Bioterrorism and Other Public Health Emergencies 

Tools and Models for Planning and Preparedness 

Mass Medical Care with Scarce Resources 

A Community Planning Guide 

Prepared for: 

Agency for Healthcare Research and Quality 

540 Gaither Road, Rockville, MD 20850 

Contract No. 290-04-0010 

Prepared by: 

Health Systems Research, Inc.

An Altarum company

Editors 

Sally J. Phillips, R.N., Ph.D. 

Public Health Emergency Preparedness Research Program 

Agency for Healthcare Research and Quality 

Ann Knebel, R.N., D.N.Sc., FAAN 

Office of Preparedness and Emergency Operations 

Office of the Assistant Secretary for Preparedness and Response 

Lead Authors 

Marc Roberts, Ph.D., Harvard University 

James G. Hodge, Jr., J.D., LL.M., Georgetown and Johns Hopkins Universities 

Edward Gabriel, M.P.A., AEMT-P, Walt Disney Corporation 

John L. Hick, M.D., Hennepin County Medical Center 

Stephen Cantrill, M.D., Denver Health Medical Center 

Anne M. Wilkinson, Ph.D., M.S., RAND Corporation 

Marianne Matzo, Ph.D., APRN, BC, FAAN, University of Oklahoma College of Nursing 

February 2007 

AHRQ Publication No. 07-0001 

Providing Mass Medical Care with Scarce Resources: A Community Planning Guide 
Funding to support Mass Medical Care with Scarce Resources: A Community Planning Guide

was provided by the U.S. Department of Health and Human Services’ Office of the Assistant 

Secretary for Preparedness and Response (formerly Office of Public Health Emergency 

Preparedness through an Agency for Healthcare Research and Quality contract to Health 

Systems Research, Inc., an Altarum company (Contract No. 290-04-0010). 

The authors of this report are responsible for its content. No statement in the report should be 

construed as an official position of the Agency for Healthcare Research and Quality or the 

U.S. Department of Health and Human Services. 

This document is in the public domain and may be used and reprinted without permission 

except those copyrighted materials noted, for which further reproduction is prohibited without 

the express permission of copyright holders.

Suggested Citation 

Phillips SJ, Knebel A, eds. Mass Medical Care with Scarce Resources: A Community Planning Guide. 

Prepared by Health Systems Research, Inc., an Altarum company, under contract No. 290-04-0010. 

AHRQ Publication No. 07-0001. Rockville, MD: Agency for Healthcare Research and Quality 2007.
 About This Guide 

Purpose of the Guide 

The purpose of this guide is to provide community planners – as well as planners at the 

facility/community, State, and Federal levels – with valuable information and insights that will help them 

in their efforts to plan for and respond to a mass casualty event (MCE). This guide provides information 

on: 

 The circumstances that communities likely would face as a result of an MCE. 

 Key constructs, principles, and structures to be incorporated into the planning for an MCE. 

 Approaches and strategies that could be used to provide the most appropriate standards of care 

possible under the circumstances. 

 Examples of tools and resources available to help States and communities in their planning process. 

 Illustrative examples of how certain health systems, communities, or States have approached 

certain issues as part of their MCE-related planning efforts. 

This information will be useful in helping planners address the issues associated with preparing for and 

responding to an MCE in the context of broader emergency planning processes, such as those laid out in 

Standing Together: An Emergency Planning Guide for America’s Communities, published by the Joint 

Commission on the Accreditation of Healthcare Organizations, 2005. 

This document is intended not to reflect Department of Health and Human Services policy but to provide 

State and local planners with options to consider when planning their response to an MCE. 

Development of the Guide 

This guide builds and expands on an earlier document published by the Agency for Healthcare Research 

and Quality (AHRQ) that explored the issues and outlined the principles associated with the provision of 

medical care in the face of overwhelming numbers of casualties. It is the product of collaboration between 

the Office of the Assistant Secretary for Preparedness and Response (formerly the Office of Public Health 

Emergency Preparedness) and AHRQ, who coedited the guide. Leading experts were identified and a 

series of papers was commissioned to address issues pertaining to six critical fields related to mass casualty 

care. Working individually or as parts of writing teams, the experts prepared drafts of their papers, which 

were presented for discussion among a broader group of experts at a meeting held in Washington, DC, on 

June 1–2, 2006. The writers incorporated much of the discussion and input from that meeting into their 

respective chapters. The list of meeting participants, including lead authors and the members of the writing 

teams, is presented in Appendix A. 
Acknowledgements

This planning guide is the product of a collaborative effort and as such reflects the extensive contributions of 

many knowledgeable individuals who shared their time, insights, experiences, and expertise. Their 

backgrounds and perspectives range from field experience in providing mass medical care with scarce 

resources to planning for such eventualities and all the related challenges. 

We particularly would like to thank our expert teams who crafted critical content in specific areas. In the area 

of prehospital care, our thanks go to Edward Gabriel, M.P.A., AEMT-P (Writing Team Lead); Peter Pons, 

M.D.; George Foltin, M.D.; Richard Serino, EMT-P; and Paul Maniscalco, M.P.A., EMT-P. The writing 

team that addressed hospital and acute care issues was comprised of John L. Hick, M.D. (Writing Team 

Lead); Lewis Rubinson, M.D., Ph.D.; Daniel O’Laughlin, M.D.; Gabor Kelen, M.D.; Richard Waldhorn, 

M.D.; and Dennis P. Whalen. The issues of alternative care sites were addressed by Stephen Cantrill, M.D. 

(Writing Team Lead); Dan Hanfling, M.D., FACEP; Peter Pons, M.D.; and Carl Bonnett, M.D. An overview 

of the issues and challenges of providing palliative care was provided by Anne M. Wilkinson, M.S., Ph.D. 

(Writing Team Colead); Marianne Matzo, Ph.D., APRN, BC, FAAN (Writing Team Colead); Maria Gatto, 

M.A., APRN; and Joanne Lynn, M.D., M.A., M.S. In addition, we would like to acknowledge the expert 

writings on ethical considerations provided by Marc Roberts, Ph.D., and Evan G. DeRenzo, Ph.D., and on 

the legal environment provided by James G. Hodge, Jr., J.D., LL.M. 

This planning guide was prepared under contract with Health Systems Research, Inc. (HSR), an Altarum 

company. HSR staff members’ contributions ranged from organizing and managing the input of all the expert 

teams and the planning, logistics, and facilitation of the expert meeting to the overall planning guide concept, 

design, and production. We would like to thank the HSR writing, editing, and production staff who were so 

instrumental in shaping this planning guide and ensuring that the final product would be of the greatest use 

for community planners in all settings: Lawrence Bartlett, Ph.D.; Valerie Gwinner, M.P.P., M.A.; Laurene 

Graig, M.A.; Dennis Zaenger, M.P.H.; Holly Doggett; Isha Fleming; Stephen Gilberg; Maureen Ball; Cheryl 

Bell; Katherine Flore, M.P.H.; and Laura Sternesky, M.P.A. 

We sincerely hope that this community guide will serve as a practical tool for community planners across the 

United States as they consider the challenge of providing mass medical care with scarce resources.

Sally Phillips, R.N., Ph.D. Ann Knebel, R.N., D.N.Sc., FAAN 

Director, Public Health Emergency Preparedness Captain, U.S. Public Health Service 

 Research Program Deputy Director for Preparedness Planning 

Agency for Healthcare Research and Quality Office of Assistant Secretary for Preparedness and Response 

U.S. Department of Health and Human Services U.S. Department of Health and Human Services 

 
Contents 

Executive Summary 

vii 

 

Chapter I. Introduction 

1 

Chapter II. Ethical Considerations in Community 

Disaster Planning 

9 

Chapter III. Assessing the Legal Environment 

Concerning Mass Casualty Event Planning and 

Response

25 

Chapter IV. Prehospital Care 

39 

Chapter V. Hospital/Acute Care 

53 

Chapter VI. Alternative Care Sites

75 

Chapter VII. Palliative Care

101 

Chapter VIII. Influenza Pandemic Case Study

117 

Appendix A. Participant List

147 

Appendix B. Bibliography

155
Executive Summary vi
Executive Summary 
Background 

In the event of a catastrophic public health- or terrorism-related event, such as an influenza 

pandemic or the detonation of improvised nuclear devices, the resulting tens of thousands of 

victims will be likely to overwhelm the resources of a community’s health care system. In this 

dire scenario, which we refer to as a mass casualty event (MCE), it will be necessary to allocate 

scarce resources in a manner that is different from usual circumstances but appropriate to the 

situation. Making optimal decisions concerning the allocation of scarce resources could make a 

big difference in the degree to which health care systems continue to function; ultimately it 

could mean saving many thousands of lives. 

