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This resource was part of AHRQ's Public Health Emergency Preparedness (PHEP) program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
In the event of an MCE, decisions and policies regarding resource allocation in hospitals will have to be developed in advance at multiple levels, ranging from the State to local communities and institutions. Hospitals must have in place a system of coordination with other local hospitals, public health departments, incident commands, public safety, and EMS systems to provide care. The ICS has been adopted as the National Incident Management System, a national training curriculum for public and private sector users that can be applied to multihazard and planned event situations. The establishment of hospital coalitions, compacts, and mutual aid agreements to create a common platform for planning and response. The designation of a particular hospital or local public health agency as a 'trusted source' to serve as the hospital's resource and policy gateway within the region during a major multijurisdictional event. The Hospital Incident Command System (HICS) was developed in California to provide an emergency management system for hospitals for use during a medical disaster. The Incident Command Section provides overall coordination of the response and is the central communications point. The Operations Section conducts tactical medical operations to carry out the incident action plan. The Planning Section prepares and documents the Incident Action Plan (IAP) by collecting and evaluating information, maintaining resource status and documentation for incident records. The Logistics Section provides support, resources, and other services, including personnel, needed to meet operational objectives. Finance and Administration is responsible for time-recording, procurement, accounting, and cost analysis. The planning framework should be transparent and shared with key stakeholders in the health department, attorney general's office, and governor's office and with the community, both in advance of and during an MCE. Integrate response strategies and tactics across facilities and agencies at the local, regional, State, and Federal levels (Figure 1). In advance of an MCE, hospitals should establish a preference list of supplemental providers to expand staff capacity. State Emergency Systems for Advanced Registration of Volunteer Healthcare Professionals (ESAR-VHP). Policies should be in place in advance for credentialing staff members and managing deployment of nonhospital personnel in the hospital.
An important staffing issue in the context of MCE planning is the concern that a significant proportion of health care providers will fail to report to work if they perceive possible harm to themselves or their family members. Careful determination of priority groups and essential personnel, facilitation of child care, providing adequate personal protective equipment, and providing housing apart from family for workers who request it, all can help ensure that health care workers are willing and able to work (and work safely) during a disaster. Short-term strategies may be applied to increase healthcare facility capacity in cases in which resource shortages can be expected to be resolved relatively quickly (within hours or days). Employing rapid discharge of emergency department and other outpatients who can continue their care at home safely.
Employing rapid discharge of inpatients who can safely continue their care at home or at alternate facilities if they are available. Canceling elective surgeries and procedures, with reassignment of surgical staff members and space. Designating wards or areas of the facility that can be converted to negative pressure or isolated from the rest of the ventilation system for cohorting contagious patients; or use of these areas to cohort health care providers caring for contagious patients to minimize disease transmission. Facilitating home-based care for patients in cooperation with public health and home care agencies. Activating memoranda of understanding (MOU) with regional and distant hospitals, health systems, or State disaster medical assistance teams. If these strategies are not sufficient to meet the demands of the incident and no immediate relief is available, then an evaluation of the level of care being provided must be conducted. In the case of a long-term resource shortage, strategies for meeting the demands of an MCE can be classified along a spectrum that includes two categories of changes: administrative adaptations and clinical adaptations.

