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 5. Hospital/Acute Care
By John L. Hick, M.D., Lead Author,a
Gabor Kelen, M.D.,b Daniel O'Laughlin, M.D.,c Lewis Rubinson, M.D., Ph.D.,d
Richard Waldhorn, M.D.,e Dennis
a Assistant Professor, Emergency
Department, Hennepin County Medical Center
b Director, Office of Critical Event Preparedness
and Response, Johns Hopkins University
c Assistant Professor of Emergency Medicine, University of Minnesota/Abbott Northwestern Hospital
d Health Officer, Deschutes County
Health Department/Bend Memorial Clinic
Scholar, Center for Biosecurity, University of Pittsburgh Medical Center
f Executive Deputy Commissioner, New York State Department of Health
Some of the most difficult decisions about providing an appropriate
standard of medical care when resources are inadequate to meet event-driven
demands will be made in hospitals. This section presents an overview of recommended
systems and processes for planning and implementing the allocation of scarce
hospital and acute care resources during a mass casualty event (MCE). It offers
planners recommendations on developing integrated and coordinated response systems
and ways to make the operational decisions for stretching and allocating scarce
resources during a catastrophic MCE.
Hospital/Acute Care Issues and Recommendations at a Glance
Major Issues and Challenges
- Hospitals already at or near capacity for emergency and trauma
- Meeting needs for basic and specialized equipment.
- Coordinating competing health care systems.
- Incompatibilities in communications systems.
- Lack of on-call specialists and other essential staff (e.g.,
- Need for security and protection.
- Issues regarding professional licensing; verification; and supervision,
both intra-and interstate.
Recommendations Prior to an MCE
- Develop an integrated incident management system.
- Establish interhospital compacts and mutual aid agreements.
- Establish a jurisdictional Emergency Operations Center; ensure
that the hospital knows how it is represented there.
- Designate a "trusted source" to serve as the hospital's resource
and policy representative at the local or regional emergency response level.
- Develop a planning framework for allocating scarce resources, ideally
based on existing Federal or State guidances, which articulates the
integration of response strategies and tactics across facilities/agencies.
- Regionalize disaster response, through Multi-Agency Coordination
- Establish a Joint Information Center (JIC) or other centralized
method to link communications regarding incident and response
at the local, regional, and State levels.
- Use expert panels or planning groups to develop decisionmaking
protocols or guidance for allocating scarce resources in the case of an MCE.
- Put into place an institutional and State position on how scarce
resources would be allocated to health care workers.
Responding to an MCE
- Increase space capacity within the hospital through rapid patient
discharge and transfer, addition of beds/cots, facilitation of home-based
care, and use of alternative care sites.
- Increase staff capacity through schedule changes, staff sharing,
promotion of home care, and the use of advance registered and
credential-verified health professional volunteers.
- Increase access to supplies through contacts/agreements
with commercial vendors.
- Institute administrative changes to facilitate
processes, reimbursements, reassignment of the staff, and schedules.
- Institute clinical changes to a level appropriate to the available
resources. Base triage and allocation decisions on existing guidance,
- Ensure security for the staff and supplies.
- Plan for mass mortuary needs.
- Develop strategies to identify large numbers of young children
who may be separated from parents and cannot give information that
would help them to be reunited.
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Hospital and Acute Care in the Context of a Catastrophic MCE
The overall goal of hospital and acute care response in an MCE is to meet
the reasonable care needs of as many patients as possible while also meeting
at least minimal obligations for comfort to each patient.63
In the case of a catastrophic MCE, however, hospitals will
not have access to many needed resources (e.g., manual resuscitation bags
to provide ventilation in response to a pandemic influenza, supply of antitoxin
in the case of mass botulism poisoning). Thus, difficult decisions will have
to be made regarding the allocation of available resources.
During an MCE, Federal and State agencies might be able to offer policy guidance,
nationally sanctioned decision tools, and event-specific relief of certain regulatory
obligations. However, the operational decisions regarding limited resource allocation
(and the liability related to such policies) will be the responsibility of individual
hospitals, communities, and regions. Thus, it will be incumbent on these localities
and entities before an event occurs to establish and test plans for
operational incident management systems that can be applied to respond to an
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Challenges for MCE Planning
Much of the hospital-based response to an MCE will rely on planning, protocols,
and actions that should be put into place and tested well ahead of time. In
order to address those planning needs, however, planners must take into account
the critical challenges that hospitals will face in responding to catastrophic
challenges include the following:
Surge Capacity Issues. A recent report on hospital-based
emergency care from the Institute of Medicine2 reveals that many hospital
emergency and trauma services are already at or near full capacity and thus
not equipped to respond to the increased demand and decreased resources that
would occur in an MCE. Interhospital agreements have the potential to alleviate
overcrowding by transferring existing inpatients to other facilities, for
example, but evidence from a Centers for Disease Control and Prevention study
indicates that only 46 percent of hospitals have agreements of this type.
