*Demand-to-available-resource ratio (Triggers).
† This information can be assessed frequently (elegant markers) and represents the institution's current ratio of patient demand to available resources (personnel, equipment, and space). The "number of ED beds" must be determined in advance, but should include only those beds that can safely accommodate admitted patients under normal circumstances. The "number of inpatient beds" should include only those beds that can be used for acute adult or pediatric medical-surgical patients (not NICU beds).
‡ Critical Resources are: essential medical gasses (e.g., oxygen and nitrous oxide), electricity, water (including a method to purify before use), natural gas (used for heating and cooking), ventilation system, food, key pharmaceuticals for the event, waste and garbage disposal, linen, essential computer systems (admission, discharge, transfer [ADT] system; pharmacy information system; radiology information system; lab information system; network; telephone and paging; and interface engine). Those responsible for providing and maintaining critical resources must provide their best estimate of the percentage of the resource that will be available over the next 24 hours.
§ The Hospital Incident Command System (HICS) is an emergency management system that employs a logical management structure, defined responsibilities, clear reporting channels, and a common nomenclature to help integrate hospital operations with other emergency responders. There are advantages to all hospitals using this particular emergency management system. It is designed to minimize the confusion and chaos commonly experienced by the hospital staff at the onset of a medical disaster. HICS is the standard for health care disaster response and offers the following features:
- Predictable chain of management
- Flexible organizational chart allows quickly tailoring the response to emergencies
- Prioritized response checklists
- Accountability of position function
- Enhanced documentation for improved accountability and cost recovery
- Common language to promote communication and facilitate outside assistance
- Cost-effective emergency planning within health care organizations
The HICS, to work effectively in disasters, must also be used during lower-Level situations. The site(s) used as the Command Center must have excellent, redundant internal and external communication systems.
|| Hospital Chief Medical Officer (CMO) or designate(s) must approve all admissions and surgeries, and enforces hospital discharge policies, as specified for each Level. At Levels 5 and 6, he also enforces the "no admission/no surgery" and "transfer all patients" policies.
# Social Services will assist with these arrangements.
** Hospital Chief Nursing Officer (CNO) or designate(s) modifies staffing patterns to use all physically available beds. (All nursing staff, including those who often function in a "Case Manager" role, will be assigned tasks to maximize their clinical effectiveness.)
†† Pre-identified surge-capacity locations may include clinical (e.g., ambulatory surgery, GI lab, minor treatment areas, cardiac catheterization lab) or nonclinical (e.g., cafeteria, waiting room) areas.
§§ Decision made by institution's Incident Commander, or the CMO, CNO, and Chief Operating Officer (COO) or their designates. They are also responsible for downgrading to a lower Disaster Plan Level, when appropriate.
## Risk Communication provides timely, accurate information through multiple sources, with the chief communicators being credible spokespeople. In health crises, these will usually be physicians. Knowledgeable risk communication specialists must educate this team in these techniques (i.e., using scripts, how to work with the press) in advance of any crisis. The same professionals will work with the designated key communicators throughout the crisis.
*** Crisis Triage Officer (CTO) is a member of the medical staff who allocates critical resources using the criteria of best outcome related to the resources needed (amount of resources times length of time used). Whenever possible, these decisions will be consistent with evidence-based medical literature. The CTO will never be the primary physician of the patient for whom a resource-allocation decision is being made. Decisions are made, whenever possible, with input from the treating team and, when necessary and if possible, other expert consultants. These decisions should be reassessed if the demand-to-resource ratio changes. However, the CTO's decisions may not be overruled.
This is the most difficult position in the triage system and, without proper experience and education, the CTO will not function effectively. CTOs, in some cases, will need to ration or deny resources to patients who, under normal circumstances, would probably survive. This includes, at Level 6, abandoning some patients whose transfer would be too dangerous or would consume too many resources. (This is analogous to triaging patients into the "Expectant" category.)
CTOs will be designated in advance. The cadre of CTOs must become familiar with the triage criteria, participate in frequent discussions with the Bioethics Committee to understand the moral basis for these resource allocation decisions, and practice this role in lower-Level situations. The senior medical and nursing staff, as well as the senior hospital administrators, must understand the CTO's role and be prepared to fully support his decisions—no matter how painful.
CTOs should be relieved every 4 to 6 hours and have an 8- to 12-hour rest period without other duties (as should others in high-stress positions during a disaster). Their rest areas should be quiet and away from any disturbance. It is essential that excellent communication (e.g., a log book with vital details and decisions) is maintained among CTO team members.
‡‡ If moving a patient places staff at risk or if the time and resources it would take would compromise the lives of other patients, the CTO will decide if the patient is to be evacuated or not.
§§§ Lockdown of the facility or evacuation of all or part of the facility may be done immediately by any senior clinician or administrator or at the direction of the law enforcement authorities. This may require moving to Disaster Level 6. Follow other parts of the plan for this Level, if possible and required by the situation.