Ensuring Continuity of Care in Health Emergencies, Study notes of Public Health

Download Ensuring Continuity of Care in Health Emergencies and more Study notes Public Health in PDF only on Docsity! 2017-2022 Health Care Preparedness and Response Capabilities Office of the Assistant Secretary for Preparedness and Response November 2016 2017-2022 Health Care Preparedness and Response Capabilities | ASPR 2 Table of Contents Introduction .............................................................................................................................................. 5 Purpose of the 2017-2022 Health Care Preparedness and Response Capabilities .............................. 6 The Four Capabilities ............................................................................................................................. 7 The Value of Health Care Coalitions in Preparedness and Response ................................................... 8 Using the Capabilities Document .......................................................................................................... 8 Capability 1. Foundation for Health Care and Medical Readiness ......................................................... 10 Objective 1: Establish and Operationalize a Health Care Coalition .................................................... 10 Activity 1. Define Health Care Coalition Boundaries ...................................................................... 11 Activity 2. Identify Health Care Coalition Members ....................................................................... 11 Activity 3. Establish Health Care Coalition Governance.................................................................. 13 Objective 2: Identify Risk and Needs .................................................................................................. 13 Activity 1. Assess Hazard Vulnerabilities and Risks ......................................................................... 13 Activity 2. Assess Regional Health Care Resources ......................................................................... 14 Activity 3. Prioritize Resource Gaps and Mitigation Strategies ...................................................... 14 Activity 4. Assess Community Planning for Children, Pregnant Women, Seniors, Individuals with Access and Functional Needs, Including People with Disabilities, and Others with Unique Needs ........................................................................................................................................................ 15 Activity 5. Assess and Identify Regulatory Compliance Requirements ........................................... 16 Objective 3: Develop a Health Care Coalition Preparedness Plan ...................................................... 17 Objective 4: Train and Prepare the Health Care and Medical Workforce .......................................... 18 Activity 1. Promote Role-Appropriate National Incident Management System Implementation . 19 Activity 2. Educate and Train on Identified Preparedness and Response Gaps ............................. 19 Activity 3. Plan and Conduct Coordinated Exercises with Health Care Coalition Members and Other Response Organizations ....................................................................................................... 20 Activity 4. Align Exercises with Federal Standards and Facility Regulatory and Accreditation Requirements .................................................................................................................................. 21 Activity 5. Evaluate Exercises and Responses to Emergencies ....................................................... 21 Activity 6. Share Leading Practices and Lessons Learned ............................................................... 22 Objective 5: Ensure Preparedness is Sustainable ............................................................................... 22 Activity 1. Promote the Value of Health Care and Medical Readiness ........................................... 22 Activity 2. Engage Health Care Executives ...................................................................................... 23 Activity 3. Engage Clinicians ............................................................................................................ 23 Activity 4. Engage Community Leaders ........................................................................................... 24 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Introduction 5 Introduction The U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Preparedness and Response (ASPR) leads the country in preparing for, responding to, and recovering from the adverse health effects of emergencies and disasters. This is accomplished by supporting the nation’s ability to withstand adversity, strengthening health and emergency response systems, and enhancing national health security. ASPR’s Hospital Preparedness Program (HPP) enables the health care delivery system to save lives during emergencies and disaster events that exceed the day-to-day capacity and capability of existing health and emergency response systems. HPP is the only source of federal funding for health care delivery system readiness, intended to improve patient outcomes, minimize the need for federal and supplemental state resources during emergencies, and enable rapid recovery. HPP prepares the health care delivery system to save lives through the development of health care coalitions (HCCs) that incentivize diverse and often competitive health care organizations with differing priorities and objectives to work together. ASPR developed the 2017-2022 Health Care Preparedness and Response Capabilities guidance to describe what the health care delivery system, including HCCs, hospitals, and emergency medical services (EMS), have to do to effectively prepare for and respond to emergencies that impact the public’s health. Each jurisdiction, including emergency management organizations and public health agencies, provides key support to the health care delivery system. Individual health care organizations, HCCs, jurisdictions, and other stakeholders that develop the capabilities outlined in the 2017-2022 Health Care Preparedness and Response Capabilities document will: • Help patients receive the care they need at the right place, at the right time, and with the right resources, during emergencies • Decrease deaths, injuries, and illnesses resulting from emergencies • Promote health care delivery system resilience in the aftermath of emergencies • Behavioral health services and organizations • Child care providers (e.g., daycare centers) • Community Emergency The intended audience for this document is any health care delivery system organization, HCC, or state or local agency that supports the provision of care during emergencies, including but not limited to: Response Teams (CERT)1 1 “Community Emergency Response Teams.” FEMA, 31 Aug. 2016. Web. Accessed 7 Sept. 2016. www.fema.gov/community-emergency-response-teams. and Medical Reserve Corps (MRC)2 2 “Medical Reserve Corps.” MRC, 22 Sept. 2016. Web. Accessed 26 Sept. 2016. https://mrc.hhs.gov. • Dialysis centers and regional Centers for Medicare & Medicaid Services (CMS)-funded end-stage renal disease (ESRD) networks3 3 “ESRD Networks.” KCER, 2016. Web. Accessed 7 Sept. 2016. http://kcercoalition.com/en/esrd-networks/. • EMS (including inter-facility and other non-EMS patient transport systems) • Emergency management organizations • Faith-based organizations • Federal facilities (e.g., U.S. Department of Veterans Affairs (VA) Medical Centers, Indian Health Service facilities, military treatment facilities) • Home health agencies, including home and community-based services 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Introduction 6 • Hospitals (e.g., acute care hospitals, trauma centers, burn centers, children's hospitals, rehabilitation hospitals) • Infrastructure companies (e.g., utility and communication companies) • Cities, counties, parishes, townships, and tribes • Local chapters of health care professional organizations (e.g., medical societies, professional societies, hospital associations) • Local public safety agencies (e.g., law enforcement and fire services) • Medical equipment and supply manufacturers and distributors • Non-governmental organizations (e.g., American Red Cross, voluntary organizations active in disasters, amateur radio operators, etc.) • Outpatient health care delivery (e.g., ambulatory care, clinics, community and tribal health centers, Federally Qualified Health Centers (FQHCs),4 4 “What are Federally qualified health centers (FQHCs)?” HRSA, n.d. Web. Accessed 7 Sept. 2016. www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Introduction/qualified.html. urgent care centers, freestanding emergency rooms, stand-alone surgery centers) • Primary care providers, including pediatric and women’s health care providers • Public health agencies • Schools and universities, including academic medical centers • Skilled nursing, nursing, and long-term care facilities • Social work services • Support service providers (e.g., clinical laboratories, pharmacies, radiology, blood banks, poison control centers) Planning for and responding to emergencies varies depending on a number of factors, including existing resources, geography (e.g., urban, suburban, rural, or frontier settings), type of health care delivery system (e.g., private sector, government), types of threats and hazards, and demographics. While the goals and objectives of these capabilities are intended for all communities across the nation, ASPR recognizes that the pathways to achieve them will differ based on the factors noted above and acknowledges the importance of flexibility and scalability. Purpose of the 2017-2022 Health Care Preparedness and Response Capabilities The 2017-2022 Health Care Preparedness and Response Capabilities document outlines the high-level objectives that the nation’s health care delivery system, including HCCs and individual health care organizations, should undertake to prepare for, respond to, and recover from emergencies. These capabilities illustrate the range of preparedness and response activities that, if conducted, represent the ideal state of readiness in the United States. ASPR recognizes that there is shared authority and accountability for the health care delivery system's readiness that rests with private organizations, government agencies, and Emergency Support Function-8 (ESF-8, Public Health and Medical Services) lead agencies. Given the many public and private entities that must come together to ensure community preparedness, HCCs serve an important communication and coordination role within their respective jurisdiction(s). These capabilities may not be achieved solely with the funding provided to HPP awardees and sub- awardees (including HCCs and health care organizations) through the HPP Cooperative Agreement. ASPR will present clear expectations and priorities, as well as performance measures for assessing HPP 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Introduction 7 awardees’ and sub-awardees’ progress toward building the capabilities, in the HPP funding opportunity announcement for the five-year project period that begins in July 2017. The Four Capabilities The four Health Care Preparedness and Response Capabilities are: Capability 1: Foundation for Health Care and Medical Readiness Goal of Capability 1: The community’s5 5 As the HCC defines in Capability 1, Objective 1, Activity 1 – Define HCC Boundaries health care organizations and other stakeholders—coordinated through a sustainable HCC—have strong relationships, identify hazards and risks, and prioritize and address gaps through planning, training, exercising, and managing resources. Capability 2: Health Care and Medical Response Coordination Goal of Capability 2: Health care organizations, the HCC, their jurisdiction(s), and the ESF-8 lead agency plan and collaborate to share and analyze information, manage and share resources, and coordinate strategies to deliver medical care to all populations during emergencies and planned events. Capability 3: Continuity of Health Care Service Delivery Goal of Capability 3: Health care organizations, with support from the HCC and the ESF-8 lead agency, provide uninterrupted, optimal medical care to all populations in the face of damaged or disabled health care infrastructure. Health care workers are well-trained, well-educated, and well-equipped to care for patients during emergencies. Simultaneous response and recovery operations result in a return to normal or, ideally, improved operations. Capability 4: Medical Surge Goal of Capability 4: Health care organizations—including hospitals, EMS, and out-of-hospital providers—deliver timely and efficient care to their patients even when the demand for health care services exceeds available supply. The HCC, in collaboration with the ESF-8 lead agency, coordinates information and available resources for its members to maintain conventional surge response. When an emergency overwhelms the HCC’s collective resources, the HCC supports the health care delivery system’s transition to contingency and crisis surge response6 6 Altevogt, Bruce M., et al. “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations.” The National Academies Press, 2009. Web. Accessed 26 Oct. 2016. www.nap.edu/read/12749/chapter/1. and promotes a timely return to conventional standards of care as soon as possible. These four capabilities were developed based on guidance provided in the 2012 Healthcare Preparedness Capabilities: National Guidance for Healthcare System Preparedness document. They support and cascade from guidance documented in the National Response Framework,7 7 “National Response Framework.” FEMA, ed. 3, Jun. 2016. PDF. Accessed 24 Aug. 2016. www.fema.gov/media- library-data/1466014682982-9bcf8245ba4c60c120aa915abe74e15d/National_Response_Framework3rd.pdf. 8 “National Preparedness Goal.” FEMA, ed. 2. 