Inadequate Supplies. Lack of sufficient supplies, particularly
of specialized equipment such as personal protective equipment, ventilators,
and negative pressure rooms, will be a challenge for most hospitals.
Need for Coordination, Cooperation, and Consistency Between Health
Care Systems That Are in Competition With One Another. Public health
and State government may have certain authorities to make decisions during
an emergency, but the scope of their powers often does not extend into health
care facilities. Thought should be given to approaches to facilitating or
enhancing cooperation between diverse, and potentially competing, entities.
Communication Barriers. In order to respond at a level appropriate
to the incident, critical information must be shared and processed across
systems to give an overview of the event, guide the mobilization of necessary
resources, and inform the development of strategies and tactics at the hospital
and community levels. The fragmented nature of emergency care systems leads
to incompatibilities in communications and data systems between EMS systems,
hospitals, trauma centers, public safety services and public health agencies.
Lack of Specialists and Other Essential Staff Members. Even
in the current emergency and trauma care system, the supply of on-call specialists
and other essential staff members (e.g., nurses) is not great enough to meet
demand—a gap that will be greatly exacerbated in an MCE.
Need for Security Presence and Protection. Hospital staff
members, supplies, and assets will need to be protected in the case of an
MCE, which naturally will result in scarcities and the potential for fear,
theft, or violence.
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Recommendations Related to Advance Planning
In the event of a catastrophic MCE, decisions and policies regarding resource
allocation within hospitals will have to occur at multiple levels, ranging
from the State down to local communities and institutions. Ideally, these
decisions and policies should be crafted in advance of the event and should
reflect nationally sanctioned guidance.
Hospital administrators and local and State elected officials must work
to ensure that the framework for such decisionmaking is in place and that
a public conversation is held that ensures understanding of the resources
and limitations of the health care system.
They must be prepared to defend this planning to State agencies and government
and help them to understand the implications of resource allocations. Local
and regional legal issues must be raised and defined, and solutions must be
Planning Template for Hospitals
To help stimulate discussion and planning for MCEs within hospital
facilities as well as at the local and regional levels, a Mass
Casualty Disaster Plan Checklist for Health Care Facilities has been
developed by the Center for the Study of Bioterrorism and Emerging Infections
and the Association for Professionals in Infection Control and Epidemiology,
Inc. It is available at: http://www.gnyha.org/eprc/general/.
Ideally, hospitals should be able to follow guidance and decision support
tools to make resource allocation decisions (e.g., who should receive mechanical
ventilation) that are sanctioned and approved at the Federal level and are
distributed by the State. Even with the support of these tools or policies,
however, it is the hospital that will have to take on the role of implementing
To plan for addressing the hospital and acute care needs following an
MCE prior to an event, hospitals and their partners should do the following:
Develop an Integrated Incident Management System. In order
to respond to the demands and scarcity of resources that would be brought
on by an MCE, hospitals must have in place a system of coordination with other
local hospitals, public health departments, incident commanders, public safety,
and EMS systems to provide care.
Thus, integrated incident management is critical to preparing for an MCE and
must be developed prior to any catastrophic event.66
Incident Management System Curriculum
The complexity of incident management, coupled with the growing need
for multiagency and multifunctional involvement in incidents, has increased
the need for a single standard incident management system that can be
used by all emergency response disciplines. The Incident Command System,
originally designed in California to respond to wildfires, 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. Information on the training
curriculum is available at: http://www.nimsonline.com/ics_training/index.htm .
The Institute of Medicine report on hospital-based emergency care
recommends that coordination and incident management require the following
- 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 former Hospital Emergency
Incident Command System, which has been revised and renamed the Hospital
Incident Command System (HICS). HICS is a well-instituted and nationally
recognized approach to disaster management.
- The establishment of a jurisdictional Emergency Operations Center. Each
hospital should be familiar with its local office of emergency preparedness
and know how it is represented there, whether through assignment of direct
liaison, the public health department, a hospital association, the EMS system,
or another mechanism.
- 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
HICS applies the principles of incident management to health
care facilities. The system helps coordinate emergency response between
hospitals and other emergency responders with a system based on a
predictable chain of management, defined responsibilities, prioritized
response checklists, clear reporting channels for documentation and
accountability, and a common nomenclature to facilitate communications.