Purpose of the Guide 

The purpose of this guide is to provide community planners – as well as planners at the 

facility/community, State, and Federal levels – with valuable insights and information that will 

help them in their efforts to plan for and respond to an MCE. The guide aims to present planners 

with approaches and strategies that would enable them to provide the most appropriate 

standards of care possible under the circumstances of an MCE. 

This document is intended not to reflect Department of Health and Human Services policy but to 

provide State and local planners with options to consider when planning their response to an 

MCE. 

Development of the Guide 

This guide builds and expands on an earlier document published by the Agency for Healthcare 

Research and Quality (AHRQ). Altered Standards of Care in Mass Casualty Events (available 

on the AHRQ Web site at http://www.ahrq.gov/research/altstand/) explored the issues and 

outlined the principles associated with the provision of medical care in the face of 

overwhelming numbers of casualties. 

This planning guide is the product of a collaborative effort between AHRQ and the Office of the 

Assistant Secretary for Preparedness and Response (formerly the Office of Public Health 

Emergency Preparedness). 

Organization of the Guide 

This planning guide looks at issues and challenges in MCE response and preparedness issues 

across the spectrum of health care settings and provides recommendations for planners specific 

to each area. The planning guide begins with a discussion of the ethical and legal considerations 

and then discusses issues related to MCE planning in three care settings: prehospital, hospital 

and acute care, and alternative care sites (ACSs). This is followed by a discussion of palliative 

Executive Summary viii 
care issues, which must be integrated throughout the planning for and response to an MCE. The 

planning guide concludes with a presentation of a case study: an influenza pandemic. 

Ethical Considerations 

We live in a world where a whole range of manmade and natural disasters are of increasing 

concern to communities across the Nation. Terrorism, epidemics, hurricanes, earthquakes, 

floods, and fires are all too possible in an industrialized and increasingly interdependent world. 

For this reason, serious and systematic disaster planning and preparedness at the community 

level are absolutely essential. If or when a disaster occurs, communities must be prepared for 

the possibility that the arrival of government assistance may be delayed. Indeed, potentially 

significant interruptions in the deployment of medical assistance may occur in certain kinds of 

events (e.g., pandemic influenza) or in situations in which several events occur simultaneously. 

Government agencies at all levels may be overstretched by multiple challenges and competing 

demands or have their ability to function degraded by catastrophic events. 

Hurricane Katrina, for example, demonstrated that communications systems may be damaged or 

temporarily severed at the outset of a disaster. While such systems are being reestablished or 

put in place, local communities that have planned for such a possibility will have a head start on 

meeting community care needs. 

Indeed, one reality is clear: communities that have not planned and prepared for such an 

eventuality will be less equipped to face the complexities of such an event than communities 

that have planned. Moreover, once a planning process is undertaken, it will become clear that 

serious ethical decisions are central to shaping any community’s disaster response. It is 

important to realize that once a disaster strikes, difficult choices will have to be made, and the 

more fully the ethical issues raised by such choices are discussed prior to making them, the 

greater the potential for the choices to be ethically sound. The ethical issues and considerations 

in MCE planning are discussed in Chapter II. 

Legal Issues 

Laws at all levels of government are a critical part of emergency responses and allocation 

decisions involving scarce resources in an MCE. Legal issues that need to be considered in the 

context of MCE planning include understanding the changing legal landscape during 

emergencies, the balance of individual and communal interests, the suspension of existing legal 

requirements, interjurisdictional legal coordination issues, medical licensure reciprocity, 

liability and other protections for health care workers and volunteers, property management and 

control, and legal triage. 

Chapter III contains a detailed discussion of relevant laws and their potential impact on the 

ability of planners to allocate scarce resources during an MCE. 

Executive Summary ix 
Prehospital Care 

In the event of an MCE, the emergency medical services (EMS) systems will be called on to 

provide first-responder rescue, assessment, care, and transportation and access to the emergency 

medical health care system. The bulk of EMS in this country is provided through a complex 

system of highly variable organizational structures. While efforts are ongoing to standardize 

EMS disaster training, no single oversight agency is responsible for ensuring consistency in 

training, certification, or guidelines for disaster response; the use of personal protective 

equipment; or the coordination of EMS response and operations. 

The unique context in which EMS systems operate in this country serves to amplify the 

challenges of providing emergency medical services in the context of an MCE. The issues and 

challenges of providing such services are discussed in Chapter IV.

Hospital and Acute Care 

The overall goal of hospital and acute care response to an MCE is to maximize care across the 

greatest number of people while meeting at least minimal obligations for care to all who are in 

need. In the case of an MCE, however, hospitals will not have access to many needed resources. 

Thus, some of the most difficult decisions about providing an appropriate standard of medical 

care in an environment of scarce resources will be made in hospitals. 

The major challenges that hospitals will face in an MCE include surge capacity issues, the fact 

that they are already at or near capacity for emergency and trauma services, a lack of on-call 

specialists and nurses, the need to coordinate between competing health care systems, 

incompatibilities in communications systems, and the need for security and protection, to name 

just a few. The issues related to MCE planning and response in the hospital sector are discussed 

in detail in Chapter V. 

ACSs 

The impact of an MCE of any significant magnitude likely will overwhelm hospitals and other 

traditional venues for health care services. Indeed, it may render them inoperable, necessitating 

the establishment of ACSs for the provision of care that normally would be provided in an 

inpatient facility. Advance planning is critical to the establishment and operation of ACSs; this 

planning must be coordinated with existing health care facilities as well as home care entities. 

Planners must delineate the specific medical functions and treatment objectives of the ACS. The 

principle of managing patients under relatively austere conditions, with only limited supplies, 

equipment, and access to pharmaceuticals and a minimal staffing arrangement, is the starting 

point for ACS planning. 

Executive Summary x 
The issues and challenges of establishing and operating ACSs during an MCE, as well as 

specific case study examples of ACSs in operation during the response to Hurricane Katrina, are 

discussed in detail in Chapter VI. 

Palliative Care 

In the event of an MCE, it will be assumed that some people may survive the onset of the 

disaster but will have sustained such serious illness or injury that they will live only for a 

relatively short period of time. In addition, there will be vulnerable individuals (e.g., the elderly, 

those sick in hospitals, nursing homes, the disabled, children) who may be negatively impacted 

by the resulting scarcity of resources. In some instances, decisions will need to be made to 

withdraw resources from those not likely to survive and shunt those resources to others. 

The goal of an organized and coordinated response to an MCE should be to maximize the 

number of lives saved. At the same time, there should be a goal to provide the greatest comfort 

and minimize the psychological suffering of those whose lives may be shortened as a result of 

an MCE. These issues fall under the broad rubric of palliative care, which refers to the 

aggressive management of symptoms and relief of suffering. 

The overarching issue of how to provide optimal support for the dying, those facing lifelimiting illness or injury, and those caring for them must be integrated into initial planning 

efforts as well as addressed throughout the response to an MCE, as discussed in Chapter VII. 

Case Study: Influenza Pandemic 

The concepts, strategies, and approaches that planners need to consider in the context of an 

MCE highlighted in the chapters of the planning guide are applied to a specific case study 

scenario. The case study selected involves a potential influenza pandemic. The key issues that 

planners need to consider when faced with the challenges of allocating scarce resources in the 

context of a pandemic are presented in Chapter VIII. 