5 Jul. 2016. PDF. Accessed 26 Oct. 2016. https://www.fema.gov/media-library-data/1443799615171- 2aae90be55041740f97e8532fc680d40/National_Preparedness_Goal_2nd_Edition.pdf 9 “National Health Security Strategy and Implementation Plan.” ASPR, HHS, 2015-2018. PDF. Accessed 26 Oct. 2016. http://www.phe.gov/Preparedness/planning/authority/nhss/Documents/nhss-ip.pdf National Preparedness Goal,8 and the National Health Security Strategy9 to build community health resilience and 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Foundation for Health Care and Medical Readiness 10 Capability 1. Foundation for Health Care and Medical Readiness The foundation for health care and medical readiness enables the health care delivery system and other organizations that contribute to responses to coordinate efforts before, during, and after emergencies; continue operations; and appropriately surge as necessary. This is primarily accomplished through health care coalitions (HCCs) that incentivize diverse and often competitive health care organizations with differing priorities and objectives to work together. HCCs should collaborate with a variety of stakeholders to ensure the community has the necessary medical equipment and supplies, real-time information, communication systems, and trained and educated health care personnel to respond to an emergency. These stakeholders include core HCC members—hospitals, emergency medical services (EMS), emergency management organizations, and public health agencies—additional HCC members, and the Emergency Support Function-8 (ESF-8, Public Health and Medical Services) lead agency. (For more information, see Capability 1, Objective 1, Activity 2 – Identify Health Care Coalition Members.) Goal for Capability 1: Foundation for Health Care and Medical Readiness The community’s13 13 As the HCC defines in Capability 1, Objective 1, Activity 1 – Define HCC Boundaries health care organizations and other stakeholders—coordinated through a sustainable HCC—have strong relationships, identify hazards and risks, and prioritize and address gaps through planning, training, exercising, and managing resources. e Objective 1: Establish and Operationalize a Health Care Coalition HCCs should coordinate with their members to facilitate: • Strategic planning • Identification of gaps and mitigation strategies • Operational planning and response • Information sharing for improved situational awareness • Resource coordination and management HCCs serve as multiagency coordination groups that support and integrate with other ESF-8 activities. Coordination between the HCC and the ESF-8 lead agency can occur in a number of ways. Some HCCs serve as the ESF-8 lead agency for their jurisdiction(s). Others integrate with their ESF-8 lead agency through an identified designee at the jurisdiction’s Emergency Operations Center (EOC) who represents HCC issues and needs and provides timely, efficient, and bi-directional information flow to support situational awareness. (Se Capability 2 – Health Care and Medical Response Coordination for details on ESF-8 and situational awareness.) HCCs serve as a public-private partnership. As stated in the National Response Framework: “…private sector organizations contribute to response efforts through partnerships with each level of government….During an incident, key private sector partners should have a direct link to 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Foundation for Health Care and Medical Readiness 11 emergency managers and, in some cases, be involved in the decision making process….Private sector entities can assist in delivering the response core capabilities by collaborating with emergency management personnel before an incident occurs to determine what assistance may be necessary and how they can support local emergency management organizations during response operations….”14 14 “National Response Framework.” FEMA, ed. 3, Jun. 2016, pp. 10, 29. PDF. Accessed 24 Aug. 2016. https://www.fema.gov/media-library-data/1466014682982- 9bcf8245ba4c60c120aa915abe74e15d/National_Response_Framework3rd.pdf. Activity 1. Define Health Care Coalition Boundaries The HCC should define its boundaries based on daily health care delivery patterns—including those established by corporate health systems—and organizations within a defined geographic region, such as independent organizations and federal health care facilities. Additionally, the HCC may consider boundaries based on defined catchment areas, such as regional EMS councils, trauma regions, accountable care organizations, emergency management regions, etc. Defined boundaries should encompass more than one of each member type (e.g., hospitals, EMS) to enable coordination and enhance the HCC’s ability to share the load during an emergency. HCC boundaries may span several jurisdictional or political boundaries, and the HCC should coordinate with all ESF-8 lead agencies within its defined boundaries. The HCC should: • Include enough members to ensure adequate resources; however, at the same time, having too many members may make the HCC unmanageable • Consider existing regional service areas, as they define common and known health care delivery patterns and emergency response activities • Consider HCC boundaries that cross state borders where appropriate • Engage the jurisdiction’s public health agency to ensure all health care facilities, including independent facilities, belong to an HCC and that there are no geographic gaps in HCC coverage Activity 2. Identify Health Care Coalition Members An HCC member is defined as an entity within the HCC’s defined boundaries that actively contributes to HCC strategic planning, identification of gaps and mitigation strategies, operational planning and response, information sharing, and resource coordination and management. In cases where there are multiple entities of an HCC member type, there may be a subcommittee structure that establishes a lead entity to communicate common interests to the HCC (e.g., multiple dialysis centers forming a subcommittee). HCC membership does not begin or end with attending meetings. The HCC should include a diverse membership to ensure a successful whole community response. If segments of the community are unprepared or not engaged, there is greater risk that the health care delivery system will be overwhelmed. As such, the HCC should liaise with the broader response community on a regular basis (see Introduction for a list of stakeholders). The list is recreated below, delineating core and additional HCC members. • Core HCC members should include, at a minimum, the following:  Hospitals  EMS (including inter-facility and other non-EMS patient transport systems) 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Foundation for Health Care and Medical Readiness 12  Emergency management organizations  Public health agencies • Additional HCC members may include but are not limited to the following:  Behavioral health services and organizations  Community Emergency Response Team (CERT)15 15 “Community Emergency Response Teams.” FEMA, 31 Aug. 2016. Web. Accessed 7 Sept. 2016. www.fema.gov/community-emergency-response-teams/. and Medical Reserve Corps (MRC)16 16 “Medical Reserve Corps.” MRC, 22 Sept. 2016. Web. Accessed 26 Sept. 2016. https://mrc.hhs.gov.  Dialysis centers and regional Centers for Medicare & Medicaid Services (CMS)-funded end-stage renal disease (ESRD) networks17 17 “ESRD Networks.” KCER, 2016. Web. Accessed 7 Sept. 2016. http://kcercoalition.com/en/esrd-networks/.  Federal facilities (e.g., U.S. Department of Veterans Affairs (VA) Medical Centers, Indian Health Service facilities, military treatment facilities)  Home health agencies (including home and community-based services)  Infrastructure companies (e.g., utility and communication companies)  Jurisdictional partners, including cities, counties, and tribes  Local chapters of health care professional organizations (e.g., medical society, professional society, hospital association)  Local public safety agencies (e.g., law enforcement and fire services)  Medical and device manufacturers and distributors  Non-governmental organizations (e.g., American Red Cross, voluntary organizations active in disasters, amateur radio operators, etc.)  Outpatient health care delivery (e.g., ambulatory care, clinics, community and tribal health centers, Federally Qualified Health Centers (FQHCs),18 18 “What are Federally qualified health centers (FQHCs)?” HRSA, n.d. Web. Accessed 7 Sept. 2016. www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Introduction/qualified.html. urgent care centers, freestanding emergency rooms, stand-alone surgery centers)  Primary care providers, including pediatric and women’s health care providers  Schools and universities, including academic medical centers  Skilled nursing, nursing, and long-term care facilities  Support service providers (e.g., clinical laboratories, pharmacies, radiology, blood banks, poison control centers)  Other (e.g., child care services, dental clinics, social work services, faith-based organizations) Specialty patient referral centers (e.g., pediatric, burn, trauma, and psychiatric centers) should ideally be HCC members within their geographic boundaries. They may also serve as referral centers to other HCCs where that specialty care does not exist. In such cases, referral centers’ support of HCC planning, exercises, and response activities can be mutually beneficial. Urban and rural HCCs may have different membership compositions based on population characteristics, geography, and types of hazards. For example, in rural and frontier areas—where the distance between hospitals may exceed 50 miles and where the next closest hospitals are also critical access hospitals with limited services—tribal health centers, referral centers, or support services may play a more prominent role in the HCC. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Foundation for Health Care and Medical Readiness 15 mitigation strategies based on the time, materials, and resources necessary to address and close gaps. Gaps may be addressed through coordination, planning, training, or resource acquisition. Ultimately, the HCC should focus its time and resource investments on closing those gaps that affect the care of acutely ill and injured patients. Certain response activities may require external support or intervention, as emergencies may exceed the preparedness thresholds the HCC, its members, and the community have deemed reasonable. Thus, during the prioritization process, planning to access and integrate external partners and resources (i.e., federal, state, and/or local) is a key part of gap closure. Activity 4. Assess Community Planning for Children, Pregnant Women, Seniors, Individuals with Access and Functional Needs, Including People with Disabilities, and Others with Unique Needs Certain individuals may require additional assistance before, during, and after an emergency. The HCC and its members should conduct inclusive planning for the whole community, including children; pregnant women; seniors; individuals with access and functional needs, such as people with disabilities; individuals with pre-existing, serious behavioral health conditions; and others with unique needs.21 21 Public Health Service Act § 2802, 42 U.S.C. 300hh–1 (2013). The HCC should: • Support public health agencies with situational awareness and IT tools already in use that can help identify children; pregnant women; seniors; and individuals with access and functional needs, including people with disabilities; and others with unique needs (e.g., the U.S. Department of Health and Human Services emPOWER map,22 22 “HHS emPOWER Map.” ASPR, 2016. Web. Accessed 17 APR. 2017. https://empowermap/hhs.gov. which provides information on Medicare beneficiaries who rely on electricity-dependent medical and assistive equipment, such as ventilators, at-home dialysis machines, and wheelchairs) • Support public health agencies in developing or augmenting existing response plans for these populations, including mechanisms for family reunification • Identify potential health care delivery system support for these populations (pre- and post- event) that can reduce stress on hospitals during an emergency • Assess needs and contribute to medical planning that may enable individuals to remain in their residences. When that is not possible, coordinate with the ESF-8 lead agency to support the ESF- 6 (Mass Care, Emergency Assistance, Housing, and Human Services) lead agency with inclusion of medical care at shelter sites • Coordinate with the ESF-8 lead agency to assess medical transport needs for these populations • Assess specific treatment and access to care needs; incorporate how to address needs into individual HCC member Emergency Operations Plans (EOPs) and the HCC response plan (see Capability 2, Objective 1 – Develop and Coordinate Health Care Organization and Health Care Coalition Response Plans) • Coordinate with the U.S. Department of Veterans Affairs (VA) Medical Center to identify veterans in the HCC’s coverage area (if applicable) 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Foundation for Health Care and Medical Readiness 16 Activity 5. Assess and Identify Regulatory Compliance Requirements The HCC, in collaboration with the ESF-8 lead agency and state authorities, should assess and identify regulatory compliance requirements that are applicable to day-to-day operations and may play a role in planning for, responding to, and recovering from emergencies. The HCC should: • Understand federal statutory, regulatory, or national accreditation requirements that impact emergency medical care, including:  Centers for Medicare & Medicaid Services (CMS) conditions of participation, (including CMS-3178-F Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers)23 23 See “Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers.” 81 Fed. Reg. 63859. (16 Sept. 2016.) Federal Register: The Daily Journal of the United States. Web. Accessed 26 Oct. 2016.  Clinical Laboratory Improvement Amendments (CLIA)24 24 See “Clinical Laboratory Improvement Amendments (CLIA).” CMS, May 2016. Web. Accessed 18 Aug. 2016. https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/index.html.  Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule requirements25 25 See “Emergency Situations: Preparedness, Planning, and Response.” HHS, 2016. Web. Accessed 19 Jul. 2016. www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html. and circumstances when covered entities can disclose protected health information (PHI) without individual authorization including to public health authorities and as directed by laws (e.g., state law)26 26 “HIPAA and Disasters: What Emergency Professionals Need to Know.” ASPR TRACIE, 31 Aug. 2016. PDF. Accessed 21 Oct. 2016. https://asprtracie.hhs.gov/documents/aspr-tracie-hipaa-emergency-fact-sheet.pdf  Emergency Medical Treatment & Labor Act (EMTALA) requirements27 27 See “Emergency Medical Treatment & Labor Act (EMTALA).” CMS. 2012. Web. Accessed 19 Jul. 2016. https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/.  