compliant ICS is utilized to coordinate ESF-8 assets. Includes
Task 3Public agencies (public health, emergency management) understand their authorities to initiate ACS within the community at public sites (private sites are established by the health care facilities that operate them). Function 4. ControlTask 1MAC group and ACS site staff understand the interface for resource requests and the acquisition process (as well as any existing plans for resource triage/allocation) with local and state emergency management. Task 2Emergency management agreements/plans reflect how public health and health care facilities support sheltered populations with medical needs. Task 3ACS site staff understand the need for security/access controls and community law enforcement support options as appropriate. Task 4ACS options reflect a phased expansion of surge capacity/capabilities for conventional, contingency, and crisis care situations (from electronic to augmented services at private and public sites). Task 5MAC group has a process for ongoing incident analysis to maintain situational awareness and facilitate ACS decisions. Function 5. CommunicationsTask 1Public health agencies have policies and procedures for exchanging situational updates with hospitals/outpatient care facilities, EMS, and emergency management. Task 2MAC group/center has a means of communicating with key stakeholders (including those listed under Function 2, Task 1) to maintain incident communications (including redundant communications mechanisms as required). Function 6. CoordinationTask 1MAC group understands the interfaces among local public health and emergency management agencies and local/regional hospital coalitions, including existing agreements. Task 2MAC group understands the function of the state disaster medical advisory committee and any regional medical coordination center or regional disaster medical advisory committees, and can activate/ facilitate regional groups according to local plans. Function 7. Public InformationTask 1MAC group ensures that appropriate risk communications relevant to ACS are developed for the public regarding when and where to seek care (e.g., traditional media, websites, calling programs, e-mail, social media). This includes the ability to reach key cultural groups served by ACS. Task 2MAC group or public health agencies coordinate information with other agencies and participate in JIS and JIC activities when implemented by the jurisdiction, state, or coalition. Function 8. OperationsTask 1Local/state public health agencies maintain an inventory of usual and surge medical resources. Task 2Local/state public health agencies understand private/public ACS capacities to augment health system capacity, including
Task 3For each of these public sites (or for similar sites that are incident specific) MAC group understands the activation process (and any authorities or agreements involved). Task 4Plans are made for patient registration, tracking, and record keeping, including access to and storage of medical records. Task 5Plans are made for laboratory and pharmacy services appropriate to the site, including clinical ordering and results systems. Task 6Scope of clinical operations is defined and modified according to the evolving needs of the incident and the supplies available. Task 7ACS site has staff trained to provide psychological first aid to patients/ evacuees, can implement psychological triage processes (such as PsySTART) as required, and has a referral/management plan for those with acute mental health needs. Task 8ACS policies and education address the provision of palliative care (either on site or facilitated in the home environment). Function 9. LogisticsStaffingTask 1Local public health agencies identify sources of potential staffing (e.g., health care systems/coalitions, Medical Reserve Corps, EMS) for the various types of public ACS sites. Task 2ACS credentialing policies and procedures are congruent with applicable regulations and statutes. Task 3Plans are made for staff orientation, education, and supervision. Task 4Capacity of nontraditional resources (family members, volunteers) to provide nonmedical care is examined and addressed as needed within the ACS operations plan. Task 5Legal liability, worker’s compensation, compensation, and other issues are addressed according to the source of the staff (e.g., hospital, volunteer, MAC group). SuppliesTask 1Supply lists for each type of ACS (shelter, ambulatory, nonambulatory) are developed, optimally, including the source of initial supply and resupply. Task 2Emergency management and public health agencies, health care facilities, and medical supply vendors understand their role in the ACS setup, resupply, and delivery processes. Task 3For local or state cached supplies (such as a local pharmaceutical cache) or SNS supplies, MAC group/ACS facility understands the process for request, receipt, and distribution of these supplies. SpaceTask 1Health care facilities identify privately owned spaces for ACS establishment on site or at other owned and modified sites. Task 2Public health and emergency management agencies identify public spaces for major ACS facilities and establish any necessary agreements or authorities required to utilize them (recognizing that no-notice incidents may require ACS sites at ad hoc locations). Special ConsiderationsTask 1Patient groups requiring special consideration are identified, and, to the degree possible, equipment and supplies to address the needs of these groups are purchased and/or stockpiled in relation to the expected size of the alternate care site, potentially including