MCE Advance Planning Themes and Recommendations 

In the event of a catastrophic MCE, community planners will face the challenge of allocating 

scarce resources in a timely enough fashion to prevent undue illness and death. As the chapters 

of this guide indicate, in order to prepare for such an eventuality, planners need to focus on the 

following: 

 BE PROACTIVE. Good planning must be undertaken ahead of time. Planners should anticipate 

to the degree possible the types of health care needs and resource shortfalls that will occur, and 

they must identify policy and operational adjustments that will need to take place in response. 

Executive Summary xi 
 BUILD AND MAINTAIN RELATIONSHIPS. It is important to forge partnerships, memoranda of 

understanding, interhospital agreements, and other relationships with key stakeholders from the 

health care system, emergency management system, State and local public health systems, local 

emergency responders, emergency medical services, home health care, and other medical 

providers; volunteer agencies; public safety; and other public and private partners at all levels 

(State, local, regional, and Federal). 

 ESTABLISH REGIONAL AND LOCAL MULTIAGENCY COORDINATION. Public and private health 

agencies, facilities, and responders must have a common vision within their cooperative 

regional area for how they will function during a disaster. Regional coordination may involve 

regions within a State or between States, particularly when a metropolitan area is situated in 

more than one State. Multiagency coordination may take the form of a planning committee, an 

extension of a Metropolitan Medical Response System, or something else. Regardless of the 

form it takes, the key is to provide a mechanism for cooperative coordination of activities, 

resources, and policy across multiple agencies and jurisdictions. 

 DEVISE, MODEL, AND EXERCISE MCE RESPONSE PLANS. Plans must include ways to increase 

surge capacity in anticipation of large numbers of patients needing care in the face of scarce 

resources. Stakeholders should understand and practice the processes that responders and health 

facilities will use to request resources from each other, from supply vendors, from special 

stockpiles, and from emergency management contacts. Opportunities such as special events 

(e.g., major sporting events, political conventions) can be used to test disaster planning. 

 ESTABLISH CLEAR CHANNELS OF COMMUNICATION to link the public health community, diverse 

health care entities, and emergency response systems. A process must be in place for sharing 

accurate, real-time situational information with involved stakeholders across multiple 

jurisdictions. 

 ESTABLISH CLEAR MESSAGES AND COMMUNICATIONS STRATEGIES to inform the public about 

the status of the event and what actions they should take. It is important to work with the media, 

9-1-1 dispatchers, special information phone lines, and other communications mechanisms to 

share clear and accurate messages.

 EMPHASIZE PREVENTION. Planners should recognize the preeminent value of prevention. This 

is particularly true in MCEs such as an influenza pandemic, where a focus on prevention of 

transmission is critical to minimizing the burden of disease.

 CLARIFY THE PROCESS FOR LEADERSHIP AND COORDINATION. It is critical to identify leaders, 

alternates, and the decisionmaking process for resource allocation and policy guidance. 

 IDENTIFY EXISTING NATIONAL AND STATE TOOLS, PROTOCOLS, AND PROCESSES for each phase 

of the MCE. Many products and resources have been developed to help plan for catastrophic 

events. Numerous examples of these are presented within the chapters of this guide. 

Executive Summary xii 
CONSIDER THE LEGAL AND ETHICAL ISSUES RELATED TO PLANNING AND RESPONDING TO AN MCE. 

Planners must be familiar with State emergency powers and have a solid understanding of what 

types of events or circumstances would trigger their implementation. Planners also must be 

familiar with the ethical principles that underlie decisionmaking for the allocation of scarce 

resources.

INTEGRATE PALLIATIVE CARE STRATEGIES ACROSS THE PLANNING PROCESS. Plans should be made 

for how to care for individuals who are not expected to survive the MCE and how to support the 

family members and others who are caring for them. 

 CONSIDER THE FINANCIAL IMPLICATIONS OF RESPONDING TO AN MCE and the potential need to 

enact administrative or policy changes to facilitate reimbursement and recordkeeping 

obligations. 

 CONSIDER VULNERABLE POPULATIONS. Explicit planning must occur at all levels for 

vulnerable populations including infants, children, the frail elderly, pregnant women, the 

disabled, the mentally ill, and special needs groups with chronic medical conditions (e.g., 

cardiac, dialysis, HIV and oncology patients). Prior experience has demonstrated that without 

explicit planning, the needs of these populations will not be adequately met. 

 DEVELOP ROBUST SECURITY PLANS. Security is especially important in the case of a largescale MCE due to the chaos and confusion that it engenders. Having a uniformed presence (e.g., 

hospital security personnel, off-duty police officers, National Guard members, volunteers) helps 

maintain order as do clear identification tags; visiting rules; and procedures for accessing 

supplies, service sites, and patients. 

Clearly, the optimal allocation of scarce resources in response to an MCE is unlikely to occur 

without proper advance planning at the health care facility, community, State, and Federal 

levels. Simply put, the goal of this planning guide is to promote and assist in those efforts. 

Executive Summary xiii 
Executive Summary xiv 
Chapter I. Introduction

Chapter I. Introduction 1
The Context: A Mass Casualty Event 

In the event of a catastrophic public health or terrorism-related event, such as an influenza 

pandemic or the detonation of improvised nuclear devices, the result is likely to be tens of 

thousands of victims whose needs will overwhelm the resources of a community’s health care 

system. Indeed, if the event incapacitates health care workers, damages facilities, or destroys 

supplies, the capacity of the health care system to respond to the tremendous surge in demand 

for its services already may be severely compromised. If other communities are faced with 

similar demands (as would be the case in an 

influenza pandemic or a nuclear detonation, 

for example), the arrival of additional health 

care resources, including assistance from the 

Federal Government, likely would be 

significantly delayed. Additional resources 

may not arrive at all. 

EXAMPLES OF TWO CATEGORIES OF MCE 

Figure 1. Immediate (Sudden Peak) Impact 

Explosions, Airplane or Train Crashes Due to Bombings 

(e.g., Madrid Train Bombings), Earthquakes 

In this dire scenario, which we refer to as a 

mass casualty event (MCE), it will be 

necessary to allocate scarce resources in a 

manner that is different from normal 

circumstances but appropriate for the 

situation if the health care system is to 

remain functioning and save as many lives 

as possible. Making optimal decisions 

concerning the allocation of scarce resources 

in an MCE could make a big difference in 

the degree to which health care systems 

continue to function; ultimately it could save 

many thousands of lives. 

Types of MCEs 

In general, MCEs can be organized into two 

categories: (1) those that result in an 

immediate or sudden impact and (2) those 

that result in a developing or sustained 

impact. A schematic representation of the 

two types of MCE is shown in Figures 1 and 2; this is for illustrative purposes only, as the 

duration and magnitude of the two events would vary. 

The first category of MCE includes events such as the detonation of a bomb or a series of dirty 

bombs, airplane or train crashes as a result of bombings, and earthquakes. This immediate 

Figure 2. Developing (Sustained) Impact 

Patients 

Time

Anthrax, Smallpox, Flu Pandemic 

Patients 

Time 

Chapter I. Introduction 2 
impact category is characterized by large numbers of casualties at the outset of the event that 

generally taper off. In some cases there may be a second wave of casualties due to depleted 

resources or such factors as secondary exposure to natural elements, unclean water, and 

contagious diseases. 

The second MCE category features events such as a massive exposure to anthrax or smallpox. 

Another example of this second type of MCE, and one that we discuss in detail in Chapter VIII 

of this guide, is the potential case of an influenza pandemic, in which there would be a gradual 

increase in the number of people affected, rising to a catastrophic number of patients. In this 

type of MCE, the number of cases may decline due to treatment and prophylactic efforts, for 

example, only to increase due to reinfection with a different strain or as a result of an additional 

wave or waves of the disease. This second type of MCE would necessitate a more sustained 

response, as the impact would be felt over a much longer period than the immediate-impact 

MCE. 