Licensing and accrediting agencies for hospitals, clinics, laboratories, and blood banks (e.g., Joint Commission,28 28 “Emergency Management Resources DNV GL – Healthcare29 29 “DNV GL Healthcare )  Federal disaster declaration processes30 30 See “The Disaster Declaration Process.” FEMA, 3 Jun. 2016. Web. Accessed 19 Jul. 2016. www.fema.gov/disaster- declaration-process. ,31 31 See “Legal Authority of the Secretary.” ASPR, 2016. Web. Accessed 19 Jul. 2016. www.phe.gov/preparedness/support/secauthority/Pages/default.aspx. and public health authorities  Available federal liability protections for responders (e.g., Public Readiness and Emergency Preparedness (PREP) Act32 32 See “Public Readiness and Emergency Preparedness Act.” ASPR, Dec. 2015. Web. Accessed 14 Aug. 2016. http://www.phe.gov/preparedness/legal/prepact/pages/default.aspx. )  Environmental Protection Agency (EPA) requirements33 33 See “EPA Laws and Regulations.” EPA, Jun. 2016. Web. Accessed 19 Jul. 2016. www.epa.gov/laws-regulations.  Occupational Safety and Health Administration (OSHA) requirements34 34 See “OSHA laws and regulations.” OSHA, 2016. Web. 19 Jul. 2016. www.osha.gov/law-regs.html. (e.g., general duty clause, blood-borne pathogen standard) .” The Joint Commission, 24 Aug. 2016. Web. Accessed 24 Aug. 2016. www.jointcommission.org/emergency_management.aspx. .” DNV GL Healthcare, 2016. Web. Accessed 19 Jul. 2016. dnvglhealthcare.com/. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Foundation for Health Care and Medical Readiness 17 • Understand state or local regulations or programs that impact emergency medical care, including:  Scope and breadth of emergency declarations  Regulations for health care practitioner licensure, practice standards, reciprocity, scope of practice limitations, and staff-to-patient ratios  Legal authorization to allocate personnel, resources, equipment, and supplies among health care organizations  Laws governing the conditions under which an individual can be isolated or quarantined  Available state liability protections for responders • Understand the process and information required to request necessary waivers and suspension of regulations, including:  Processes for emergency resource acquisition (this may require coordination with the federal, state, and/or local government)  Special waiver processes (e.g., section 1135 of the Social Security Act waivers35 35 See “1135 Waivers.” ASPR, 2 May 2013. Web. Accessed 12 Sept. 2016. http://www.phe.gov/Preparedness/legal/Pages/1135-waivers.aspx. ) of key regulatory requirements pursuant to emergency declarations  Process and implications for Food and Drug Administration (FDA) issuance of emergency use authorizations for use of non-approved drugs or devices or use of approved drugs or devices for unapproved uses  Legal resources36 36 “Hospital Legal Preparedness: Relevant Resources.” CDC, 20 Apr. 2015. Web. Accessed 19 Jul. 2016. www.cdc.gov/phlp/publications/topic/hospital.html. related to hospital legal preparedness, such as the deployment and use of volunteer health practitioners  Legal and regulatory issues related to alternate care sites and practices  Legal issues regarding population-based interventions, such as mass prophylaxis and vaccination  Processes for emergency decision making from state or local legislature • Support crisis standards of care planning,37 37 Altevogt, Bruce M., et al. “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations.” The National Academies Press, 2009. Web. Accessed 26 Oct. 2016. www.nap.edu/read/12749/chapter/1. including the identification of appropriate legal authorities and protections necessary when crisis standards of care are implemented (see Capability 4 – Medical Surge) • Maintain awareness of standing contracts for resource support during emergencies Objective 3: Develop a Health Care Coalition Preparedness Plan The HCC preparedness plan enhances preparedness and risk mitigation through cooperative activities based on common priorities and objectives. In collaboration with the ESF-8 lead agency, the HCC should develop a preparedness plan that includes information collected on hazard vulnerabilities and risks, resources, gaps, needs, and legal and regulatory considerations (as collected in Capability 1, Objective 2, Activities 1-5 above). The HCC preparedness plan should emphasize strategies and tactics that promote communications, information sharing, resource coordination, and operational response planning with HCC members and other stakeholders. The HCC should develop its preparedness plan to include core HCC members and additional HCC members so that, at a minimum, hospitals, EMS, emergency 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Foundation for Health Care and Medical Readiness 20 • Develop and implement training plans, including those that support appropriate health care providers and first responders. Training plans may include but are not limited to, initial education, continuing education, appropriate certifications, and just-in-time training • Employ a variety of modalities (e.g., online, classroom, etc.) Activity 3. Plan and Conduct Coordinated Exercises with Health Care Coalition Members and Other Response Organizations The HCC, in collaboration with its members, should plan and conduct coordinated exercises to assess the health care delivery system’s readiness. The HCC should focus exercises on the outcomes of HVAs and other assessments that identify resource needs and gaps, identify individuals who may require additional assistance before, during, and after an emergency, and highlight applicable regulatory and compliance issues. The HCC should: • Plan and conduct health care delivery system-wide exercises that incorporate hospitals, EMS, emergency management organizations, public health agencies, and additional HCC member participation • Base exercises on specific gaps and needs identified by HCC members, including emerging infectious diseases and CBRNE threats • Update an exercise schedule annually or in accordance with jurisdictional needs • Provide opportunities for clinical laboratory participation • Assess readiness to support emergencies involving children across the age and developmental trajectory; children represent nearly 25 percent of the population42 42 Lofquist, Daphne, et al. “Households ad Families: 2010.” 2010 Census Briefs, Apr. 2012. PDF. Accessed 26 Aug. 2016. www.census.gov/prod/cen2010/briefs/c2010br-14.pdf. and have unique response needs during emergencies, including special medical equipment and treatment needs and family reunification considerations • Assess readiness to support other individuals who have special health needs and may require additional assistance before, during, and after an emergency (e.g., pregnant women, seniors, individuals who depend on electricity-dependent medical and assistive equipment, etc.) • Exercise Continuity of Operations (COOP) plans (see Capability 3, Objective 2, Activity 1 – Develop a Health Care Organization Continuity of Operations Plan and Capability 3, Objective 2, Activity 2 – Develop a Health Care Coalition Continuity of Operations Plan) • Exercise medical surge capacity and capability,43 43 “Health Care Coalition Surge Evaluation Tool.” ASPR, Jun. 2016. Web. Accessed 19 Jul. 2016. www.phe.gov/Preparedness/planning/hpp/Pages/coaltion-tool.aspx. including decisions leading to the implementation of crisis standards of care (see Capability 4 – Medical Surge)  Assess the mobilization of beds, personnel, and key resources, including equipment, supplies, and pharmaceuticals • Coordinate exercises with other response organizations (e.g., Federal Emergency Management Agency [FEMA], National Guard, etc.) • When appropriate, include federal, state, and local response resources in exercises (e.g., National Disaster Medical System [NDMS] Disaster Medical Assistance Teams [DMAT],44 44 “Disaster Medical Assistance Team.” ASPR, 25 Sept. 2015. Web. Accessed 15 Sept. 2016. www.phe.gov/preparedness/responders/ndms/teams/pages/dmat.aspx. NDMS 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Foundation for Health Care and Medical Readiness 21 Federal Coordinating Centers [FCCs],45 45 “National Disaster Medical System: Federal Coordinating Center Guide.” NDMS, Apr. 2014. PDF. Accessed 12 Sept. 2016. http://www.dmrti.army.mil/01_FCC%20Guide%20Apr%202014.pdf. Emergency System for Advance Registration of Volunteer Health Professionals [ESAR-VHP],46 46 “The Emergency System for Advance Registration of Volunteer Health Professionals.” ASPR, n.d. Web. Accessed 7 Sept. 2016. http://www.phe.gov/esarvhp/pages/default.aspx. state medical teams, MRC, and other federal, state, local, and tribal assets) • Collect information about HCC member operating status and resource availability during exercises and disseminate the information to other members • Develop an after-action report (AAR) and improvement plan (IP) that incorporates lessons learned from exercises and a follow-up process, including steps to overcome the identified gaps in the AAR/IP (see Capability 1, Objective 4, Activity 5 – Evaluate Exercises and Responses to Emergencies below) Activity 4. Align Exercises with Federal Standards and Facility Regulatory and Accreditation Requirements The HCC should consider the following when developing and executing exercises: • Apply Homeland Security Exercise and Evaluation Program (HSEEP) fundamentals47 47 “Homeland Security Exercise and Evaluation Program (HSEEP).” FEMA, Apr. 2013. pp. 1-1. Web. Accessed 19 Jul 2016. http://www.fema.gov/media-library-data/20130726-1914-25045-8890/hseep_apr13_.pdf. to both the exercise program and the execution of individual exercises • Integrate current health care accreditation requirements such as the Joint Commission Emergency Management Standards, and health care regulatory requirements such as CMS- 3178-F Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers • Use a stepwise progression of exercise complexity for a variety of emergency response scenarios (e.g., workshop to tabletop to functional to full-scale exercises) Activity 5. Evaluate Exercises and Responses to Emergencies The HCC should coordinate with its members and other response organizations to complete an AAR and an IP after exercises and real-world events. The same exercise or response may generate facility, member type, HCC, and community AAR/IPs – each with a somewhat different focus and level of detail. The AAR should document gaps in HCC member composition, planning, resources, or skills revealed during the exercise and response evaluation processes. The IP should detail a plan for addressing the identified gaps, including responsible entities and the required time and resources to address the gaps. The IP should also recommend processes to retest the revised plans and capabilities. Facility and organization evaluations should follow a similar process. AARs may also reveal leading practices that can be shared with HCC members and other HCCs. Successful HCC maturation depends on integrating AAR/IP findings into the next planning, training, exercise, and resource allocation cycle. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Foundation for Health Care and Medical Readiness 22 Activity 6. Share Leading Practices and Lessons Learned The HCC should coordinate with its members, government partners, and other HCCs to share leading practices and lessons learned. Sharing information between HCCs will improve cross-HCC coordination during an emergency and will help further improve coordination efforts. The HCC should employ the following principles when sharing leading practices and lessons learned: • Ensure information is shared among HCCs after real-world events and exercises to identify gaps, leading practices, and lessons learned • Incorporate lessons learned from real-world events and exercises into HCC plans, training, and exercises • Utilize mechanisms to rapidly acquire and share new clinical knowledge for a wide range of hazards and threats during exercise scenarios and real-world events. Examples include:  Utilizing the Office of the Assistant Secretary for Preparedness and Response (ASPR) Technical Resources, Assistance Center, and Information Exchange (TRACIE)48 48 “ASPR TRACIE Evaluation of Hazard Vulnerability Assessment Tools.” ASPR TRACIE, 19 Jul. 2016. PDF. Accessed 24 Aug. 2016. asprtracie.hhs.gov/documents/tracie-evaluation-of-HVA-tools.pdf.  Sharing hazardous material (HAZMAT) information from poison control centers  Using virtual telemedicine platforms (e.g., Project ECHO49 49 “Project ECHO.” UNM School of Medicine, 2016. Web. 19 Jul. 2016. echo.unm.edu/. )  Obtaining information from federal alert systems (e.g., Centers for Disease Control and Prevention [CDC], FDA, FEMA)  Coordinating clinical treatment information on conference calls or webinars (e.g., CDC Clinician Outreach and Communication Activity [COCA]50 50 “Clinician Outreach and Communication Activity (COCA).” CDC, 18 Aug. 2016. Web. Accessed 7 Sept. 2016. http://emergency.cdc.gov/coca/. ) Objective 5: Ensure Preparedness is Sustainable Sustainability planning is a critical component to HCC development. Strong governance mechanisms, constant regional stakeholder engagement, and sound financial planning help form the foundation to continue HCC activities well into the future. Sustainability should emphasize HCC processes and activities that support member needs and regulatory requirements (e.g., exercises and evacuation planning). Activity 1. Promote the Value of Health Care and Medical Readiness The HCC, with support from its health care organization members, should be able to articulate its mission, including its role in community preparedness and how that provides benefit (both direct and indirect) to the region. The HCC has a duty to plan for a full range of emergencies and both planned and unplanned events that could affect its community. It is essential that the HCC has leaders who can serve as primary points of contact to promote preparedness and response needs to community leaders. Additionally, members have a shared responsibility to ensure the HCC has visibility into their activities in the region. The HCC should: 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Health Care and Medical Response Coordination 25 Capability 2. Health Care and Medical Response Coordination Health care and medical response coordination enables the health care delivery system and other organizations to share information, manage and share resources, and integrate their activities with their jurisdictions’ Emergency Support Function-8 (ESF-8, Public Health and Medical Services) lead agency and ESF-6 (Mass Care, Emergency Assistance, Housing, and Human Services) lead agency at both the federal and state levels. Private health care organizations and government agencies, including those serving as ESF-8 lead agencies, have shared authority and accountability for health care delivery system readiness, along with specific roles. In this context, health care coalitions (HCCs) serve a communication and coordination role within their respective jurisdiction(s). This coordination ensures the integration of health care delivery into the broader community’s incident planning objectives and strategy development. It also ensures that resource needs that cannot be managed within the HCC itself are rapidly communicated to the ESF- 8 lead agency. HCC coordination may occur at its own coordination center, the local Emergency Operations Center (EOC), or by virtual means – all of which are intended to interface with the ESF-8 lead agency. Coordination between the HCC and the ESF-8 lead agency can occur in a number of ways. Some HCCs serve as the ESF-8 lead agency for their jurisdiction(s). Others integrate with their ESF-8 lead agency through an identified designee at the jurisdiction’s EOC who represents HCC issues and needs and provides timely, efficient, and bi-directional information flow to support situational awareness. Regardless, HCCs connect the elements of medical response and provide the coordination mechanism among health care organizations—including hospitals and emergency medical services (EMS)— emergency management organizations, and public health agencies. Goal for Capability 2: Health Care and Medical Response Coordination Health care organizations, the HCC, their jurisdiction(s), and the ESF-8 lead agency plan and collaborate to share and analyze information, manage and share resources, and coordinate strategies to deliver medical care to all populations during emergencies and planned events. Objective 1: Develop and Coordinate Health Care Organization and Health Care Coalition Response Plans Health care organizations respond to emergent patient care needs every day. During an emergency response, health care organizations and other HCC members contribute to the coordination of information exchange and resource sharing to ensure the best patient care outcomes possible. HCCs and their members can best achieve enhanced coordination and improved situational awareness when there is active participation from hospitals, EMS, emergency management organizations, and public health agencies and by documenting roles, responsibilities, and authorities before, during, and immediately after an emergency. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Health Care and Medical Response Coordination 26 Every individual health care organization must have an Emergency Operations Plan (EOP) per federal and state regulations and multiple accreditation standards. The HCC, in collaboration with the ESF-8 lead agency, should have a collective response plan that is informed by its members’ individual EOPs. In cases where the HCC serves as the ESF-8 lead agency, the HCC response plan may be the same as the ESF-8 response plan. The purpose of coordinating response plans is not to supplant existing ESF-8 structures, but to enhance effective response in accordance with the wide array of existing federal, state, and municipal legal authorities in which HCC members operate (e.g., Emergency Medical Treatment & Labor Act [EMTALA]53 53 See “Emergency Medical Treatment & Labor Act (EMTALA).” CMS. 2012. Web. Accessed 19 Jul. 2016. https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/. , communicable disease reporting, and the Health Insurance Portability and Accountability Act [HIPAA] Privacy Rule). Activity 1. Develop a Health Care Organization Emergency Operations Plan Each health care organization should have an EOP to address a wide range of emergencies. The EOP should detail the use of incident management—including specific indicators for plan activation, alert, and notification processes, response procedures, and resource acquisition and sharing—and a process that delineates the thresholds to demobilize and begin the transition to recovery and the restoration of normal operations (see Capability 3, Objective 7 – Coordinate Health Care Delivery System Recovery). The plan should define the internal and external sources of information that will be necessary to assess the impact of the emergency on the health care organization. The plan should also address how the individual HCC member communicates this information to the HCC and to key health care organization leadership. Critical elements of the health care organization’s EOP include: • Identification of triggers to activate the plan • Communications (internal and external) • Information management • Access to resources and supplies • Safety and security measures • Delineation of staff roles and responsibilities within the incident command system (ICS) • Utility readiness (e.g., back-up generator, water supplies) • Provision of clinical care • Support activities The EOP should summarize the actions required to initiate and sustain a response to an emergency. Health care organizations’ departmental plans should provide specific information for each unit or area. Employees should have a clear understanding of their actions and how to communicate with the facility or organization’s EOC during a response. The EOP should include plans for caring for employees and their dependents during and after an emergency in an effort to promote their return to work54 54 “Tips for Retaining and Caring for Staff after a Disaster.” ASPR TRACIE, 10 Sep. 2016. PDF. Accessed 26 Oct. 2016. https://asprtracie.hhs.gov/documents/tips-for-retaining-and-caring-for-staff-after-disaster.pdf. (see Capability 3, Objective 5 – Protect Responders’ Safety and Health). During an emergency, the EOP should inform the HCC’s expectations related to sharing information, attaining situational awareness, and managing and sharing resources, at a minimum. The HCC may help 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Health Care and Medical Response Coordination 27 health care organizations facilitate patient and resource distribution (or re-distribution) during a surge emergency (see Capability 4 – Medical Surge). The EOP may contain annexes that document specific planning actions for various types of medical responses (e.g., evacuation and relocation, hazardous material (HAZMAT), burn mass casualty, pediatric mass casualty). Additionally, the EOP may contain provisions, including an annex, regarding actions required by the health care organization if it is a member of the National Disaster Medical System (NDMS) in a Federal Coordinating Center’s (FCC)55 55 “National Disaster Medical System: Federal Coordinating Center Guide.” NDMS, Apr. 2014. PDF. Accessed 12 Sept. 2016. http://www.dmrti.army.mil/01_FCC%20Guide%20Apr%202014.pdf. patient receiving area. In coordination with their HCC, health care organizations should review and update their EOPs regularly, and after exercises and real-world events. The review should involve identifying gaps in the health care organization’s response plan. Health care organization leadership, supported by the HCC, should take steps to define strategies and tactics that address those gaps to ensure a more robust response in the next emergency. The HCC should continuously monitor the health care organization’s progress toward gap closure and offer assistance to help close the gaps as appropriate. Activity 2. Develop a Health Care Coalition Response Plan The HCC, in collaboration with the ESF-8 lead agency, should have a collective response plan that is informed by its members’ individual plans. In cases where the HCC serves as the ESF-8 lead agency, the HCC response plan may be the same as the ESF-8 response plan. Regardless of the HCC structure, the HCC response plan should describe HCC operations that support strategic planning, information sharing, and resource management. The plan should also describe the integration of these functions with the ESF-8 lead agency to ensure information is provided to local officials and to effectively communicate and address resource and other needs requiring ESF-8 assistance. The HCC should develop a response plan that clearly outlines: • Individual HCC member organization and HCC contact information • Locations that may be used for multiagency coordination • Brief summary of each individual member’s resources and responsibilities • Integration with appropriate ESF-8 lead agencies • Emergency activation thresholds and processes • Alert and notification procedures • Essential Elements of Information (EEIs) agreed to be shared, including information format (e.g., bed reporting, resource requests and allocation, patient distribution and tracking procedures, processes for keeping track of unidentified [John Doe/Jane Doe] patients) • Communication and information technology (IT) platforms and redundancies for information sharing • Support and mutual aid agreements • Evacuation and relocation processes • Policies and processes for the allocation of scarce resources and crisis standards of care,56 56 Altevogt, Bruce M., et al. “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations.” The National Academies Press, 2009. Web. Accessed 26 Oct. 2016. www.nap.edu/read/12749/chapter/1. including steps to prevent crisis standards of care without compromising quality of care (e.g., conserve supplies, substitute for available resources, adapt practices, etc.) (See Capability 4, Objective 1, Activity 1 – Incorporate Medical Surge into the HCC Response Plan) 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Health Care and Medical Response Coordination 30 • HCC members should inform the HCC of their operational status, actions taken, and resource needs. The HCC should relay this information to the jurisdiction’s EOC and the ESF-8 lead agency • Resource management should include logging, tracking, and vetting resource requests across the HCC and in coordination with the ESF-8 lead agency • Ideally, systems should track beds available by bed type57 57 Bed types include but are not limited to: adult ICU, adult medical/surgical, burn, pediatric ICU, pediatric medical/surgical, psychiatric, airborne infection isolation, operating rooms (ideally, common bed types are defined across the jurisdiction), resource requests, and resources shared between HCC members, from HCC-controlled or other resource caches • The HCC should work with distributors to understand and communicate which health care organizations and facilities should receive prioritized deliveries of supplies and equipment (e.g., personal protective equipment [PPE]) depending on their role in the emergency. HCC members should collectively determine the prioritization of limited resources provided by distributors, reflecting needs at the time of the emergency (see Capability 3, Objective 3, Activity 1 – Assess Supply Chain Integrity) Activity 2. Coordinate Incident Action Planning During an Emergency During an emergency or planned event, each health care organization should develop an Incident Action Plan (IAP)58 58 “FEMA Incident Action Planning Guide.” FEMA, Jan. 2012. PDF. Accessed 18 Jul. 2016. http://www.fema.gov/media-library-data/20130726-1822-25045- 1815/incident_action_planning_guide_1_26_2012.pdf. and utilize incident action planning cycles to identify and modify objectives and strategies. The HCC should develop an IAP based on its individual HCC members’ plans, with its own focus on planning cycles, objectives, and strategies. Ultimately, the HCC’s IAP should be integrated into the jurisdiction’s IAP, via the ESF-8 lead agency. This will enable a consistent, transparent, and scalable approach to establishing strategies and tactics that will govern the response to an emergency or planned event. Keeping response strategies (e.g., implementing alternate care sites, allocating resources, and developing policies on visitors during infectious disease outbreaks) consistent across HCC members requires coordinated discussion and joint decision making. The IAP can address both response and recovery or a separate recovery plan may be developed in accordance with existing plans at the state or local level (see Capability 3, Objective 7 – Coordinate Health Care Delivery System Recovery). Activity 3. Communicate with Health Care Providers, Non-Clinical Staff, Patients, and Visitors during an Emergency Sharing accurate and timely information is critical during an emergency. Health care organizations should have the ability to rapidly alert and notify their employees, patients, and visitors to update them on the situation, protect their health and safety (see Capability 3, Objective 5 – Protect Responders’ Safety and Health), and facilitate provider-to-provider communication. The HCC, in coordination with its public health agency members, should develop processes and procedures to rapidly acquire and share clinical knowledge among health care providers and among health care organizations during responses to a variety of emergencies (e.g., chemical, biological, radiological, nuclear or explosive [CBRNE], trauma, burn, pediatrics, or highly infectious disease) in order to improve patient management, particularly at facilities that may not care for these patients regularly. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Health Care and Medical Response Coordination 31 Activity 4. Communicate with the Public during an Emergency HCC members should coordinate relevant health care information with the community’s Joint Information System (JIS) to ensure information is accurate, consistent, linguistically and culturally appropriate, and disseminated to the community using one voice. Coordinated health care information that could be shared with the JIS includes but is not limited to: • Current health care facility operating status • When and where to seek care • Alternate care site locations • Screening or intervention sites • Expected health and behavioral health effects related to the emergency • Information to facilitate reunification of families • Other relevant health care guidance, including preventive strategies for the public’s health The HCC and its members should agree upon the type of information that will be disseminated by either the HCC or individual members. The HCC should provide Public Information Officer (PIO) training (including health risk communication training) to those designated to act in that capacity during an emergency. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Continuity of Health Care Service Delivery 32 Capability 3. Continuity of Health Care Service Delivery Optimal emergency medical care relies on intact infrastructure, functioning communications and information systems, and support services. The ability to deliver health care services is likely to be interrupted when internal or external systems such as utilities, electronic health records (EHRs), and supply chains are compromised. Disruptions may occur during a sudden or slow-onset emergency or in the context of daily operations. Historically, continuity of operations planning has focused on business continuity and ensuring information technology (IT) redundancies. However, health care organizations and health care coalitions (HCCs) should take a broader view and address all risks that could compromise continuity of health care service delivery. Continuity disruptions may range from an isolated cyberattack on a single hospital’s IT system to a long-term, widespread infrastructure disruption impacting the entire community and all of its health care organizations. A safe, prepared, and healthy workforce and comprehensive recovery plans will bolster the health care delivery system’s ability to continue services during an emergency and return to normal operations more rapidly. Goal for Capability 3: Continuity of Health Care Service Delivery Health care organizations, with support from the HCC and the Emergency Support Function-8 (ESF-8) lead agency, provide uninterrupted, optimal medical care to all populations in the face of damaged or disabled health care infrastructure. Health care workers are well-trained, well-educated, and well-equipped to care for patients during emergencies. Simultaneous response and recovery result in a return to normal or, ideally, improved operations. Objective 1: Identify Essential Functions for Health Care Delivery There are key health care functions (e.g., Mission Essential Functions [MEFs]) that should be continued after a disruption of normal activities and are a priority for restoration should any be compromised.59 59 “Healthcare: COOP & Recovery Planning: Concepts, Principles, Templates & Resources.” ASPR HPP, Jan. 2015. PDF. Accessed 12 Sept. 2016. www.phe.gov/Preparedness/planning/hpp/reports/Documents/hc-coop2- recovery.pdf. Health care organizations should first determine its key functions when planning for continuity of health care service delivery. The HCC may play an important role in assessing and supporting the maintenance of these functions. These key health care functions include clinical services and infrastructure: • Pre-hospital care • Inpatient services • Outpatient care • Skilled nursing facilities and long-term care facilities • Home care • Laboratory • Radiology 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Continuity of Health Care Service Delivery 35 • Decision-making criteria and authorities • Identification of patient and non-patient care locations to provide protection from the external environment • Operational procedures for shutting down HVAC, lock-down, and access control • Assessment of internal capabilities and needs • Acquisition of supplies, equipment, pharmaceuticals, and other necessary resources for sustainment (e.g., water and food), as well as materials that may be important for children and others during extended sheltering (e.g., books and games) • Internal and external communications plans, including plans for communicating with patients’ and workforce’s families • Triggers for lifting shelter-in-place orders Objective 3: Maintain Access to Non-Personnel Resources during an Emergency Critical equipment and supplies for all populations should be available to ensure the ongoing delivery of patient care services. HCC members should assess equipment and supply needs that will likely be in demand during an emergency and develop strategies to address potential shortfalls. Activity 1. Assess Supply Chain Integrity Each individual HCC member should examine its supply chain vulnerabilities by collaborating with manufacturers and distributors to determine access to critical supplies, amounts available in regional systems, and potential alternate delivery options in the case that access or infrastructure is compromised. The HCC should then collect and use this information to coordinate effectively within the region, in collaboration with the ESF-8 lead agency. The supply chain integrity assessment should include the following: • Blood banks • Medical gas suppliers • Fuel suppliers • Nutritional suppliers and food vendors • Pharmaceutical vendors • Leasing entities for biomedical (monitors, ventilators, etc.) and other durable medical equipment and beds • Manufacturers and distributors for disposable supplies • Manufacturers and distributors for PPE • Hazardous waste removal services The HCC should collaborate with health care organization members and other stakeholders to develop joint understanding and strategies to address supply chain vulnerabilities. These vulnerabilities may be addressed at a health care organization and/or HCC level by decisions and mitigation strategies including but not limited to: • Accessing stockpile (or maintain and rotate higher stock levels) • Accessing vendor- and/or distributor-managed inventory/stockpile • Establishing secondary vendors • Developing ‘push’ or pre-event disaster supply procedures and triggers for activation 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Continuity of Health Care Service Delivery 36 • Identifying alternate modes of delivery • Using bulk purchasing to benefit from advantages in pricing and availability across HCC members Health care organizations will need to determine whether additional new contracts or other agreements are needed prior to an emergency. In many cases, there is little redundancy in available vendors and little available inventory, which may contribute to rapid exhaustion of supplies in a major emergency. HCC agreements to share supplies may provide a critical resource during emergencies. These agreements should be developed and documented prior to an emergency (see Capability 1, Objective 2, Activity 2 – Assess Regional Health Care Resources). The HCC and its members should also be aware of the need for redundancies in backup planning (e.g., in events affecting all HCC members, individual facilities may plan for the same vendors to provide backup supplies or utilities). When these strategies fail, health care organizations and the HCC should consider implementing contingency plans, which may include conservation, substitution, adaptation, reuse, or reallocation. Additional strategies may include transferring resources from other HCCs and/or coordinating with the ESF-8 lead agency to request assets from the 61 61 Altevogt, Bruce M., et al. “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations.” The National Academies Press, 2009. Web. Accessed 26 Oct. 2016. www.nap.edu/read/12749/chapter/1. Strategic National Stockpile (SNS).62 62 “Strategic National Stockpile.” CDC, Jun. 17, 2016. Web. Accessed 26 Aug. 2016. www.cdc.gov/phpr/stockpile/stockpile.htm. Activity 2. Assess and Address Equipment, Supply, and Pharmaceutical Requirements Pharmaceuticals and medical materiel are needed for both emergency treatment and to maintain the health of patients, health care providers, and first responders. Health care organizations should maintain awareness of critical medications and materiel they have on hand and how to obtain additional supplies through their established procurement processes, their HCC, and any state/local stockpiles. Certain categories of pharmaceuticals and medical materiel are more likely to be required during a patient surge, such as: • Pharmaceuticals  Analgesia and sedation medications (including oral and injectable)  Anesthesia medications (e.g., paralytics)  Antibiotics (including oral and injectable)  Antivirals (e.g., oseltamivir)  Tetanus vaccine  Pressor medications  Antiemetics  Respiratory medications (e.g., albuterol)  Anticonvulsant drugs  Antidotes (e.g., atropine, hydroxocobalamin) – based on community risks and resources  Psychotropic medications • Medical supplies and equipment  Blood products  Intravenous fluids and infusion pumps 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Continuity of Health Care Service Delivery 37  Ventilators  Bedside monitors  Airway suction for all populations, including children  Surgical equipment and supplies  Supplies needed to administer pharmaceuticals, blood products, and intravenous fluids (e.g., needles, syringes, etc.) Health care organizations should ensure access to formulations appropriate for dosing all patient types, including children and other special populations. For most health care organizations, small increases above baseline levels of common, inexpensive medications will provide a buffer, particularly when organizations can share resources with HCC members during an emergency. Decisions to stockpile medications are complex and rely on a risk assessment and resource commitments by health care organizations, the HCC, and other stakeholders. Acquisition, storage, rotation, activation, use, and disposal decisions should all be considered and documented. All health care organizations and the HCC should understand the SNS distribution plan for their jurisdiction(s). Health care organizations and HCCs in jurisdictions participating in the CHEMPACK63 63 “CHEMPACK.” HHS, 25 Jun. 2011. Web. Accessed 19 Jul. 2016. chemm.nlm.nih.gov/chempack.htm. program, the Cities Readiness Initiative (CRI),64 64 “Cities Readiness Initiative.” CDC, 17 Jun. 2016. Web. Accessed 19 Jul. 2016. www.cdc.gov/phpr/stockpile/cri/. and local and state-based plans that maintain treatment or prophylaxis caches should be engaged in the development, training, and exercising of those distribution plans. Objective 4: Develop Strategies to Protect Health Care Information Systems and Networks Cyberattacks on health care organizations have had significant effects on every aspect of patient care and organizational continuity. With increasing reliance on information systems, including EHRs, administrative and payment systems, mobile technology, communication systems, and networked medical devices, there is a potential risk to their integrity and safety. To combat these risks, health care organizations should implement cybersecurity leading practices and conduct robust planning and exercising for cyber incident response and consequence management. As the number of cyberattacks on the health care sector increases, health care practitioners, executives, IT professionals, legal and risk management professionals, and emergency managers should remain current on the ever-changing nature and type of threats to their organizations, systems, patients, and staff.65 65 “Cybersecurity Topic Collection: 6/16/2016.” ASPR TRACIE, 16 Jun.2016. PDF. Accessed 16 Sept. 2016. asprtracie.hhs.gov/documents/cybersecurity.pdf. Health care organizations, assisted by the HCC, should explore industry cybersecurity standards, guidelines, and leading practices necessary to protect these systems (e.g., National Institute of Standards and Technology Cybersecurity Framework - Framework for Improving Critical Infrastructure Cybersecurity), 66 66 “Framework for Improving Critical Infrastructure Cybersecurity.” NIST, 12 Feb. 2014. PDF. Accessed 26 Oct. 2016. https://www.nist.gov/sites/default/files/documents/cyberframework/cybersecurity-framework-021214.pdf and have a plan in place for response and recovery should they be compromised. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Continuity of Health Care Service Delivery 40 Activity 3. Develop Health Care Worker Resilience A resilient workforce is critical to successful emergency response and recovery. The HCC and its members should consider the following: • Pre-emergency resilience building, such as encouraging healthy lifestyles; developing family emergency plans; conducting staff training for active shooter events and psychological first aid; and instituting workplace violence reduction strategies • Emergency resilience support, such as rotating staff to limit fatigue; providing support to staff and families (e.g., child care); providing accurate and timely updates during an emergency; providing opportunities for interacting with health care organization leadership; and providing just-in-time training relative to the emergency • Post-emergency support, 71 71 “Tips for Retaining and Caring for Staff after a Disaster.” ASPR TRACIE, 10 Sep. 2016. PDF. Accessed 26 Oct. 2016. https://asprtracie.hhs.gov/documents/tips-for-retaining-and-caring-for-staff-after-disaster.pdf. such as providing psychological first aid; distributing information on expected stress responses; conducting self- and peer-assessment and monitoring activities; providing access to employee assistance programs, including professional behavioral health services; and modifying duty assignments. Post-emergency activities may continue for months and even years beyond the emergency • Ongoing health and safety monitoring activities, such as determining which groups of responders should be included in a health care or disease registry program to monitor their long-term physical and behavioral health; establishing and implementing long-term tracking of responder health, and where appropriate, community health; and providing technical assistance to help determine the appropriate duration and content of long-term health tracking The HCC can disseminate information and promote these programs and initiatives to all HCC members. Objective 6: Plan for and Coordinate Health Care Evacuation and Relocation Health care organizations should evacuate or relocate when continuity planning efforts cannot sustain a safe working environment or when a government entity orders a health care organization to evacuate. The HCC should ensure all members and other stakeholders are included in evacuation and relocation planning including but not limited to, skilled nursing facilities and long-term care facilities. The HCC plays a critical role in coordinating the various elements of patient evacuation and relocation. Activity 1: Develop and Implement Evacuation and Relocation Plans The HCC and its members should prepare for evacuation or relocation with little or no warning. Evacuation and relocation plans assist health care organizations with the safe and effective care of patients, use of equipment, and utilization of staff when relocating to another part of the facility or when evacuating patients to another facility. Health care organizations may rely on the HCC and their affiliated corporate health systems to assist in planning, evacuation, and relocation processes. The HCC and its members, in coordination with the ESF-8 lead agency, should consider the following when planning and coordinating patient evacuation and relocation: • Planning considerations: 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Continuity of Health Care Service Delivery 41  Establish authorities for decision-making processes, including triggers for evacuation  Ensure internal and external communications  Identify appropriate relocation and evacuation staging areas within the facility  Integrate health care organization evacuation planning with local and regional patient movement plans  Identify situations for early discharge  Identify available destination facilities and their ability to expand existing services to receive patients from evacuating facilities  Establish processes for when patients cannot be moved (see Capability 3, Objective 2, Activity 4 – Plan for Health Care Organization Sheltering-in-Place)  Establish