Further information is available at: http://www.emsa.ca.gov.
Develop a Planning Framework for Allocating Scarce Resources. This
framework should be transparent and shared with key stakeholders in the health
department, attorney general's office, and governor's office as
well as with the community, both in advance of and during an MCE. The framework
should establish ways to do the following:
- Define or project the resource shortfalls and the impact on clinical
- Identify the facilities and area to be affected.
- Request additional resources, facilitate the transfer of patients out of
the affected area, or facilitate alternative strategies for patient care
(e.g., offsite care, 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.
Sources of expertise may include the academic, private, or public medical
care system. 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 in good-faith compliance
with such policies and guidance.
- Include guidance on the equitable management and allocation of
scarce resources. For example, prior to an MCE both government and private
institutions should know the extent to which they can commandeer equipment
or information about remaining supplies and to allocate resources.
- Articulate the integration of response
strategies and tactics across facilities and agencies at the local and regional
levels (go to Figure 5.1). Use a tiered
approach, ranging from the smallest unit, the individual health care facility
(HCF) or group of providers (Tier 1); through health care coalitions (Tier 2)
and jurisdictional incident management systems (Tier 3); to broader State,
interstate, and Federal response levels (Tiers 4-6). Resource coordination needs
that overwhelm the lower tiers spill over onto the higher tiers either to meet
the resource needs or to make policy decisions to cope with the lack of resources.
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Coordinating Community and Regional Planning of Hospital/Acute Care MCE Responses
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), which can assist the State health
department in managing resource allocation within their area. This arrangement
establishes a more effective span of control for the State, with only a few
regions rather than multiple individual facilities, reporting data and resource
needs. It also allows for plans to consolidate inventories of 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 (go to
Figure 5.2). Planners
should expect that there will be issues with communication, coordination,
and overlapping responsibilities, and thus it is important to practice all
elements of the State, regional, or local interface in advance. Such advance
practice would enable planners to find ways to account for and adapt to the
variability in relationships among local emergency operations centers, hospitals,
regional MACs, and the State.
Interstate regional coordination is another means of managing allocation
of scarce resources. Interstate agreements and cooperation help promote
sharing of assets across State lines. These types of agreements also help
ensure consistency of response (e.g., National Capital Region) where inconsistencies
between State plans could prove problematic. This level of interstate cooperation
is difficult to achieve but is one of the most important ways to maximize
resource allocation. The development of national-level clinical decision tools
to address commonly limited resources (e.g., dialysis, mechanical ventilation)
would be very valuable in helping to facilitate greater interstate cooperation.
The Minnesota Department of Health MAC Plan has
been developed to facilitate health-related policy coordination and
resource allocation decisions among multiple jurisdictions and health-related
entities to provide for the safe, rapid, and coordinated response to
a health-related emergency. Information is available at: http://www.health.state.mn.us/oep/planning/allhazards.html#macresponserecovery
A Patient Care Coordination Planning Guide, also
developed by the Minnesota Department of Health, is available on CD
by request to MDH Office of Emergency Preparedness at: http://www.health.state.mn.us/oep.
Coordination and Communication
The State, rather than local jurisdictions, should take responsibility for
overall risk communication management. This includes information provided
to hospitals and health care systems, as well as the provision of public information
releases and information for providers or members of the public that are posted
through telephone, the Internet, the media, and other access points. A JIC
should be established as well as other ways to link communications at the
local, jurisdictional, and State levels to establish mechanisms for media
Communications strategies must be established and practiced
ahead of time to ensure that messages will come from accurate sources in a
timely and consistent manner. These strategies should include the use of risk
communication, regular media releases, and press conferences.
Joint Information Center (JIC)
A JIC is a centralized communication hub for handling emergency events.
It serves to gather incident data, analyze public perceptions of the
event, and give the public or special targeted audiences accurate and
comprehensive incident and response information. Planning for the JIC
should be undertaken in advance, including processes, procedures, and
staff training. This allows communities to be more proactive in their
response to the information needs of the public, industry, and government.
A full description of the JIC model is available from the U.S. National
Response Team Web site at:
Using Expert Panels or Planning Groups
At this time, no current predictive model is sufficient to serve as a decision
framework for determining the allocation of critical care resources (e.g.,
ventilators, intensive care therapies). One valuable strategy for examining
the allocation of scarce resources, however, is to convene a balanced expert
panel that can bring in multiple viewpoints and establish decisionmaking guidelines.