Planners also need to consider situations in which the event destroys essential infrastructure 

(such as a nuclear detonation or natural disasters such as Hurricane Katrina), resulting in a crisis 

requiring a mass migration of survivors. In such circumstances, the delivery of basic care 

should be contingent on the recognition that all victims of a disaster should be accorded basic 

humanitarian rights, including “the right to life with dignity.” In the international disaster 

response arena, the Sphere Project has developed “minimum standards” in six critical areas – 

water supply, water sanitation, nutrition, access to food, shelter, and health care services – 

required for all victims of disaster. It would be useful to consider these minimum standards in 

the context of MCE response planning. 

The Sphere Handbook is available on the Web 

at http://www.sphereproject.org/handbook/. 

It is also important for planners to consider 

relaxation of standards for emergency 

medical services (EMS), for instance, when 

and if these resources are scarce or 

unavailable. This approach would facilitate 

evacuation of survivors, which may be the primary life-saving intervention. Such relaxation of 

standards might include reducing the number of personnel required per vehicle, using 

nonstandard vehicles, and using nonprofessionals as volunteer drivers, for example. 

Planners also need to consider relieving pressure on EMS systems during an MCE by using call 

centers (e.g., poison centers, nurse advice lines, public health hotlines, etc.) to answer the 

public’s questions and address their concerns. These issues are discussed further in Chapters IV 

and V of this guide. 

Planners should recognize an important distinction in the level of preparedness between the two 

types of MCEs. The sudden impact MCE -- explosions and train bombings, for example -- is 

unpredictable and requires an immediate response in terms of the need to triage and temporize 

until the necessary resources arrive. In the case of a developing MCE, the rising numbers of 

Chapter I. Introduction 3 
victims poses significant resource problems if the MCE is nationwide. The impact of an 

influenza pandemic, for example, could be considered predictable, and preparedness planning 

efforts could be made to mitigate its impact through prevention and public education. 

Thus, planners need to be aware of the important distinctions between the two types of MCEs, 

as well as the implications of these distinctions in terms of the demands on the health care 

system and the type of response required. Regardless of the type of MCE for which planners are 

preparing, however, planning must occur prior to the event. 

Advance Planning – Guiding Principles 

Regardless of the type of MCE, advance planning is critical. Thus, the purpose of this guide is 

to provide State and community planners with information, recommendations, and resources 

that can encourage and support MCE planning efforts. 

To inform the development of this guide, the authors referred to the recommendations of a 2004 

expert panel,1 which articulated five principles that should steer the development of MCE response 

plans. 

These guiding principles have served as the 

framework for the development of this planning 

guide. They have helped formulate the topics of 

specific chapters and also are applied across all 

chapters. 

Guiding Principles 

PRINCIPLE #1 has set the foundation for each 

chapter’s discussions within the context of the 

fundamental tenets of maximizing good 

outcomes for the greatest number of people 

while having agencies, organizations, and 

individuals act in good faith to meet their duties 

and obligations in the face of an MCE. This first 

principle provides the underpinnings for the 

ethical, legal, and practical planning 

considerations relating to the allocation of 

scarce resources in a catastrophic situation. 

Discussions regarding this principle have 

included the question of what becomes of those 

individuals who cannot be saved or are not 

expected to survive as a result of the MCE 

episode itself or because of the lack of resources. Thus, the issue of providing palliative care to 

Principle #1: In planning for an MCE, the aim 

should be to keep the health care system 

functioning and to deliver acceptable quality of 

care to preserve as many lives as possible. 

Principle #2: Planning a public health and 

medical response to an MCE must be 

comprehensive, community based, and 

coordinated at the regional level. 

Principle #3: There must be an adequate legal 

framework for providing health and medical care 

in an MCE. 

Principle #4: The rights of individuals must be 

protected to the extent possible and reasonable 

under the circumstances. 

Principle #5: Clear communication with the 

public is essential before, during, and after an 

MCE. 

Chapter I. Introduction 4 
the individuals who cannot be saved has been integrated into planning considerations 

throughout this guide and also constitutes a separate chapter (VII). 

PRINCIPLE #2 touches on an underlying reality of disaster management, which is that 

catastrophic events need to be handled at the lowest possible geographic, community, and 

jurisdictional levels with clear advance plans for the local and regional coordination of available 

services, staff, and resources. The themes of comprehensive incident management, 

coordination, and regionalization are central for MCE planning, and they are discussed 

throughout the chapters of this planning guide. 

PRINCIPLE #3 addresses legal issues associated with providing care in an MCE and the resulting 

decisions regarding the allocation of scarce resources. These issues are the focus of Chapter III. 

The rights of individuals, which are addressed in PRINCIPLE #4, constitute the basis of Chapter 

II. That chapter looks at the ethical issues involved in planning and responding to MCEs. 

The importance of PRINCIPLE #5, communicating with the public, is recognized throughout 

numerous considerations and recommendations related to managing the “worried well,” sharing 

reliable information and instructions with the public, and emphasizing the role of home care and 

individuals in supporting the health care demands of an MCE. In addition, the issue of 

developing and testing communication mechanisms to link MCE responders, health systems and 

institutions, public health, and local authorities also constitutes an area of focus throughout this 

guide.1

Advance Planning – Overarching Themes and Recommendations 

In the event of a catastrophic MCE, whether an immediate or a developing one, community 

planners will face the challenge of allocating scarce resources quickly enough to prevent undue 

illness and death. As the following chapters of this guide indicate, to prepare for such an 

eventuality planners need to take several steps. 

BE PROACTIVE. Good planning must be undertaken ahead of time. Planners should anticipate to 

the degree possible the types of health care needs and resource shortfalls that will occur, and 

they must identify policy and operational adjustments that will need to take place in response. 

Many useful planning lessons can be learned and applied from real case responses to natural 

and manmade events in the United States and abroad (e.g., Hurricanes Rita and Katrina in the 

United States, the London public transport bombings, the Madrid train bombing, the 2004 

tsunami in southern Asia). 

BUILD AND MAINTAIN RELATIONSHIPS. It is important to unite and forge partnerships, memoranda 

of understanding, interhospital agreements, and other relationships with key stakeholders from 

the health care system, emergency management system, State and local public health systems, 

local emergency responders, emergency medical services, home health care, and other medical 

Chapter I. Introduction 5 
providers; volunteer agencies; public safety agencies; and other public and private partners at all 

levels (State, local, regional, and Federal). 

ESTABLISH REGIONAL AND LOCAL MULTIAGENCY COORDINATION. Public and private health 

agencies, facilities, and responders must have a common vision within their cooperative 

regional area for how they will function during a disaster. Regional coordination may involve 

regions within or between States, particularly when a metropolitan area is situated in more than 

one State. Multiagency coordination may take the form of a planning committee, an extension 

of a Metropolitan Medical Response System, or something else. The key is that it provides a 

mechanism for cooperative coordination of activities, resources, and policy across multiple 

agencies and jurisdictions. 

DEVISE, MODEL, AND EXERCISE MCE RESPONSE PLANS. Plans must include ways to increase surge 

capacity in anticipation of large numbers of patients needing care in the face of scarce 

resources. Stakeholders should understand and practice the processes that responders and health 

facilities will use to request resources from each other, from supply vendors, from special 

stockpiles, and from emergency management contacts. Opportunities such as special events 

(e.g., major sporting events, political conventions) can be used to test disaster planning. Plans 

should be modified and refined continually based on input and lessons from response partners, 

exercises, and changing conditions. 

ESTABLISH CLEAR CHANNELS OF COMMUNICATION to link the public health community, diverse 

health care entities, and emergency response systems. A process must be in place for sharing 

accurate, real-time situational information with involved stakeholders across multiple 

jurisdictions. 

