How Will You Care in a Crisis?

EMS providers know the basics of triage. Most of us learn in our initial education or through refreshers what to do when patients outnumber available resources. But what happens when an incident is simply too large, and overwhelms the healthcare system as we know it? In those extreme circumstances, what types of decisions must be made so that available resources can get to patients who need them?

The 2011 tornado that devastated Joplin, MO, the earthquake and tsunami that year that rocked Japan, and even the H1N1 pandemic of 2009–10 are recent examples of the kinds of events that can overpower healthcare systems and the EMS agencies within them.

In 2009, at the request of the Department of Health and Human Services, the Institute of Medicine (IOM) formed a committee of subject-matter experts in emergency response, public health, EMS, medicine and bioethics to develop guidance health officials could use to establish and implement standards of care during disasters.

In its first report, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, published that September, the committee defined crisis standards of care (CSC) as “the level of care that can be delivered in a public health emergency, justified by specific circumstances” under conditions effecting a substantial change in healthcare operations. The committee went on to note that there was no single national set of guidance for states outlining crisis standards of care that could be generalized to all crisis events. The report concluded with six clear general recommendations for the medical community to embrace:

• Develop consistent state CSC protocols with key outlined elements;
• Seek community and provider engagement;
• Adhere to ethical norms during CSC;
• Provide necessary legal protections for healthcare practitioners and institutions implementing CSC;
• Ensure consistency in CSC implementation; and
• Ensure intrastate and interstate consistency among neighboring jurisdictions.

What’s That Mean to EMS?

In a new follow-up report, Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response, the IOM committee examines the effect of its 2009 report and offers templates to guide the efforts of professionals and organizations responsible for CSC planning and implementation.

Integrated planning for a coordinated response by state and local governments, EMS, healthcare organizations and healthcare providers is critical to successfully responding to disasters. To that end, the report provides a foundation of underlying principles and steps needed to achieve implementation. These templates make up the majority of the document. Each one is specific to a distinct discipline with significant responsibilities in a catastrophic event (EMS, hospitals, state and local government, etc.), yet reflects that integrated planning is critical to successfully responding to disasters.

Two templates are specific to EMS: “Core Functions of EMS Systems in the Development of State Crisis Standards of Care Plans” and “Core Functions of EMS Systems and EMS Personnel in the Implementation of CSC Plans.” The first pertains to both state and regional/local EMS entities and breaks down various key functions, including the assessment of jurisdictional authority and planning resources; development of consistent and comprehensive plans under the state disaster medical advisory committee structure; assuring stakeholder and public engagement; and monitoring, evaluation and modification of the CSC plan.

The second goes further into actual implementation of the CSC plans and the various roles and responsibilities of both state and regional/local EMS entities. The functions identified in this template include assessment and activation of the EMS component of the state CSC plan, alert and notification (who gets notified about the situation as well as redundant communications), command (implementation of ICS, activation of an EOC), control, communications, public information, logistics and planning. The template then drills down to the EMS personnel level and addresses functions such as notification, operations, logistics, mental health and legal issues.