Task 2Facility understands any regional plans or resources for specific groups (e.g., pediatric-specific disaster supplies, regional pediatric or dialysis networks) and the ACS site’s role in these plans. Function 10. PlanningTask 1Technical specialists are available as needed to provide input on infection control, clinical care, and other issues arising at the ACS site. This may include input from the regional or state disaster medical advisory committee. Task 2Planning section maintains situational awareness and modifies clinical care guidelines or supply/staffing requests to meet demand/anticipated demand. Task 3Planning section addresses policy modifications and demobilization based on incident demands. Function 11. AdministrationNotes and Resources See Chapter 4 for a more detailed discussion. AuthorityTask 1Public health and emergency management examine their delegation of authority to public ACS site incident commanders during a disaster and make any changes necessary to ensure that CSC decisions to open an ACS site are supported (i.e., that the incident commander is acting with the authority of the agency and any necessary political entities). During a crisis, the administration may require additional communications and coordination with the incident commander. Task 2Public health and emergency management agencies understand their authorities to open and provide ACS services, including the ability to facilitate private ACS sites through use of regulatory relief and emergency orders. Regulatory and Legal IssuesTask 1Health care facilities and emergency management agencies understand relevant changes to agency/facility authorities and protections when state declarations of emergency/public health emergency are made, including legal protections or obligations for medical providers (e.g., duty to serve). Task 2Agency heads/political leaders are aware of surge capacity/CSC plans and implications for patient care, including ACS sites. Task 3Legal counsel identify state and local laws and regulations that would constrain public and private ability to open ACS sites and potential relief mechanisms. Core Functions of the Outpatient Sector in CSC Planning and ImplementationOut-of-Hospital Providers Function 1. NotificationTask 1Providers ensure that up-to-date contact information and acknowledgment of receipt of exercise and incident messaging are provided to employers (and any other relevant groups, such as the MRC). Function 2. Command, Control, Communications, and CoordinationTask 1When a disaster occurs that affects the providers’ facility/agency, providers understand where they report, to whom they answer, and how to execute their roles. They also understand the range of their potential roles within the rest of the health care system and opportunities for volunteer assignment (for example, reassignment to an alternate care site or a hospital within the corporate system). Task 2Providers know how to contact and provide situational updates to and/ or request resources from their administrator/emergency operations center/command center as applicable to the facility/agency plan. Task 3Providers receive incident command training appropriate to their role in the command structure, including
Function 3. Public InformationTask 1Providers understand key sources of facility/community information in a disaster (e.g., web, social media, e-mail, hotline). Function 4. OperationsNotes and Resources See the ethics section of Chapter 4. See the mental health and palliative care sections of Chapter 4 for a more detailed discussion. Task 1Providers understand facility-based actions during expansion of care from conventional to crisis (e.g., expanded facility hours, scheduling changes, triage of appointments, use of ancillary spaces). Task 2Providers are prepared to perform triage as it relates to their role (may involve triage of appointments, or may involve another triage role within their system, such as telephone triage). Task 3Providers likely to perform triage (both reactive and proactive) understand the criteria they may consider (as well as what not to consider) when making triage decisions. Task 4Providers understand sources of employee mental health support. Task 5Providers understand normal stress reactions and coping mechanisms, as well as danger signs, and receive training in psychological first aid and psychological triage appropriate for their roles. Task 6Providers understand their potential role in providing/facilitating palliative care during a disaster. Function 5. LogisticsTask 1Providers understand the utilization of space in their facility and other expansion plans that involve their department/unit. Task 2Providers understand how their unit staffing and hours may change during a disaster. Task 3Providers understand how their role may be changed/expanded during a crisis, including incorporation of staff from outside the unit or facility, and any potential roles at other sites within their health system (if applicable). Task 4Providers understand how record keeping and other duties may change in crisis situations (e.g., where to find and how to use paper forms). Task 5Providers understand the process for requesting necessary clinical resources during an incident. Function 6. Legal IssuesNotes and Resources Chapter 3 provides a more detailed discussion. Task 1Providers understand legal obligations and liabilities for practice both within and outside of their facility/agency when
REFERENCES
1 Personal communication, Lewis Soloff, New York City Department of Health, November 16, 2011. |