ESTABLISH CLEAR MESSAGES AND COMMUNICATIONS STRATEGIES to inform the public about the 

status of the event and what actions they should take. It is important to work with the media, 9-

1-1 dispatchers, special information lines, and other communications mechanisms to share clear 

and accurate messages such as the status of the MCE, how individuals should protect 

themselves and others, when it is safer to stay home, how to provide the best possible care at 

home, where to go for particular services, and when to go or not to go to the emergency room. 

EMPHASIZE PREVENTION. Planners should recognize the preeminent value of prevention. This is 

particularly true in MCEs such as an influenza pandemic, where a focus on prevention of 

transmission is critical to minimize the burden of disease. 

CLARIFY THE PROCESS FOR LEADERSHIP AND COORDINATION. It is critical to identify leaders, 

alternates, and the decisionmaking process for resource allocation and policy guidance. 

IDENTIFY EXISTING NATIONAL AND STATE TOOLS, PROTOCOLS, AND PROCESSES for each phase of 

the MCE. Many products and resources have been developed to help plan for catastrophic 

events. Numerous examples of these are presented in the chapters of this guide. 

Chapter I. Introduction 6 
CONSIDER THE LEGAL AND ETHICAL ISSUES RELATED TO PLANNING AND RESPONDING TO AN MCE. 

Planners must be familiar with State and local emergency powers and have a solid 

understanding of what types of events or circumstances would trigger their implementation. 

INTEGRATE PALLIATIVE CARE STRATEGIES ACROSS THE PLANNING PROCESS. Plans should be made 

for how to care for individuals who are not expected to survive the MCE and how to support the 

family members and others who are caring for them. 

CONSIDER THE FINANCIAL IMPLICATIONS OF RESPONDING TO AN MCE and the potential need to 

enact administrative or policy changes to facilitate reimbursement and recordkeeping 

obligations. Take into account any funding from the Centers for Disease Control and 

Prevention’s Public Health Emergency Preparedness Program and Health Resources and 

Services Administration National Bioterrorism Hospital Preparedness Program.

CONSIDER VULNERABLE POPULATIONS. Explicit planning must occur at all levels for vulnerable 

populations including infants, children, the frail elderly, pregnant women, the disabled and the 

mentally ill, and those with chronic medical conditions (e.g., cardiac, dialysis, HIV, and 

oncology patients). Experience has demonstrated that without explicit planning, the needs of 

these populations will not be adequately met. For example, planners must consider pediatric 

issues, such as differences in physiology, anatomy, development, and emotions, that require 

appropriate planning and equipment. Planners must ensure that appropriate expertise is included 

for vulnerable populations and recognize the value of specialty caregivers. 

DEVELOP ROBUST SECURITY PLANS. Security is especially important in the case of a large-scale 

MCE due to the chaos and confusion such an event engenders. Having a uniformed presence 

(e.g., hospital security personnel, off-duty police officers, National Guard members, volunteers) 

helps maintain order as do clear identification tags; visiting rules; and procedures for accessing 

supplies, service sites, and patients. 

Clearly, the optimal allocation of scarce resources in response to an MCE is unlikely to occur 

without proper advance planning at the institutional, community, State, and Federal levels. 

Simply put, the goal of this document is to promote and assist in those planning efforts.

Organization of the Guide 

This planning guide is organized as follows: 

 Chapter II contains a discussion about the ETHICAL ISSUES that must be taken into 

consideration by planners. 

 Chapter III highlights the KEY LEGAL ISSUES that must be considered in developing a plan for 

responding to an MCE. 

Chapter I. Introduction 7 
 The succeeding three chapters (Chapters IV, V, and VI) examine the important issues, 

considerations, strategies, models and tools related to MCE planning at THREE DIFFERENT 

SITES/SETTINGS: PREHOSPITAL CARE, HOSPITAL AND ACUTE CARE SETTINGS, AND ALTERNATIVE 

CARE SITES.

 Chapter VII discusses the issues and approaches associated with providing PALLIATIVE CARE 

to the dying or individuals who are not expected to survive and offering support to the people 

who care for them during MCEs. 

 Finally, Chapter VIII pulls key issues and strategies from all of the previous chapters and 

summarizes them in the context of an INFLUENZA PANDEMIC CASE STUDY.

It is hoped that the information and material presented in this guide will enable community 

planners to prepare effective MCE response plans. 

Endnote 

1. Altered Standards of Care in Mass Casualty Events: Bioterrorism and Other Public Health Emergencies. AHRQ Publication 

No. 05-0043. Rockville, MD: Agency for Healthcare Research and Quality; April 2005, 16-18. Available at: 

http://www.ahrq.gov/research/altstand/index.html. Accessed November 27, 2006.

Chapter I. Introduction 8 
Chapter II. Ethical Considerations 

in Community Disaster Planning 

AUTHOR 

Marc Roberts, Ph.D., Professor of Economy, Department of Health Policy Management, Harvard University 

CONTRIBUTING AUTHOR 

Evan G. DeRenzo, Ph.D., Bioethicist, Center for Ethics, Washington Hospital Center, Washington, DC 

This chapter discusses the range of ethical issues that are critical to 

shaping any community’s disaster response planning as well as the 

implementation of those plans. The chapter explores what it means to 

plan for and act ethically in a disaster situation and underscores the 

importance of advanced planning for making choices that are 

ethically sound. 

Chapter II. Ethical Considerations in Community Disaster Planning 9 
Context for the Discussion 

We live in a world where a whole range of manmade and natural disasters (and cases that mix the 

two) are increasingly of concern to communities across America. Terrorism, epidemics, 

hurricanes, earthquakes, fires, floods – all of these are all too possible in an industrialized and 

interdependent world. Our settlements increasingly impinge on inherently risky terrain, such as 

over fault lines or on barrier islands. Ever-improving worldwide transportation and 

communication systems increase our vulnerability to those motivated by destructive ideologies. 

These same systems also make possible the “jet spread” of new infectious disease – as Toronto 

found out during the SARS outbreak. 

In such a world, serious and systematic disaster planning and preparedness at the community 

level is essential. If a disaster does occur, communities must be prepared for the possibility that 

government assistance may be delayed or may not arrive at all. Government agencies may be 

overstretched by multiple challenges or have their ability to function degraded by catastrophic 

events. 

Serious and systematic disaster planning 

and preparedness at the community level are 

absolutely essential. 

One reality is clear. Communities that have not planned and prepared for such an eventuality will 

be less well-equipped to face its complexities than communities that have. The noted political 

scientist Richard Neustadt once wrote, “Crises 

are a bad time to do planning. Only if plans are 

developed in advance, and then critiqued, 

rehearsed, and refined, will various agencies 

and actors be able to respond effectively to a 

disaster.” 

Once a planning process is undertaken, it will become clear almost immediately that serious 

ethical decisions are central to shaping any community’s disaster response. This will be true of 

both the planning phase and the implementation phase. At the planning phase, there will be 

innumerable issues, each with its own ethical components. Whom do we protect, and to what 

level of safety? How do we set budgets and priorities? Answers arrived at during the planning 

stage should be based on ethical analysis that can provide guidance during implementation even 

if the planned solutions must be altered in real time. Other issues include: 

 Who do we evacuate first? 

 How do we deal with those who do not want to cooperate? 

 When do we stop expending resources on rescue efforts and shift to recovery mode? 

The way these questions are answered reflects the ethical perspectives and moral analysis 

strategies of the planning group(s). 

Chapter II. Ethical Considerations in Community Disaster Planning 10 
We also need to expect that planning will be imperfect. Unexpected events will occur. 

Operational failures will develop. Those with field responsibility will have to make on-the-spot 

decisions that will require ethical judgments. For that reason, it is important that ethical 

considerations are made explicit during the planning process so that when on-the-spot decisions 

must be made they can be made consistent with the spirit of the ethical judgments that guided the 

planning process. 