Administrative adaptations are designed to increase provider availability for patient care.
Administrative changes generally can be implemented with minimal discussion, but they require planning.
Changes to reduce provider documentation, billing and coding, registration, and other administrative policy burdens. Reassignment of qualified administrative nursing staff members to clinical roles or use of nonhospital staff members, potentially including family members, to provide basic patient care.
Adoption of Continuity of Operations (COOP) strategies in each department as needed to cope with the impact of the event. Clinical adaptations represent the allocation of scarce resources or services based on preestablished ethical principles as discussed earlier. Triage of patients who would otherwise be treated as inpatients to home care, acute care sites, or other alternative care sites. There are no clear trip points to indicate when the shift from reactive, mostly administrative changes to proactive, clinical changes must occur.
If there is no differentiation in criteria between patients, then resources should be allocated on a first-come, first-served basis.
In addition to allocating scarce resources, an MCE will require that hospitals address many operational considerations, including security and mass mortuary. A lockdown plan that can be rapidly implemented (including campus buildings that may be used in nontraditional capacities as part of the facility response plan).
Increased law enforcement presence (mutual aid agreements must be in place ahead of an event. Provisions should be made for appropriate solutions to barriers presented by culturally based funeral and burial practices. Behavioral Health intervention has become a valued dimension of immediate and long-term disaster response. Behavioral Health supportive services include psychological first aid, skills for psychological recovery, support to healthcare and school interventions, referrals to community behavioral health providers to help deal with loss, disruption and in some cases, tragedy. Maine’s Disaster Behavioral Health Response Team (DBHRT) is a statewide team of trained volunteers who respond locally to help minimize the impact of disasters and public health emergencies.
While each disaster and community is unique, Maine faces similar challenges as we mobilize to respond to weather-related events; public health emergencies and community tragedies.
The Maine CDC contracts with AdCare Maine to perform specific disaster behavioral health preparedness and emergency response projects that serve to enhance Maine’s disaster behavioral health infrastructure and support the Maine CDC mission. The Alberta government and Red Cross announced details of how emergency funding will be made available to Fort McMurray wildfire evacuees. This may be facilitated by the use of an existing program, such as the Hospital Incident Command System (HICS).
Hospitals should be familiar with its local office of emergency preparedness and know how it is represented there. The system helps coordinate emergency response between hospitals and other emergency responders and is based on a clear chain of management, clearly defined responsibilities, prioritized response checklists, clear reporting channels for documentation and accountability, and a common nomenclature. Clinical guidance or decision aids should reflect any available Federal guidance and ideally be flexible enough to allow hospital and clinician discretion in making resource allocation decisions, as deemed medically justified.
The six-tier construct depicts public health and medical asset management levels during response to mass casualty or mass effect incidents. Some States have intrastate regional coalitions (clearinghouse hospitals, regional coordinating hospitals) that can help the State health department in managing resource allocation in their area. This level of interstate cooperation is difficult to achieve but is one of the most important ways to maximize resource allocation. Local hospital staff, clinic staff, and health professional volunteers registered with an ESAR-VHP have had their credentials verified. Local MRC units of volunteers may include medical and public health professionals, such as physicians, nurses, pharmacists, dentists, veterinarians, epidemiologists, and paramedics.

Some States have provisions to delicense or otherwise sanction providers who do not report for duty during a declared disaster. These strategies usually do not require a systematic assessment of the standard of care being provided. The definition of 'elective' may vary with the severity and duration of the situation and requires daily review; a surgery to remove a neoplasm, for example, may be elective for 24 hours but not for weeks. These locations also may be used to screen patients with mild symptoms when medications are available and must be taken early in the course of illness to be effective. Though their effect on clinical care should be minimal, it must be recognized that changes in shift length or staffing patterns will increase the risk for complications such as infections. These changes should be discussed in advance with the State and Federal agencies that oversee public health insurance programs and with private payers. A good COOP plan details the critical functions and staffing within each department and lists ways for these functions to be carried out when the staff or infrastructure is inadequate to carry on daily operations.
Situational awareness by the Incident Commander and Planning Section Chief can help anticipate or recognize resource bottlenecks that may require intervention. A patient surge that results in scarce resources may increase the potential for violence against health care facilities and providers. Every effort should be made to plan for adjusting standards of care as appropriate to the situation, to advise and involve the public and faith-based communities in these decisions, and to ensure as little disruption as possible to cultural practices and that the maximum level of dignity is afforded the deceased and their families. Medical and Health Incident Management System: A Comprehensive Functional System Description for Mass Casualty Medical and Health Incident Management.
Click on Get involved to sign up and share your skills, community knowledge and commitment to your friends and family members, while helping all Maine residents. Even with the support of these tools or policies, however, it is the hospital that will have to take on the role of implementing them.
The tiers range from individual health care organizations or other healthcare assets and their integration into a local healthcare coalition to coordination of Federal assistance. This arrangement allows for plans to consolidate supplies, epidemiological data, medical response, communications, and command and control. Nevertheless, there are real concerns for providers about duty to family and child care issues that may not be solved easily.
When there is little advance evidence to guide allocation decisions (for example, not knowing how different age groups of patients in an influenza pandemic respond to mechanical ventilation), good clinical judgment by experienced clinicians will be the final common denominator to justify resource allocation decisions.
Hospitals should work with their community law enforcement agencies and hospital security staff to develop a security assessment and vulnerability analysis and a plan for increasing hospital security during a widespread disaster. In some cases, hospital responsibilities for record-keeping and reporting will change in a disaster.
To plan for addressing hospital and acute care needs following an MCE, hospitals and their partners need to prepare. These intrastate regional coalitions, where they exist, should be incorporated into regional Multi-Agency Coordination (MAC) planning and response. The decisionmaking process should be shared openly with staff members, patients, and the public and should be as consistent as possible across facilities. This plan should prioritize hospital assets for protection and rely, when possible, on physical and technological solutions rather than human solutions. Temporary facility morgue facilities may be required, and regional processing sites may be needed.

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