The panel must be inclusive of relevant stakeholders who reflect the jurisdictional
area and its demographics, in addition to recognizing border issues with adjoining
States. The composition, functions, and operational role of these groups must
be carefully considered.
Convening an Expert Panel to Address the Allocation of Scarce Resources:
The Example of New York State
In March 2006, the New York State Task Force on Life and the Law
(TFLL), in partnership with the State's Department of Health,
convened a workgroup to consider clinical and ethical challenges in
the allocation of mechanical ventilators in a public health crisis.
The group includes experts in the areas of law, medicine, policymaking,
and ethics. Its goal is to develop clinical and ethical guidance for
local health care systems that will promote the just allocation of ventilators
in an influenza pandemic. The panel considered a range of policy options
necessary to support such an allocation system, including the development
of recommendations for laws or regulations in areas including liability
and appropriate standards of care.
Further information on the TFLL is
available at: http://www.health.state.ny.us/nysdoh/taskfce/index
Issues of resource allocation ideally would be addressed by expert panels
or groups as part of MCE planning. An ad hoc expert panel may be called on
to address an unexpected event to determine which factors will be used for
decisionmaking based on a particular situation and the specific resource in
short supply. The community member panels that allocated scarce hemodialysis
resources in the city of Seattle during the 1960s can serve as an historic
example of this process.
Using Community Panels to Help Allocate Scarce Resources: The Example of
Hemodialysis in Seattle
When hemodialysis was first introduced in 1960, it was available only in
limited supply. In order to decide which patients would receive this life-prolonging
treatment, the city of Seattle established a two-committee decisionmaking process. The
first committee was comprised of physicians and the second made up of a cross-section
of community representatives. The physician committee took into account medical and
psychiatric criteria, while the community group weighed factors such as age, future
potential, and other intangible measures of personal and community value.
Some questions that States should consider when developing an expert panel
- Is the group considered an advisory body or a policy development body
for the health department? If it is advisory, what internal process within the
department is followed to develop and approve the policy?
- What is the liability of the members of the group (if any) for their decisions?
- What is the expectation of the group during an event? How often will they
meet? What will be their sources of information? Is there enough redundancy
in the group in case of illness or absence?
- Would the composition of the group need to be modified based on the type
of MCE? If so, who would decide?
- How does the group convene, develop consensus and recommendations, and modify
them as needed?
The recommendations of the expert panel should be vetted and shared with
larger, more diverse groups to allow feedback and further modifications.
Those groups might include physicians or other health care professionals,
palliative care providers, ethicists, State health officers, representatives
from the Office of Emergency Preparedness, community leaders, and others.
Any guidelines or decisionmaking framework developed should be circulated
between facilities and jurisdictions prior to an event.
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Increasing System Capacity During an MCE
During an MCE, the capacity of the health care system should be expanded
according to an incident management system-directed mobilization of physical
space, personnel, and material resources—sometimes referred to as "space,
staff, and stuff." For example, in advance of an MCE, hospitals should
establish a preference list of supplemental providers to expand staff capacity.
These providers might include local hospital staff, clinic staff, and health
professional volunteers who have registered with and had their credentials
verified by one of the State Emergency Systems for Advance Registration of
Volunteer Healthcare Professionals (ESAR-VHP), Medical Reserve Corps, National
Disaster Medical System teams, trainees, patient family members, military
members, Community Emergency Response Teams, and lay volunteers. Policies
should be in place in advance to credential staff members and manage deployment
of nonhospital personnel at community and hospital levels, and there should
be a plan for managing spontaneous volunteers.
Another critical component of increasing system capacity during an MCE is informing
the public. It is important to provide the public with information on two fronts:
information about ongoing events and how to care for themselves, as well as information
that will enable them to make appropriate decisions about their own personal health
care situation. This information process will help limit or slow the spread of disease
while engaging the public in the allocation of scarce resources.
The goal of informing the public can be achieved through a two-pronged approach:
the use of effective media campaigns to educate and inform most of the public,
supported by enlisting the assistance of established community health call
centers (poison centers, nurse advice lines, public health hotlines) to help
address the public's additional concerns and questions. This approach should enable
most people to care for themselves, and at the same time, will help to lessen
demands on the healthcare system.
Short-term strategies may be applied to increase healthcare facility capacity
in cases where 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. They may include
Increase space capacity with:
- Rapid discharge of emergency department (ED) and other outpatients who
can continue their care at home safely.
- Rapid discharge of inpatients who can safely continue their care at home
(or at alternate facilities if they are available).