Ethical Ideas as a Resource for Disaster Preparedness 

Human beings have been thinking and writing about ethics in general, disaster management in 

particular, and the application of ethical ideas to public policy for as long as we have been 

thinking and writing. Literally 5,000 years ago, the Egyptians struggled with their idea of maat – 

by which they meant the appropriate good order of society – and the role of the Pharaoh in 

preserving or restoring that when the annual Nile floods got out of hand. 

In the 19th century, various thinkers began to try to apply technical and scientific reasoning to 

public policy problems. French engineers argued that the value of a bridge across the Seine was 

what people would pay for it, even if they in fact paid nothing because the bridge was free. 

Florence Nightingale tried to convince the British government to improve medical care for 

wounded people in the Crimean War by showing that the cost of replacing a soldier was greater 

than the cost of saving one. These ideas found clear expression in the English philosopher 

Jeremy Bentham’s utilitarian claim that public policy should maximize the good across the 

greatest number. Utilitarian theory, or what is often referred to as consequentialist ethics, 

assesses what is right or good based on whether the consequences of the actions to be taken will 

be good. 

Another strand of thought, arising contemporaneously and in opposition to consequentialist 

ethics, is the duty-based ethical perspective. Advanced most notably by Immanuel Kant and 

referred to formally as deontology, duty-based ethics focuses on nonconsequentially based 

notions of good. In duty-based ethics, deciding what is right or good is based on meeting duties 

and obligations. 

Both theoretical perspectives have obvious applicability to planning for mass-casualty situations. 

Both have weaknesses, however, that need to be taken into account when either is invoked as a 

justification for proposed policy. Consequentialism suffers from two main weaknesses. First, it is 

difficult to predict consequences. Especially under emergency conditions, reality often looks 

little like what was expected. Second, in maximizing the good across the greatest number, the 

rights and welfare of the few can be ignored or, worse, trampled. Duty-based ethics provides a 

counterweight but one that is imperfect also. The main weaknesses of uncritical application of 

duty-based justifications are that duties and obligations are difficult to delineate and that even 

when they are delineated, invariably conflict. In planning for a mass disaster, for example, it will 

be difficult for communities to clarify the scope of obligations for the multiple players involved. 

Chapter II. Ethical Considerations in Community Disaster Planning 11 
Even where duties and responsibilities are clear, it is likely that persons and organizations will 

have conflicting duties, such as physicians to patients as well as to their own families. 

Nonetheless, applying these theoretical perspectives in systematic ways can address our 

contemporary concerns for upholding important ethical principles and values, such as fairness 

and equity, and for the role such principles and values play in disaster preparedness. Making 

explicit and transparent the ethical perspectives raised during the planning process can build 

commitment to any plan that is created. 

As this overview suggests, the ethical ideas that are widely shared in our culture are neither 

simple nor consistent. It is easy to invoke the notion of the greatest good, but attempting to 

maximize the good while providing universal assistance is a complex task indeed. That is, how 

do we incorporate the various appreciations of doing good into concrete policies in disaster 

preparedness planning? For example, do we measure “good” by lives saved or years of life 

saved? Our priority setting would be very different depending on how we answered that question. 

The same is true of concerns about “rights” and “fairness.” How much are we obligated to spend 

to save people from a flood who refuse to evacuate when told to do so? 

How do we balance maximum gain against fairness when these conflict? Such decisions need to 

be based on sound ethical judgment. All of this implies that using ethical ideas to guide disaster 

preparedness is a complicated business. The process will inevitably involve judgment and 

compromise. The broad ideas will have to be made applicable to specific contexts, refined, and 

defined in operational terms. And these realizations have important implications for what 

communities need to do, in both planning and implementing disaster plans, if they are to act in an 

ethically responsible manner. 

What Would It Mean to Plan for and Act Ethically in a Disaster 

Situation? 

The ethical obligations of the professionals in a community responsible for disaster planning and 

preparedness obviously begin well before any disaster actually occurs. The first of these has to 

do with what might be called “ethical preparedness.” We have noted the ambiguity and conflict 

inherent in some of the principal ethical norms that planners might want to invoke to guide their 

actions. This implies that waiting for a disaster to occur to face these challenges means waiting 

too long. We all know that buses or radios or vaccine stores cannot be conjured up at the last 

minute. By the same token, the reality of a catastrophic event will play out differently than could 

have been imagined so that tough choices will have to be made in the midst of crisis. Sound 

planning can take this expectation into account by providing ethical guidelines and principles for 

making tough choices in a real-time environment. 

Thus, it is advisable that the planning process anticipate judgments that will have to be made and 

then model making such judgments explicit and shared widely. Applying and practicing applying 

Chapter II. Ethical Considerations in Community Disaster Planning 12 
such transparency serves multiple purposes. First, like any other “strategy” or “mission” 

statement, being open about guiding ethical principles can be an important management tool. It 

can serve to coordinate activity and produce more consistent implementation when 

decisionmaking has to be decentralized to frontline workers and their supervisors. That often will 

be the case in a disaster situation. 

Transparency also serves the goal of accountability. Priority-setting judgments are not purely 

technical matters. In a democratic society, citizens have a right to know what decisions public 

institutions make on their behalf – especially when the stakes are high as in the life-or-death 

choices that a disaster can produce. Such public knowledge also serves to open the process to 

public feedback, criticism, and discussion. This can help professionals ensure that their plans 

reflect community values and concerns. 

Public discussion also serves the vital purpose that some have called “democratic education” or 

“civic capacity building.” Only when the public openly discusses and debates difficult choices 

does the capacity of community members to fulfill their roles as “citizens” become appropriately 

enhanced. We can expect the public to accept and support difficult choices in difficult times only 

if they have become knowledgeable about and committed to those choices beforehand and if they 

feel they have had some input into the process. Transparency is a prerequisite to such outcome. 

Transparency alone, however, will not suffice. The processes for making decisions themselves 

also have to meet their own ethical tests. Here, two ideas about democratic participation seem 

especially relevant. First is the need for the collaborative involvement of elected officials from 

all levels of government with local planners and citizens groups. Elections are, after all, the 

method democracies use to choose their leaders and, in the process, to resolve important value 

controversies. Different from the role of governmental agency officials is the equally important 

role of technical experts. Technical expertise is essential for clarifying options and being clear 

about alternatives. But what technical experts are expert about is the science: how influenza 

viruses are likely to mutate, the storm resistance of levees, or the atmosphere transport of 

radioactivity. They are not “moral experts.” When it comes to making ethical judgments under 

stressful and complex conditions in which diverse value perspectives must be harmonized, 

technical expertise confers no special moral importance during ethical discussions. For 

community commitment to congeal around a disaster preparedness plan that will include 

judgments about complex moral problems such as tradeoffs between cost-effectiveness and 

fairness or the relative importance of prioritizing attempts to save one population group before 

another, we rely on politics – the combined actions of those we elect, those who are appointed, 

and local citizens working together. 

Responsible elected leaders do need input, however, both on the science and on community 

values. Elected bodies (city councils, State legislatures) have their virtues and values in this 

regard. Further, there will be a role for more direct citizen participation. What is at issue here is 

an opportunity for discussion among a cross-section of community leaders, both those with a 

Chapter II. Ethical Considerations in Community Disaster Planning 13 
special competence and responsibility and those with an especially large stake in disaster 

planning decisions. Such a group can bring knowledge, sensitivity, and realism to the process 

that more general political bodies do not possess. 

It is vital to remember that all community-planning and participatory processes are subject to 

certain risks. One risk is that those groups with more resources or expertise will dominate. 

Another risk is that some will seek to hold up the process by refusing to cooperate unless their 

narrow demands are met. All this suggests a need for careful planning, effective outreach, 

impartial staff support, and other now-well-understood prerequisites if the right kind of 

discussion is to occur. 

The ethics of disaster planning apply not only to the process but also to the plan itself. In fact, 

almost all participants in the planning process face conflicting interests, if not frank conflicts of 

interest. Politicians seek political support, care-giving institutions want additional resources, and 

various first-responder agencies (State and local, police and fire) will maneuver for authority and 

leadership. The standard to which the resulting plan should be held is not that of meeting any one 

player’s interests. Rather, the standard should be whether it meets some broader ethical tests and 

concerns, as we discuss further below. 

