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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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Chapter 1. Introduction


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.

Most 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 White Paper summarizes the deliberations and recommendations of this group of experts. Chapter 2 provides these experts' assessment of the need to develop and plan for the possible implementation of altered standards of care in response to a mass casualty event. Chapter 3 then outlines a framework and set of principles that can guide the development of strategies for adjusting the manner in which health and medical care is delivered in a mass casualty event to maximize the number of lives saved. Chapter 4 identifies an important set of related issues that must be addressed if these strategies are to be as effective as possible in achieving their goal. And, finally, Chapter 5 presents the experts' recommendations concerning the action steps to be taken to help States, communities, health systems, and providers to be prepared to respond to a mass casualty event in ways that save as many lives as possible.

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