procedures for facility closure • Evacuation and relocation considerations:  Prioritize the order and category of patients chosen for evacuation and relocation  Obtain section 1135 of the Social Security Act waivers;72 72 See “1135 Waivers.” ASPR, 2 May 2013. Web. Accessed 12 Sept. 2016. http://www.phe.gov/Preparedness/legal/Pages/1135-waivers.aspx. these waivers can be obtained retroactively in certain emergency situations  Match patient needs with available transport resources (including non-EMS transportation assets)  Move and track patients and their belongings, staff, and medical records; ensure vital patient medications and equipment (e.g., mechanical ventilators, monitors, intravenous [IV] poles, etc.) are brought with the patient during patient transport and are returned to the facility of origin  Notify families, and initiate reunification Planning, training, and exercising these activities are critical to the success of evacuation and relocation. High risk patients should be given special consideration during evacuation and relocation. These patients include adults, children, and neonates in critical care units, current operative cases, psychiatric (including memory/dementia care) patients, and other patients who may need specialized care during evacuation and relocation. Activity 2. Develop and Implement Evacuation Transportation Plans The HCC and its members, in collaboration with the ESF-8 lead agency, should develop and implement transportation plans for evacuating patients from one health care facility to another. The plans should: • Articulate the HCC’s role in coordinating EMS assistance • Include a process to appoint a transport manager or similar position under the ICS operations section • Identify a coordinating entity for public and private EMS agencies, including both ground and air medical services • Identify transportation assets including non-medical transportation partners, such as commercial bus companies • Identify processes to access specialized transportation assets through emergency management organizations (e.g., National Guard [State Active Duty], tractors, boats) 2017-2022 Health Care Preparedness and Response Capabilities | ASPR • Consider age- and size-related transportation equipment needs • Develop processes to track patients and staff during transport Continuity of Health Care Service Delivery 42 • Establish processes for transport partners to communicate with sending and receiving facilities • Establish processes to communicate with patients’ families when transferring patients to the next health care provider Objective 7: Coordinate Health Care Delivery System Recovery Effective recovery and reconstitution of the health care delivery system includes pre-incident planning and implementation of recovery processes that begin at the outset of a response. The HCC can play an important role in monitoring and facilitating the recovery processes of the health care delivery system disrupted by an emergency. These efforts are intended to promote an effective and efficient return to normal or, ideally, improved operations for the provision of and access to health care in the community. Activity 1. Plan for Health Care Delivery System Recovery Recovery processes can be integrated into existing plans (e.g., annex to EOPs) or be developed as a separate stand-alone plan. The HCC and its members should participate in state and local pre-emergency recovery planning activities as described in the National Disaster Recovery Framework73 73 “National Disaster Recovery Framework.” FEMA, ed. 2, Jun. 2016. PDF. Accessed 12 Sept. 2016. www.fema.gov/media-library-data/1466014998123- 4bec8550930f774269e0c5968b120ba2/National_Disaster_Recovery_Framework2nd.pdf in order to leverage existing recovery resources, programs, projects, and activities. Response, continuity operations, and recovery are overlapping, interdependent, and often conducted concurrently. Therefore, identifying connected functions, tasks, or activities in the post-emergency environment will facilitate a coordinated transition from response to recovery. Key considerations to recovery planning include: • Goals and strategic priorities for the continued delivery of essential health care services, including behavioral health, and opportunities for improvement after an emergency • Flexible operational objectives and tactics to accommodate different recovery approaches • Integration with pre-incident assessments and plans (e.g., community health needs assessments, community health improvement plans, organizational capital improvement plans) • Critical infrastructure dependencies (e.g., public utilities, IT, transportation, etc.) • Workforce retention issues essential to operations (e.g., access to child or adult dependent care) Activity 2. Assess Health Care Delivery System Recovery after an Emergency The HCC may assist its members’ assessment of emergency-related structural, functional, and operational impacts. The HCC can assist its members with the following activities: • Data collection and analysis to identify priorities in the reconstitution and delivery of community health care services at the outset of an emergency 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Medical Surge 45 Capacity and Capability (MSCC)81 81 Barbera, Joseph. A., Macintyre, Anthony. G., M.D. “Medical Surge Capacity and Capability: A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies.” HHS, Second Edition. Sept. 2007. PDF. Accessed 24 Aug. 2016. www.phe.gov/preparedness/planning/mscc/handbook/documents/mscc080626.pdf. tiered approach, where successive levels of assistance are activated as the emergency evolves. Goal for Capability 4: Medical Surge Health care organizations—including hospitals, emergency medical services (EMS), and out- of-hospital providers—deliver timely and efficient care to their patients even when the demand for health care services exceeds available supply. The HCC, in collaboration with the Emergency Support Function-8 (ESF-8) lead agency, coordinates information and available resources for its members to maintain conventional surge response. When an emergency overwhelms the HCC’s collective resources, the HCC supports the health care delivery system’s transition to contingency and crisis surge response and promotes a timely return to conventional standards of care as soon as possible. Objective 1: Plan for a Medical Surge Health care organizations can most effectively implement and manage medical surge when appropriate information sharing systems and procedures have been established, appropriate plans for all levels of care and populations have been developed, and personnel have been trained in their use. Activity 1. Incorporate Medical Surge Planning into a Health Care Organization Emergency Operations Plan An emergency event will require the HCC and its members to share information, attain and maintain situational awareness, and manage and share resources, at a minimum. The HCC may help facilitate patient and resource distribution (or re-distribution) during a surge emergency. The health care organization’s Emergency Operations Plan (EOP) will help inform these efforts. The health care organization EOP should summarize the actions to initiate a response to a medical surge. The EOP should include individual departmental sections that provide specific surge strategies for each unit or service line. Further, employees should clearly know how to communicate with the organization’s Emergency Operations Center (EOC). The EOP should include a process for the health care organization to request waivers and emergency use authorizations. As the response evolves and situational awareness is enhanced, the health care organization can refine its response strategies according to the scope of the emergency. For more information on the health care organization’s EOP, see Capability 2 – Health Care and Medical Response Coordination. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Medical Surge 46 Activity 2. Incorporate Medical Surge into an Emergency Medical Services Emergency Operations Plan EMS organizations, the HCC, and its members support each other during medical surge. The EMS EOP should incorporate information on dispatch, response, pre-hospital triage and treatment, transportation, supplies, and equipment. Like the health care organization EOP, the EMS EOP will help inform the overarching HCC response. The EMS EOP should detail the implementation of a stepwise approach to medical surge, including the use of conventional, contingency, and crisis care strategies, as well as state (e.g., request for National Guard) and interstate (e.g., Emergency Management Assistance Compact [EMAC]82 82 “Emergency Management Assistance Compact.” EMAC, 2015. Web. Accessed 15 Sept. 2016. http://www.emacweb.org/. ) resources to address potential shortfalls. Ultimately, EMS organizations should strive to return to normal operations as quickly as possible. EMS providers should develop and consistently implement common strategies within the HCC. EMS medical directors and managers should develop and activate surge procedures appropriate for the emergency that enable their employees to make informed decisions in the field so they can provide the best care possible, given limited resources and staff. Table 1 below outlines key elements to incorporate into an EMS EOP. Table 1 Medical Surge Elements to Incorporate into an EMS Emergency Operations Plan Category Elements to incorporate into an EMS EOP Dispatch • Identify procedures to:  Alert hospitals of an emergency  Communicate hospital capacity and capability to EMS providers  Track patient distribution (or redistribution)  Change emergency dispatch processes (e.g., not dispatching EMS to motor vehicle crashes until police or fire report signific t injuries)an  Assign low priority calls to other resources or alternative forms of transport Response • Match appropriate specialized providers and equipment with the nature of the emergency (e.g., hazardous materials [HAZMAT] trained crews during a chemical spill) • Consider surge strategies such as changing shift lengths or crew configurations, using alternate vehicles, using community paramedicine, or other non-ambulance responses in coordination with dispatch priorities 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Medical Surge 47 Category Elements to incorporate into an EMS EOP Pre-hospital triage and treatment • Implement disaster triage procedures and other standard operating procedures (e.g., eliminate requirement for verbal orders) • Consider processes that allow for expanded scope of practice • Plan for specialty responses, such as HAZMAT, highly infectious disease, mass burn, mass trauma, and mass pediatric emergencies Transportation • Identify procedures to surge the numbers of patients transported per vehicle or aircraft • Identify procedures for changing preferred destination facilities (e.g., trauma center, pediatric hospital) or not using the closest hospital • Identify procedures for type and level of pre-hospital care delivery and mode of transport (ground and air medical) • Develop and implement EMS patient distribution strategies to avoid overloading any single hospital • Identify procedures for transporting patients to alternate care sites Supplies and equipment • Utilize physical resources including supplies, equipment, and cached materials to support a medical surge Activity 3. Incorporate Medical Surge into a Health Care Coalition Response Plan The HCC response plan as described in Capability 2 – Health Care and Medical Response Coordination should detail the activation and notification processes for initiating medical surge response coordination among HCC members, including ESF-8 partners. The HCC response plan should include the following elements related to medical surge: • Strategies to implement if the emergency overwhelms regional capacity or specialty care (e.g., trauma, burn, pediatric) capability, including the execution of crisis standards of care plans; plans should also address steps to prevent crisis standards of care without compromising quality of care (e.g., conserve supplies, substitute for available resources, adapt practices, etc.) • Strategies for patient tracking, including a process for keeping track of unidentified (John Doe/Jane Doe) patients • Strategies for initial patient distribution (or re-distribution) in the event a facility becomes overwhelmed (e.g., across proximal geographic region among local hospitals) • Strategies for definitive patient movement out of the affected region coordinated with U.S. Department of Defense (DoD) or U.S. Department of Veterans Affairs (VA) Federal Coordinating Centers (FCCs),83 83 “National Disaster Medical System: Federal Coordinating Center Guide.” NDMS, Apr. 2014. PDF. Accessed 12 Sept. 2016. http://www.dmrti.army.mil/01_FCC%20Guide%20Apr%202014.pdf. including the establishment of aerial ports of embarkation and debarkation for patient movement (e.g., deployable U.S. Department of Health and Human Services [HHS] response teams, definitive medical care in National Disaster Medical System [NDMS] civilian hospitals) 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Medical Surge 50 clinic’s ability to provide care. If not adequately addressed, the demand for out-of-hospital care will usually fall on hospitals and EMS, further overloading an already burdened system. Safe, continued operations of a community’s out-of-hospital care resources are critical to an effective medical surge response. Therefore, HCC out-of-hospital members should share staff and resources and fully integrate with the region’s surge response activities. Out-of-hospital members include but are not limited to, ambulatory care (including primary care providers), Federally Qualified Health Centers (FQHCs),88 88 “What are Federally qualified health centers (FQHCs)?” HRSA, n.d. Web. Accessed 7 Sept. 2016. www.hrsa.gov/healthit/toolbox/RuralHealthITtoolbox/Introduction/qualified.html. community and tribal health centers, stand-alone surgical and specialty centers, skilled nursing facilities, long-term care facilities, clinics, private practitioners, and home care. Activity 3. Develop an Alternate Care System An alternate care system—the utilization of non-traditional settings and modalities for health care delivery—may be required when demand overwhelms a region or the nation’s health care delivery system for a prolonged period, or an emergency has significantly damaged infrastructure and limited access to health care. In these situations, the ESF-8 lead agency, in collaboration with health care organizations and the HCC, should work together to meet patient care needs. Public health agencies and emergency management organizations have leadership roles in selecting, establishing, and operating the sites, though the