Only a plan that transcends narrow interests will convince citizens that the public leadership 

entrusted with disaster preparedness is meeting its responsibilities. Those responsibilities include 

not just the exercise of technical 

“competence” but what the economist 

Kenneth Arrow called “conscience” while he 

was discussing clinical medicine, an 

argument that applies similarly here. A 

doctor or a disaster manager knows more 

than his or her patient or the at-risk public. As a consequence, the manager asks his or her experts 

to act as his or her “agents.” This means asking the expert to make decisions in keeping with the 

goals and values of the “principal” who retained them. And “conscience” is required when the 

agent has to disregard his or her own interests to fulfill the trust placed in the agent; for example, 

by not ordering an unnecessary test or by risking one's own life in a burning building. As 

Woodrow Wilson said about the treaty to end World War I, “open covenants openly arrived at” 

serve everybody’s interests. 

Only a plan that transcends narrow interests will 

convince citizens that the public leadership 

entrusted with disaster preparedness is meeting its 

responsibilities. 

Perhaps one of the most important roles of effective planning is to shape citizen expectations 

appropriately. When leaders are not realistic, the government’s performance fails to live up to 

expectations, and citizens’ trust in collective responses to community problems seriously erodes. 

Realistic plans and expectations, in contrast, can build public trust. The government then 

can meet those expectations, and a community’s belief in its own capacity is thereby enhanced. 

The resulting “social capital” (to use Robert Putnam’s phrase) is a valuable resource that 

communities surely will need if or when a real disaster does occur. 

Chapter II. Ethical Considerations in Community Disaster Planning 14 
Addressing the Ethical Aspects of Emergency Preparedness Planning 

When planning for emergencies, whether related to terrorism, epidemics, hurricanes, 

earthquakes, fires, floods or any other manmade or natural cause, the quality of the planning 

process will contribute markedly to the degree of preparedness and response success. Given that 

preparedness planning is complex and must involve all layers of public institutions and private 

citizenry, there will be disagreements about how best to organize, plan, and implement 

emergency response strategies. Any disagreement that arises will spring, in large part, from 

differences in ethical judgments. Explicit awareness that disagreement involves moral disputes is 

a requisite starting point for resolving ethical differences in ways acceptable to the needs of 

planners and citizens. 

It is critical that all parties appreciate that moral disagreement is not only inherent to the planning 

process but necessary for a sound outcome. In the event of an emergency, multiple institutions, 

agencies, and individual citizens will have to be committed to implementing the plan. There must 

be a spirit of cooperation. Prospects for such commitment and cooperation are strengthened 

when the various parties believe that the planning process has been conducted ethically. 

Acceptance of this point is required for an appropriate process to be created that allows for 

vigorous deliberation. A truly ethical planning process will be in place only through a process that 

builds in mechanisms for managing ethical disagreement and the deliberative conversations 

necessary to work through the disagreements. 

The first building block in addressing the ethical aspects of preparedness planning is creating 

planning groups that comfortably tolerate vigorous debate. Given that most persons and groups 

tend to avoid open conflict, the leaders of preparedness planning groups must have sufficient 

emotional strength and group dynamics leadership skills to competently surface the moral 

disagreements that will invariably exist across group members and then ride the waves of 

argumentation until a reasonable moral consensus is built. In so doing, provided that the group is 

sufficiently inclusive and their work transparent, the resultant plan can be expected to have solid 

commitment from those that group members represent. Even if there are particular group 

members who did not get everything they wanted, a well-argued agreement coming out of a 

seriously and thoughtfully deliberated ethical disagreement will garner the needed sense of 

fairness for future cooperation to be a reasonable expectation. 

Chapter II. Ethical Considerations in Community Disaster Planning 15 
A good plan also will minimize the need for 

tough choices by putting adequate resources 

and effective arrangements in place. 

A good disaster plan, however, does more than just explicitly confront tough choices. A good 

plan also will minimize the need for such choices by putting adequate resources and effective 

arrangements in place. In desperate situations, resources will indeed be overwhelmed. Moreover, 

resources are always scarce. Preparedness has to 

compete with schools and prisons and highways 

and environmental protection for limited public 

dollars. There never will be enough money to do 

everything, but the better the plan, the less 

wrenching and difficult it will be to carry out that plan when adverse events do occur. In that 

sense, disaster planners need to defend both their own interests and those of their communities 

through the planning process. 

Ethical Principle I: Focus on Consequences 

As noted previously, often the first ethical principle invoked in disaster situations is Bentham’s 

“greatest good for the greatest number,” which is commonly interpreted as requiring us to save 

the most lives, but again, the devil is in the details. Do we measure “good” by lives, years of life, 

or quality-adjusted years of life? If we use years of life, the young take precedent over the old. At 

any given age, the healthy would be saved before the sick and women before men – since the 

former has a longer life expectancy than the latter. 

Those who pursue a utilitarian approach to policy development define the “good” strictly in 

terms of maximization of benefits for the many. In the case of utilitarian economists, for 

example, most want to measure “good” subjectively – based on how people feel about various 

alternatives as expressed in their market choices. Thus, if someone prefers to remain in his or her 

home during a hurricane, some economists would say that that represented the “greatest good” 

for that individual. 

Public health specialists, engineers, and disaster managers who also have a philosophical 

preference for consequentialist analysis tend to focus on objective measures of the “good” of the 

“greatest number” – on lives saved or safety margins or probabilities. This contrast helps us 

understand what is at issue whenever someone asks, “Why can’t I build my house in a flood 

plain if I am willing to take the risk?” Disaster planners in this case are confronting someone 

who believes that decisions on what is good are best decentralized to the individual. One 

consequentialist way for disaster planners to proceed is to pick some metric of gain and then to 

design plans to produce maximum “expected value.” (For each possible choice, consider the 

weighted sum of the gains produced by each possible outcome – with the outcomes weighted by 

their probabilities. Then take the choice when that magnitude is greatest.) A considerable field of 

literature in areas like decision theory and operations research addresses the technical details of 

using this approach – on choosing metrics, assigning values, and estimating probabilities. 

Chapter II. Ethical Considerations in Community Disaster Planning 16 
Uncritically applying a utilitarian understanding to such values preferences, however, will not 

capture the breadth of ethical assumptions embedded in planning approaches to addressing this 

concrete prospect. Moreover, there are limits to the appeal of the impartial brutality of “the 

greatest good” approach – even in a disaster situation. Much real planning and decisionmaking 

revolves around other ethical ideas. We need to understand these as well to be better equipped to 

provide for effective disaster preparedness. 

Ethical Principle II: Focus on Duties and Obligations 

Utilitarianism is often not the only basis for much public policymaking. For example, our 

willingness to restrict, or not, individual choice both before and during a disaster can have a 

utilitarian justification but it is just as likely to be deeply influenced by duty-based concerns. The 

core idea here begins with the need to respect all human beings. Different writers root that 

respect in either a religious argument (the possession of an immortal soul) or a secular one (the 

human capacity for reasoned choice). Regardless of its origins, however, that respect is said to 

require us to treat every human being as “an end in themselves” (to use Kant’s famous phrase). 

This means we cannot sacrifice some for the sake of others – unless they volunteer. For example, 

economists argue for individual choice in part because they presume that each person’s decisions 

affect only themselves. Many disaster-related decisions, however, have what economists call 

“externalities” – they affect others beyond the decisionmaker. In particular, those who build in 

flood plains or refuse to follow evacuation orders may impose the cost of expensive search, 

rescue, and recovery efforts on the community. 