- Cancellation of elective surgeries and procedures, with reassignment of
surgical staff members and space.
- Reduction of the usual use of imaging, laboratory testing, and other ancillary
- Expansion of 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.
- Conversion of single rooms to double rooms or double rooms to triple rooms if
- Designation of 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 those health
care providers caring for contagious patients to minimize disease transmission
to uninfected patients.
- Use of cots and beds in flat space areas (e.g., classrooms, gymnasiums,
lobbies) within the hospital for noncritical patient care.
- Transfer of patients to other institutions in the State, interstate region,
- Facilitation of home-based care for patients in cooperation with public
health and home care agencies.
- Establishment of mobile or temporary evaluation and treatment facilities
in the community to supplement usual clinic locations. These locations also
may be used to screen those with mild symptoms when medications are available
and must be taken early in the course of illness to be effective.
Expand staff capacity with:
- Call-in of appropriate staff members.
- Changes in staff scheduling (e.g., duration of shifts, staffing ratios,
changes in staff assignments).
- Requests for supplemental staff members from
partner hospitals through the use of Emergency Systems for Advance Registration
of Volunteer Health Professionals (ESAR VHP), clinics, the Medical Reserve
Corps (MRC), the local American Red Cross, public health, public works,
schools, or other agencies and State and Federal sources as applicable.
- Promotion of home care and discouragement of the "worried well" from
seeking hospital evaluation and care through the use of media campaigns
and access to community health call centers.
- Establishment of guidelines and public messaging describing how to evaluate
symptoms, what treatment can be safely delayed, and how to care for themselves
- Sharing of small numbers of specialized staff members (e.g., burn nurses,
pediatric critical care staff members) with hospitals in need
- Activation of memoranda of understanding (MOUs) with regional and distant
hospitals, health systems, or State disaster medical assistance teams.
State Coordination of Volunteer Resources: Emergency Systems for Advance Registration of Volunteer Health Professionals
State Emergency Systems for Advance Registration of Volunteer Health
Professionals (ESAR-VHP) systems are statewide mechanisms for recruiting,
registering, and verifying credential information of potential health
volunteers in a State. These systems should support and include information
about volunteers involved in organized efforts at the local level (such
as MRC units) and the State level (such as National Disaster Medical
System [NDMS] teams). The ESAR-VHP systems also will coordinate broader
Statewide recruitment and registration of health professionals who would
be willing to serve in an emergency, but are not interested in being
a part of a trained, organized unit structure such as MRC or NDMS. State
ESAR-VHP systems provide a single, centralized source of volunteer information
to facilitate intrastate, State-to-State, and State-to-Federal transfer
and mobilization of volunteer health professionals.
about the national effort to develop State ESAR-VHP systems, including
information about the legal protections offered to volunteers in each
State and Territory, and links to State systems is available at: http://www.hhs.gov/.
Increase access to supplies by:
- Activation of MOUs with commercial companies for supply chain continuity.
If these strategies are not sufficient to meet the demands of the incident
and no immediate relief is available, then a systematic evaluation of the
level of care being provided must be conducted. These surge strategies should
be reviewed and revised based on the available resources.
The Medical Reserve Corps (MRC)
The mission of the MRC is to organize medical, public health, and
other volunteers in support of existing programs and resources to improve
the health and safety of communities and the Nation. MRC units provide
personnel to support and supplement the existing emergency and public
health agencies in the community. MRC leaders are encouraged to adopt
an all-hazards approach and more broad-based public health initiatives,
including a focus on increasing disease prevention efforts, and enhancing
emergency preparedness. Medical Reserve Corps volunteers include medical
and public health professionals such as physicians, nurses, pharmacists,
dentists, veterinarians, and epidemiologists.
During the 2005
Hurricane Season, MRC members provided support for American Red Cross
health services, mental health and shelter operations. MRC members also
supported Federal response efforts by staffing special needs shelters,
Community Health Centers and health clinics, and assisting health assessment
teams in the Gulf Coast region. For example, The Southside (Boydton,
VA) MRC organized, conducted, and supervised a local food relief
and water collection site for Hurricane Katrina victims. In all, 53,000
pounds of food and water were shipped to Lamar County, Mississippi. The
Rhode Island MRC, along with the Rhode Island DMAT team, was
largely responsible for staffing a weeklong clinic that received 105
evacuees from Louisiana. The clinic averaged 26 visits per day with
daily blood pressure checks provided.
Further information on MRC is
available at :http://www.medicalreservecorps.gov.
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