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Altered Standards of Care in Mass Casualty Events

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness (PHEP) program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Summary

Background and Purpose

The events of September 11, 2001 and subsequent anthrax attacks underscored the need for U.S. health care organizations and public health agencies to be prepared to respond to acts of bioterrorism and other public health emergencies. Much has been accomplished in the past several years to improve health system preparedness. Many States and health care organizations and systems have developed preparedness plans that include enhancing surge capacity to respond to such events.

Many of these plans assume that even in large-scale emergencies, health care will be delivered according to established standards of care and that health systems will have the resources and facilities needed to support the delivery of medical care at the required level. However, it is possible that a mass casualty event—defined, for the purpose of this paper, as an act of bioterrorism or other public health or medical emergency involving thousands, or even tens of thousands, of victims—could compromise, at least in the short term, the ability of local or regional health systems to deliver services consistent with established standards of care. Therefore, it is critically important to identify, plan, and prepare for making the necessary adjustments in current health and medical care standards to ensure that the care provided in response to a mass casualty event results in as many lives being saved as possible.

To address this extremely important issue, in August 2004, a meeting of a number of the foremost experts in the fields of bioethics, emergency medicine, emergency management, health administration, health law and policy, and public health was convened by the Agency for Healthcare Research and Quality (AHRQ) and the Office of the Assistant Secretary for Public Health Emergency Preparedness (OASPHEP) within the U.S. Department of Health and Human Services (HHS). These experts were joined by highly knowledgeable representatives from key Federal agencies and professional and other health organizations (Appendix A has a complete list of participants).

The purposes of this meeting were to:

  • Examine how current standards of care might need to be altered in response to a mass casualty event in order to save as many lives as possible.
  • Identify what planning, guidance, and tools are needed and what related issues need to be addressed to ensure an effective health and medical care response to a mass casualty event.
  • Recommend specific action that will begin to address the needs of Federal, State, regional, community, and health systems planners on this critically important subject.

Consistent with these purposes, participants were asked to address the following questions:

  • What do planners need to know to develop plans that provide an effective health and medical care response to a mass casualty event?
  • What key principles should guide the planning for a health and medical response to a mass casualty event?
  • What important issues must be considered and addressed in planning for the provision of health and medical care in a mass casualty event?
  • What information, tools, models, and other resources are available to address the needs of planners?
  • What other steps might be undertaken to move toward effective planning for such an event?

This paper summarizes the deliberations and recommendations of the expert panel.

Key Findings

The key findings that emerged from the experts' discussion of the provision of health and medical care in a mass casualty event are summarized below. These findings are discussed in greater detail in Chapters 2 and 3.

  • The goal of an organized and coordinated response to a mass casualty event should be to maximize the number of lives saved.
  • Changes in the usual standards of health and medical care in the affected locality or region will be required to achieve the goal of saving the most lives in a mass casualty event. Rather than doing everything possible to save every life, it will be necessary to allocate scarce resources in a different manner to save as many lives as possible.
  • Many health system preparedness efforts do not provide sufficient planning and guidance concerning the altered standards of care that would be required to respond to a mass casualty event.
  • The basis for allocating health and medical resources in a mass casualty event must be fair and clinically sound. The process for making these decisions should be transparent and judged by the public to be fair.
  • Protocols for triage (i.e., the sorting of victims into groups according to their need and resources available) need to be flexible enough to change as the size of a mass casualty event grows and will depend on both the nature of the event and the speed with which it occurs.
  • An effective plan for delivering health and medical care in a mass casualty event should take into account factors common to all hazards (e.g., the need to have an adequate supply of qualified providers available), as well as factors that are hazard-specific (e.g., guidelines for making isolation and quarantine decisions to contain an infectious disease).
  • Plans should ensure an adequate supply of qualified providers who are trained specifically for a mass casualty event. This includes providing protection to providers and their families (e.g., personal protective equipment, prophylaxis, staff rotation to prevent burnout, and stress management programs).
  • A number of important nonmedical issues that affect the delivery of health and medical care need to be addressed to ensure an effective response to a mass casualty event. They include:
    • The authority to activate or sanction the use of altered standards of care under certain conditions.
    • Legal issues related to liability, licensing, and intergovernmental or regional mutual aid agreements.
    • Financial issues related to reimbursement and other ways of covering medical care costs.
    • Issues related to effective communication with the public.
    • Issues related to populations with special needs.
    • Issues related to transportation of patients.
  • Guidelines and companion tools related to the development of altered standards of care in a mass casualty event are needed by, and would be extremely useful to, preparedness planners at the Federal, State, regional, community, and health systems levels.

Recommended Action

The expert panel offered recommendations for action that could be undertaken to support planning an effective response to a mass casualty event. The list of recommendations is not meant to be comprehensive, but it provides a starting point for further discussion. These ideas suggest that a collaborative approach should be taken when developing next steps. Both government and private organizations have unique roles and important contributions to make in moving forward. The panel's recommendations include:

  • Develop general and event-specific guidance for allocating scarce health and medical care resources during a mass casualty event.
  • Develop and implement a process to address nonmedical (i.e., finance, communication, etc.) issues related to the delivery of health and medical care during a mass casualty event.
  • Develop a comprehensive strategy for risk communication with the public before, during, and after a mass casualty event.
  • Identify, analyze, and consider modification of Federal, State, and local laws and regulations that affect the delivery of health and medical care during a mass casualty event.
  • Develop practical tools, such as searchable databases, for verifying credentials of medical and other health personnel prior to and onsite during a mass casualty event.
  • Create strategies to ensure health and medical leadership and coordination for the health and medical aspects of system response during a mass casualty event.
  • Continue and expand efforts to train providers and others to respond effectively in a mass casualty event.
  • Develop and support a research agenda specific to health and medical care standards for a mass casualty event.
  • Develop a Community-Based Planning Guide for Mass Casualty Care to assist preparedness planners in their efforts.
  • Identify and support States, health systems, communities, and regions to develop mass casualty health and medical care response plans based on the Planning Guide; share their results widely.

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