health care delivery system may provide support, including personnel and supplies. Initial efforts for staffing an alternate care system should not disrupt health care delivery services (see Capability 3 – Continuity of Health Care Service Delivery). Communities should utilize MRCs and other staffing augmentation efforts (e.g., nursing and medical students) to staff an alternate care system whenever possible. When these resources are no longer available, request for additional assistance (e.g., federal and state assistance, etc.) may be required. Table 3 below outlines key elements to consider when developing an alternate care system. Table 3 Key Considerations to Develop an Alternate Care System Category Key considerations Telemedicine/virtual medicine • Use telephone, internet, telemedicine consultations, or other virtual platforms to provide consultation between providers • Provide access to specialty care expertise where it does not exist within the HCC to allow for remote triage and initial patient stabilization • Establish call centers to offer scripted patient support 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Medical Surge 51 Category Key considerations Screening/early treatment • Ensure that a section 1135 of the Social Security Act waiver89 is in place if required • Establish assessment and screening centers that allow the health care delivery system to respond to increased demand for screening and early treatment (e.g., during a pandemic) • Preferentially manage patients with minor symptoms and those who might require limited medical intervention as these patients might otherwise overwhelm emergency departments Medical care at shelters • Provide medical care support at community-established shelters (may involve ESAR-VHP, MRC, state disaster medical teams, nursing home staff, or a variety of ambulatory care providers) Disaster alternate care facilities selection and operation • Be able to provide non-ambulatory care for patients when hospital beds are not available • Select sites for out-of-hospital patient care management based on recommended guidance90 • Identify the process to assist with multiagency volunteer coordination to organize, assemble, dispatch, and properly out-process volunteers (e.g., Volunteer Reception Center) • Integrate with Federal Medical Stations (FMS) 89 See “1135 Waivers.” ASPR, 2 May 2013. Web. Accessed 12 Sept. 2016. http://www.phe.gov/Preparedness/legal/Pages/1135-waivers.aspx. 90 “Disaster Alternate Care Facilities: Selection and Operation.” AHRQ, Oct. 2009. PDF. Accessed 19 Jul. 2016. archive.ahrq.gov/prep/acfselection/dacfreport.pdf. Activity 4. Provide Pediatric Care during a Medical Surge Response All hospitals should be prepared to receive, stabilize, and manage pediatric patients. However, given the limited number of pediatric specialty hospitals, an emergency affecting large numbers of children may require HCC and ESF-8 lead agency involvement to ensure those children who can most benefit from pediatric specialty services receive priority for transfer. Additionally, pediatric practitioners may be able to help identify patients who are appropriate for transfer to non-pediatric facilities. EMS resources, including providers with appropriate training and equipment, should be prepared to transport pediatric patients. The HCC should promote its members’ planning for pediatric medical emergencies and foster relationships and initiatives with emergency departments that are able to stabilize and/or manage pediatric medical emergencies. Activity 5. Provide Surge Management during a Chemical or Radiation Emergency Event Communities should be prepared to manage exposed or potentially exposed patients during a chemical or radiation emergency. During such events, individuals may go to various health care facilities, police and fire stations, and other locations for assistance. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Medical Surge 52 To ensure successful surge management, HCC members should be prepared to do the following: • Provide wet and dry decontamination by personnel trained and equipped according to the Occupational Safety and Health Administration (OSHA) guidance for first receivers91 91 “OSHA Best Practices for Hospital-based First Receivers of Victims from Mass Casualty Incidents Involving the and the Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities92 92 Cibulsky, Susan M., et al. “Patient Decontamination in a Mass Chemical Exposure Incident: National Planning Guidance for Communities.” HHS, DHS, Dec. 2014. PDF. Accessed 15 Sept. 2016. www.dhs.gov/sites/default/files/publications/Patient%20Decon%20National%20Planning%20Guidance_Final_Dec ember%202014.pdf. • Ensure involvement and coordination with regional HAZMAT resources (where available), including EMS, fire service, health care organizations, and public health agencies (for public messaging) • Distribute and administer available antidotes, including mobilization of CHEMPACKs93 93 “CHEMPACK Release of Hazardous Substances.” OSHA, Jan. 2005. Web. Accessed 19 Jul. 2016. https://www.osha.gov/dts/osta/bestpractices/html/hospital_firstreceivers.html. .” HHS, 25 Jun. 2011. Web. Accessed 19 Jul. 2016. chemm.nlm.nih.gov/chempack.htm. when necessary • Screen to differentiate exposed from unexposed patients, especially in radiation emergency events • Develop a process for radiation triage, treatment, and transport (RTR response)94 94 “Radiation Triage, Treat, and Transport System (RTR) after a Nuclear Detonation: Venues for the Medical Response.” HHS REMM, 16 Aug. 2016. Web. Accessed 15 Sept. 2016. www.remm.nlm.gov/RTR.htm. • Manage behavioral health consequences for these types of emergency events (see Capability 4 Objective 2, Activity 8 – Respond to Behavioral Health Needs during a Medical Surge Response below) Activity 6. Provide Burn Care during a Medical Surge Response All hospitals should be prepared to receive, stabilize, and manage burn patients. However, given the limited number of burn specialty hospitals, an emergency resulting in large numbers of burn patients may require HCC and ESF-8 lead agency involvement to ensure those patients who can most benefit from burn specialty services receive priority for transfer. Additionally, burn surgeons may be able to help identify patients who do not require burn center care and who are appropriate for transfer to other health care facilities. Activity 7. Provide Trauma Care during a Medical Surge Response The HCC and its members should coordinate a response to large-scale trauma emergencies with all trauma system partners. All hospitals should be prepared to receive, stabilize, and manage trauma patients. However, given the limited number of trauma centers, an emergency resulting in large numbers of trauma patients may require HCC and ESF-8 lead agency involvement to ensure those patients who can most benefit from trauma services receive priority for transfer. Health care facilities should ensure sufficient availability of operating rooms, surgeons, anesthesiologists, operating room nurses, and surgical equipment and supplies to provide immediate surgical interventions to patients with life threatening injuries. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Medical Surge 55 • Prepare for a surge in initial storage of decedents, including those who will not become medical examiner cases (e.g., pandemic) • Manage large numbers of family members and friends of decedents who may come to the hospital • Facilitate the identification of temporary, ad hoc mass fatality storage sites in the community (e.g., parking decks, ice rinks) when refrigerated trailers and other conventional storage means are not immediately available • Manage contagious, chemically, or radiologically contaminated remains 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Glossary 56 Glossary Term Definition Access and functional needs Access-based needs: All people must have access to certain resources, such as social services, accommodations, information, transportation, medications to maintain health, and so on. Function-based needs: Function-based needs refer to restrictions or limitations an individual may have that requires assistance before, during, and/or after a disaster or public health emergency.96 Alternate care sites Substitute non-medical physical locations converted to provide health care services when existing health care facilities are compromised by a hazard impact, or the volume of patients exceeds the capacity and/or capabilities of everyday health care facilities. They may be managed by private health care or public agencies.97 In some instances, these sites may be located on hospital campuses or other health care facilities. Alternate care system Encompasses a full array of organizations outside the hospital in which health care can be delivered in a health care emergency, including nursing homes, home care, skilled nursing facilities, and long-term care facilities, etc.98 Category A bioterrorism agents Category A bioterrorism agents (pathogens) are those organisms/biological agents that pose the highest risk to national security and public health because they: • Can be easily disseminated or transmitted from person to person • Result in high mortality rates and have the potential for major public health impact • Might cause public panic and social disruption • Require special action for public health preparedness99 96 “At-Risk Individuals.” ASPR, 8 Sept. 2016. Web. Accessed 16 Sept. 2016. http://www.phe.gov/Preparedness/planning/abc/Pages/atrisk.aspx. 97 “ICDRM/GWU Emergency Management Glossary of Terms.” The George Washington University Institute for Crisis, Disaster, and Risk Management, 30 Jun. 2010. pp. 6. PDF. Accessed 19 Jul. 2016. www.gwu.edu/~icdrm/publications/PDF/GLOSSARY - Emergency Management ICDRM 30 JUNE 10.pdf. 98 Hanfling, Dan, et al., “Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response.” National Academies Press, 2012 Mar. 21. 8, Out-of-Hospital and Alternate Care Systems. Web. Accessed 12 Sep. 2016. https://www.ncbi.nlm.nih.gov/books/NBK201069/. 99 “ NIAID Emerging Infectious Diseases/Pathogens.” NIAID, 25 Jan. 2016. Web. Accessed 20 Jul. 2016. https://www.niaid.nih.gov/research/emerging-infectious-diseases-pathogens. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Glossary 57 Term Definition CHEMPACK The CHEMPACK program is an ongoing initiative of the Centers for Disease Control and Prevention’s (CDC) Division of Strategic National Stockpile (SNS) launched in 2003, which provides antidotes (three countermeasures used concomitantly) to nerve agents for pre-positioning by state, local, and/or tribal officials throughout the U.S. The CHEMPACK program is envisioned as a comprehensive capability for the effective use of medical countermeasures in the event of an attack on civilians with nerve agents.100 Cities Readiness Initiative (CRI) A federally funded program designed to enhance preparedness in the nation's largest population centers where more than 50% of the U.S. population resides. Using CRI funding, state and large metropolitan public health departments develop, test, and maintain plans to quickly receive and distribute life-saving medicine and medical supplies from the nation’s Strategic National Stockpile (SNS) to local communities following a large-scale public health emergency.101 Clinical decision support (CDS) A process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and health care delivery.102 Closed point of dispensing (POD) A specific business or organization that has the ability to dispense medical countermeasures to a defined population, as opposed to the general public (e.g., private sector workplace, hospital, etc.)103 Community Emergency Response Teams (CERT) An organization of volunteer emergency workers who have received specific training in basic disaster response skills and who agree to supplement existing emergency responders in the event of an emergency or disaster.104 100 “CHEMPACK.” HHS, 25 Jan. 2011. Web. Accessed 12 Sept. 2016. https://chemm.nlm.nih.gov/chempack.htm. 101 “Cities Readiness Initiative.” CDC, 17 Jun. 2016. Web. Accessed 20 Jul. 2016. www.cdc.gov/phpr/stockpile/cri/. 102 “How to Implement EHRs: Clinical Decision Support (CDS).” ONC, 28 Mar. 2016. Web. Accessed 26 Oct. 2016. healthit.gov/providers-professionals/clinical-decision-support-cds. 103 Stroud, C., et al. “Prepositioning Antibiotics for Anthrax.” National Academies Press, 30 Sept. 2011. pp. 14. Web. Accessed 16 Sep. 2016. http://www.ncbi.nlm.nih.gov/books/NBK190049/. 104 “Community Emergency Response Teams.” FEMA, 31 Aug. 2016. Web. Accessed 7 Sept. 2016. https://www.fema.gov/community-emergency-response-teams/. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Glossary 60 Term Definition Emergency Support Function-6 (ESF-6) – Mass Care, Emergency Assistance, Temporary Housing, and Human Services Annex ESF-6 (Mass Care, Emergency Assistance, Housing, and Human Services) coordinates the delivery of federal mass care, emergency assistance, housing, and human services when local, tribal, and state response and recovery needs exceed their capabilities.114 Emergency Support Function-8 (ESF-8) – Public Health and Medical Services Annex ESF-8 (Public Health and Medical Services) provides the mechanism for coordinated federal assistance to supplement state, tribal, and local resources in response to the following: • Public health and medical care needs • Veterinary and/or animal health issues in coordination with the U.S. Department of Agriculture (USDA) • Potential or actual incidents of national significance • A developing potential health and medical situation115 Emergency System for Advance Registration of Volunteer Health Professionals (ESAR- VHP) ESAR-VHP is a federal program created to support states and territories in establishing standardized volunteer registration programs for disasters and public health and medical emergencies. The program, administered on the state level, verifies health professionals' identification and credentials so that they can respond more quickly when disaster strikes.116 Emergency use authorization This authority allows U.S. Food and Drug Administration (FDA) to help strengthen the nation’s public health protections against chemical, biological, radiological, nuclear or explosive (CBRNE) threats by facilitating the availability and use of medical countermeasures (MCMs) needed during public health emergencies. Under section 564 of the Federal Food, Drug, and Cosmetic Act, the FDA Commissioner may allow unapproved medical products or unapproved uses of approved medical products to be used in an emergency to diagnose, treat, or prevent serious or life-threatening diseases or conditions caused by CBRNE threat agents when there are no adequate, approved, and available alternatives.117 114 “Emergency Support Function #6 – Mass Care, Emergency Assistance, Housing, and Human Services Annex.” FEMA, Jan. 2008. PDF. Accessed 20 Jul. 2016. www.fema.gov/pdf/emergency/nrf/nrf-esf-06.pdf. 115 “Emergency Support Function #8 – Public Health and Medical Services Annex.” FEMA, Jan. 2008. Web. Accessed 20 Jul. 2016. www.fema.gov/media-library-data/20130726-1825-25045- 8027/emergency_support_function_8_public_health___medical_services_annex_2008.pdf 116 “The Emergency System for Advance Registration of Volunteer Health Professionals.” ASPR, n.d. Web. Accessed 20 Jul. 2016. www.phe.gov/esarvhp/Pages/about.aspx. 117 “Emergency Use Authorization.” FDA, 7 Sept. 2016. Web. Accessed 16 Sept. 2016. www.fda.gov/EmergencyPreparedness/Counterterrorism/ucm182568.htm. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Glossary 61 Term Definition ESF-8 lead agency ESF-8 language distinguishes between lead and supporting agencies to conduct an emergency response.118 Within the context of Emergency Support Functions (ESF), primary agencies have significant authorities, roles, resources, and capabilities for a particular function within an ESF. Essential Elements of Information (EEI) Important and standard information items needed to make timely and informed decisions. EEIs also provide context and contribute to analysis. EEIs are also included in situation reports.119 Federal Coordinating Center (FCC) A federal facility (U.S. Department of Defense or U.S. Department of Veterans Affairs) located in a metropolitan area of the United States, responsible for day-to-day coordination of planning, training, and operations in one or more assigned geographic National Disaster Medical System (NDMS) Patient Reception Areas (PRA). NDMS participating medical treatment facilities (MTF) should be within 5 miles of the managing FCC.120 Federal Medical Station (FMS) A U.S. Department of Health and Human Services (HHS)- deployable health care facility that can provide surge beds to support health care systems anywhere in the U.S. that are impacted by disasters or public health emergencies. FMS are not mobile and cannot be relocated once established.121 Hazard vulnerability analysis (HVA) A systematic approach to identifying all hazards that may affect an organization and/or its community, assessing the risk (probability of hazard occurrence and the consequence for the organization) associated with each hazard, and analyzing the findings to create a prioritized comparison of hazard vulnerabilities. The consequence, or “vulnerability,” is related to both the impact on organizational function and the likely service demands created by the hazard impact.122 118 “Emergency Support Functions.” ASPR, 2 Jun. 2015. Web. Accessed 12 Sept. 2016. http://www.phe.gov/Preparedness/support/esf8/Pages/default.aspx#eme. 119 “FEMA Incident Action Planning Guide.” FEMA, Jan. 2012. PDF. Accessed 18 Jul. 2016. http://www.fema.gov/media-library-data/20130726-1822-25045- 1815/incident_action_planning_guide_1_26_2012.pdf. 120 “National Disaster Medical System: Federal Coordinating Center Guide.” NDMS, Apr. 2014. PDF. Accessed 12 Sept. 2016. http://www.dmrti.army.mil/01_FCC%20Guide%20Apr%202014.pdf. 121 “Medical Assistance.” ASPR, 8 May 2015. Web. Accessed 16 Sept. 2016. http://www.phe.gov/Preparedness/support/medicalassistance/Pages/default.aspx#fms. 122 “ICDRM/GWU Emergency Management Glossary of Terms.” The George Washington University Institute for Crisis, Disaster, and Risk Management, 30 Jun. 2010. pp. 48. PDF. Accessed 19 Jul. 2016. www.gwu.edu/~icdrm/publications/PDF/GLOSSARY - Emergency Management ICDRM 30 JUNE 10.pdf. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Glossary 62 Term Definition Hazardous material (HAZMAT) Any material that is explosive, flammable, poisonous, corrosive, reactive, or radioactive (or any combination) and requires special care in handling because of the hazards posed to public health, safety, and/or the environment.123 Health and Social Services Recovery Support Function Assists locally-led recovery efforts in the restoration of the public health, health care and social services networks to promote the resilience, health and well-being of affected individuals and communities.124 Healthcare-associated infections (HAI) Healthcare-associated infections (HAIs) are infections people get while they are receiving health care for another condition. HAIs can happen in any health care facility, including hospitals, ambulatory surgical centers, end-stage renal disease facilities, and long-term care facilities. HAIs can be caused by bacteria, fungi, viruses, or other less common pathogens.125 Health care coalition (HCC) A group of individual health care and response organizations (e.g., hospitals, emergency medical services (EMS), emergency management organizations, public health agencies, etc.) in a defined geographic location. HCCs play a critical role in developing health care delivery system preparedness and response capabilities. HCCs serve as multiagency coordinating groups that support and integrate with ESF-8 activities in the context of incident command system (ICS) responsibilities. Health care coalition (HCC) member An HCC member is defined as an entity within the HCC’s defined boundaries that actively contributes to HCC strategic planning, operational planning and response, information sharing, and resource coordination and management. Health care executive Health care organization senior executives with institutional decision-making authority. Titles of health care executives may include but are not limited to, President, Chief Executive Officer, Chief Operating Officer, Chief Medical Officer, Chief Nursing Officer, and Medical Director. 123 “ICDRM/GWU Emergency Management Glossary of Terms.” The George Washington University Institute for Crisis, Disaster, and Risk Management, 30 Jun. 2010. pp. 48. PDF. Accessed 19 Jul. 2016. www.gwu.edu/~icdrm/publications/PDF/GLOSSARY - Emergency Management ICDRM 30 JUNE 10.pdf. 124 “Health and Social Services Recovery Support Function.” ASPR, 27 Apr. 2015. Web. Accessed 12 Sept. 2016. http://www.phe.gov/about/oem/recovery/Pages/hss-rsf.aspx. 125 “Overview – Heath Care-Associated Infections.” ODPHP, 16 Sept. 2016. Web. Accessed 16 Sept. 2016. health.gov/hcq/prevent-hai.asp. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Glossary 65 Term Definition Medical countermeasures (MCMs) Medical countermeasures, or MCMs, are Food and Drug Administration (FDA)-regulated products (biologics, drugs, devices) that may be used in the event of a potential public health emergency stemming from a terrorist attack with a biological, chemical, or radiological/nuclear material, a naturally occurring emerging disease, or a natural disaster. MCMs can be used to diagnose, prevent, protect from, or treat conditions associated with chemical, biological, radiological, nuclear, and explosives (CBRNE) threats, or emerging infectious diseases.135 Medical Reserve Corps (MRC) A national network of local groups of volunteers engaging local communities to strengthen public health, reduce vulnerability, build resilience, and improve preparedness, response, and recovery capabilities.136 Medical Surge Capacity and Capability (MSCC) A management methodology based on valid principles of emergency management and the incident command system (ICS). Medical and public health disciplines may apply these principles to coordinate effectively with one another and to integrate with other response organizations that have established ICS and emergency management systems (fire service, law enforcement, etc.). This promotes a common management system for all response entities—public and private—that may be brought to bear in an emergency. In addition, the MSCC Management System guides the development of public health and medical response that is consistent with the National Incident Management System (NIMS).137 Member type A category of health care coalition (HCC) members that represents a type of facility or organization (e.g., all nursing facilities, all hospitals, or all emergency medical services [EMS] agencies within one HCC). Mission Essential Functions (MEFs) Functions that are required to be performed by statute, Executive Order, or otherwise deemed essential by the heads of principal organizational elements to meet mission requirements.138 135 “What are Medical Countermeasures?” FDA, 29 Apr. 2016. Web. Accessed 20 Jul. 2016. www.fda.gov/EmergencyPreparedness/Counterterrorism/MedicalCountermeasures/AboutMCMi/ucm431268.htm 136 “Medical Reserve Corps.” MRC, 22 Sept. 2016. Web. Accessed 26 Sept. 2016. https://mrc.hhs.gov. 137 Barbera, Joseph. A., Macintyre, Anthony. G., M.D. “Medical Surge Capacity and Capability: A Management System for Integrating Medical and Health Resources During Large-Scale Emergencies.” HHS, ed. 2, Sept. 2007. PDF. Accessed 24 Aug. 2016. www.phe.gov/preparedness/planning/mscc/handbook/documents/mscc080626.pdf. 138 “ICDRM/GWU Emergency Management Glossary of Terms.” The George Washington University Institute for Crisis, Disaster, and Risk Management, 30 Jun. 2010. pp. 37. PDF. Accessed 19 Jul. 2016. www.gwu.edu/~icdrm/publications/PDF/GLOSSARY - Emergency Management ICDRM 30 JUNE 10.pdf. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Glossary 66 Term Definition Multiagency coordination group A multiagency coordination group functions within a broader multiagency coordination system. It may establish the priorities among incidents and associated resource allocations, deconflict procedures, and provide strategic guidance and direction to support incident management activities.139 National Disaster Medical System (NDMS) The National Disaster Medical System (NDMS) is a federally coordinated health care system and partnership of the U.S. Departments of Health and Human Services, Homeland Security, Defense, and Veterans Affairs. The purpose of the NDMS is to support state, local, tribal, and territorial authorities following disasters and emergencies by supplementing health and medical systems and response capabilities. The NDMS hospital network also supports the military and U.S. Department of Veterans Affairs (VA) Medical Centers in a military health emergency.140 National Incident Management System (NIMS) A systematic, proactive approach to guide departments and agencies at all levels of government, nongovernmental organizations, and the private sector to work together seamlessly and manage incidents involving all threats and hazards—regardless of cause, size, location, or complexity—in order to reduce loss of life, property, and harm to the environment.141 Personal protective equipment (PPE) Equipment worn to minimize exposure to a variety of hazards. Examples of PPE include such items as gloves, masks, foot and eye protection, protective hearing devices (earplugs, muffs) hard hats, respirators, and full body suits.142 Psychological first aid An evidence-informed modular approach for assisting people in the immediate aftermath of disaster and terrorism to reduce initial distress and to foster short- and long-term adaptive functioning.143 139 “ICDRM/GWU Emergency Management Glossary of Terms.” The George Washington University Institute for Crisis, Disaster, and Risk Management, 30 Jun. 2010. pp. 66. PDF. Accessed 19 Jul. 2016. www.gwu.edu/~icdrm/publications/PDF/GLOSSARY - Emergency Management ICDRM 30 JUNE 10.pdf. 140 “National Disaster Medical System.” ASPR, 1 Jul. 2016. Web. Accessed 20 Jul. 2016. www.phe.gov/Preparedness/responders/ndms/Pages/default.aspx. 141 “National Incident Management System.” FEMA, 28 Jun. 2016. Web. Accessed 12 Sept. 2016. http://www.fema.gov/national-incident-management-system. 142 “Personal Protective Equipment.” OSHA, n.d. Web. Accessed 20 Jul. 2016. https://www.osha.gov/SLTC/personalprotectiveequipment. 143 Jacobs A., Brymer M., et. al. “Psychological First Aid: Field Operations Guide.” National Child Traumatic Stress Network & National Center for PTSD. ed. 2, 2006. Web. Accessed 26 Oct. 2016. www.ptsd.va.gov/professional/manuals/manual-pdf/pfa/PFA_2ndEditionwithappendices.pdf. 2017-2022 Health Care Preparedness and Response Capabilities | ASPR Glossary 67 Term Definition Public Information Officer (PIO) As part of the incident response team, responsible for communicating with the public, media, and/or coordinating with other agencies, as necessary, with incident-related information requirements. The PIO is responsible for developing and releasing information about the incident to the news media, incident personnel, and other appropriate agencies and organizations.144 Public safety answering points (PSAPs) 9-1-1 call centers, also known as public safety answering points (PSAPs), are the public's first line of contact to public safety authorities in an emergency.145 Section 1135 of the Social Security Act waivers When the President declares a major disaster or an emergency under the Stafford Act or an emergency under the National Emergencies Act, and the HHS Secretary declares a public health emergency, the Secretary is authorized to take certain actions in addition to his/her regular authorities under section 1135 of the Social Security Act. [The Secretary] may waive or modify certain Medicare, Medicaid, Children’s Health Insurance Program (CHIP) and Health Insurance Portability and Accountability Act (HIPAA) requirements as necessary to ensure to the maximum extent feasible that, in an emergency area during an emergency period, sufficient health care items and services are available to meet the needs of individuals enrolled in Social Security Act (SSA) programs and that providers of such services in good faith who are unable to comply with certain statutory requirements are reimbursed and exempted from sanctions for noncompliance other than fraud or abuse.146 Strategic National Stockpile (SNS) Strategic National Stockpile (SNS) has large quantities of medicine and medical supplies to protect the American public if there is a public health emergency (e.g., terrorist attack, flu outbreak, earthquake) severe enough to cause local supplies to run out. Once federal and local authorities agree that the SNS is needed, medicines will be delivered to any state in the U.S. in time for them to be effective.147 144 “Basic Guidance for Public Information Officers (PIOs).” FEMA, Nov. 2007. Web. Accessed 20 Jul. 2016. www.fema.gov/media-library-data/20130726-1623-20490- 0276/basic_guidance_for_pios_final_draft_12_06_07.pdf. 145 “9-1-1 Call Centers/PSAPs.” FCC, n.d. Web. Accessed 18 Sept. 2016. https://transition.fcc.gov/pshs/psaps.html. 146 See “1135 Waivers.” ASPR, 2 May 2013. Web. Accessed 12 Sept. 2016. http://www.phe.gov/Preparedness/legal/Pages/1135-waivers.aspx. 147 “Strategic National Stockpile (SNS).” CDC, 17 Jun. 2016. Web. Accessed 12 Sept. 2016. http://www.cdc.gov/phpr/stockpile/stockpile.htm.