Deciding how and why to divert resources from some sector of community need to others should 

rest not only on predictions of what will produce the best outcome for the most persons but also 

should include considerations of how the resource distribution process will work to ensure that 

obligations citizens vest in their Federal, State, and local governments are met. This balance 

between utilitarian and duty-based assumptions is at work in our ethical considerations about 

allocating scarce influenza immunizations. A policy aimed at “lives” would give priority to the 

old and the sick, since they are most at risk from influenza. A policy aimed at “years of life” 

might be somewhat different – prioritizing the vulnerable young. A policy that took account of 

economic consequences would raise the priority of workers who mattered most in economic 

terms (too bad for the unemployed). The potential real-world outcomes of balancing and 

interweaving these two ethical perspectives are highlighted in thinking about influenza 

vaccination of health care providers. In a serious crisis, those health care workers who cared for 

influenza patients might get priority – on the grounds that each of them could save several other 

individuals through their care. If we were serious about such a rationale, however, cardiac 

surgeons and other subspecialists would be further down the queue because it might be reasoned 

that the obligation to provide primary care to our most vulnerable citizens comes before 

performing more resource-demanding procedures, regardless of the numbers in either group. 

Chapter II. Ethical Considerations in Community Disaster Planning 17 
In practice, our sense of humanitarian responsibility will not allow us to ignore “stay-behinds” or 

refuse rebuilding help to those whose houses have come to grief in a storm because of shared 

cultural understandings of obligations that governments have to citizens and that neighbors have 

to neighbors. 

Ethical Principle III: Rights and Fairness 

In addition to having any disaster preparedness planning process make explicit consequentialist 

and duty-based theoretical notions, refined understandings of what is meant by rights and 

fairness will be needed as well. Just as most decisions will include some mix of consequentialist 

and duty-based justifications, most decisions will include a complex of intertwined notions about 

rights and fairness. 

At least in Western philosophical traditions, “rights” refers to the belief that human beings have 

universal rights regardless of jurisdiction or other characteristics such as gender, ethnicity, or 

religious belief. Such rights are often defined by international and national laws and legislation. 

The difficulty for communities engaged in disaster preparedness planning is that one common 

criticism of rights thinking is that rather than being truly universal, or universalizable, it is prone 

to cultural relativity. For example, universal primary school education or health care insurance is 

considered by some nations a right of all their citizens. In other nations they are not seen as such. 

Laws and social programs, however, have boundaries while mass disasters do not. Moreover, 

rights and the perceived responsibility of an agency, organization, or individual will differ across 

State, national, and continental borders. The same problem arises in focusing on defining the 

concept of fairness. Nonetheless, preparedness planning groups will need to devote substantial 

effort in coming to at least their own definitions for these ethical principles if they are to devise 

plans to which the affected communities can commit. 

For example, the rights arguments have moved from just advocating the “negative” right to be 

left alone to concentrating more forcefully on a relatively expansive set of “positive” rights. 

These rights involve the expectation that the government will ensure everyone some minimum 

scope of opportunity for living a meaningful life. Indeed, most governments in industrial 

countries help their citizens – to varying degrees – with food, housing, education, and health care 

based on such arguments. And such efforts are often focused and financed in a way that is 

redistributive. Quite typically, upper-income groups cross-subsidize lower-income groups based 

on notions of “fairness” and “social responsibility” (or, in Europe, “solidarity”). 

These notions are almost certain to come into play when disaster planners face issues of priority 

setting. For example, any consideration of property values, in allocating resources, would dictate 

that less attention be paid to low-income neighborhoods. Yet, as Katrina demonstrated, it is 

likely to be poorer residents who have the fewest resources of their own and who therefore are 

most in need of public assistance. 

Chapter II. Ethical Considerations in Community Disaster Planning 18 
Once issues of fairness or equity are accepted as relevant, it is still necessary for community 

leaders to decide what fairness requires of them. One view (sometimes called “relative equity”) is 

that any difference in treatment (or in this case, say, of risk) is inherently unacceptable. An 

alternative perspective (termed “absolute equity”) requires governments to provide some 

minimum level of opportunity to all citizens. If that goal is achieved, then on this second view, 

the rich or talented can be allowed to have opportunities above the minimum level. 

In fact, disaster preparedness almost inevitably has to be concerned with “absolute” equity – with 

providing some minimum level of protection to all. Inevitably, those with stronger houses, 

houses on higher ground, or money for comfortable hotels out of town will do better than some 

of their fellow citizens. Thus, one of the questions planners will have to focus on is not whether 

any differences exist, but whether appropriately delineated obligations have been met for those 

segments of the population where such differences result in disproportionate harms. 

Of course, just what those obligations are will be a matter of much debate. Again, open 

processes, explicit decisions, transparent reporting, and political accountability – all of these 

become especially important when such difficult issues have to be decided. 

In a crisis, it well might be that the poorest 

communities are the ones most in need of help 

from a State’s National Guard assets, precisely 

because they have fewer of their own 

resources on which to rely. 

Here also is where the decentralized structure 

of disaster preparedness can become 

somewhat problematic. Poor jurisdictions are 

likely to have less in the way of equipment, 

personnel, and financial reserves than their 

more prosperous counterparts. Fairness in 

such cases may require that planners at the 

regional or State level take account of these realities when decisions are made about allocating 

resources from higher-level jurisdictions. For example, in a crisis, it well might be that the 

poorest communities are the ones most in need of help from a State’s National Guard assets, 

precisely because they have fewer of their own resources on which to rely. 

Ethical Principle IV – Respect Community Norms 

While consequences, duties, rights, and beliefs about what is fair often dominate discussions of 

public policy, these ideas do not exhaust the ethical considerations that are potentially relevant in 

such situations. In addition, there is the question of respecting the particular norms and values of 

a community. 

The ideas we have been considering so far are avowedly universalistic in their claims. Their 

proponents say they apply to everyone, everywhere. There are also ethical ideas that are 

particular to a given society and express the society’s particular sense of itself as a whole or of its 

separable communities. These, too, have a role to play in disaster preparedness. 

Chapter II. Ethical Considerations in Community Disaster Planning 19 
One of the most important areas in which such local norms apply is in our expectations of first 

responders and other disaster personnel. There are many examples of situations where rescue 

personnel put their own lives in danger on behalf of others or for the greater good of the 

community. The large number of police and fire casualties in New York on 9/11 testifies to the 

power of these ideals. 

Indeed, when disaster managers try to implement “greatest good” policies, often it is front-line 

personnel, imbued with professional pride and responsibility, who resist. Experienced senior 

firefighters will tell you that one of their most difficult tasks can be to get their people out of a 

compromised structure when that becomes the prudent course of action. 

On the other hand, some societies have high expectations of even unwilling disaster 

professionals. During the SARS epidemic in Hong Kong, doctors and nurses at the designated 

receiving hospital were quarantined inside the building (including some who were confined 

unwillingly). Several of the staff members of that hospital died in the epidemic. 

Another example of the power of the particularity of social ethical norms is revealed by the very 

high expenditure made post-Katrina on recovering and identifying those who died. While no 

comprehensive estimates have been made, informal calculations suggest figures in the range of 

$10,000 to $20,000 per recovered and identified body. Such expenditure is not easy to explain on 

either “greatest-good” or “positive-rights” principles, since only the living count in such 

analyses. 

Local norms also can affect recovery and rebuilding efforts. After the recent hurricanes, 

Mississippi and Louisiana have had to confront the question of whether their rules restricting 

gambling to off-shore locations should be maintained. There have been press reports that efforts 

to move some Mississippi shrimp boats back into the Gulf are being hampered by a reluctance to 

disturb a Native American burial ground. Again, where disaster planners and managers decide to 

respect (or not) local community values, obligations of transparency, explicitness, and 

accountability clearly apply. 

Chapter II. Ethical Considerations in Community Disaster Planning 20 
Ethics Analysis Algorithm: 

Applying a Systematic Approach to Sorting Through Ethical Disagreements

Debate about which ethical principles and theories to apply and how to prioritize them in a specific 

situation has been going on for millennia. As noted, there are no simple, formulaic schemes for such 

choices. There are, however, ways of thinking about ethical principles and theories that can help 

preparedness planners devise strategies for emergency response. These involve a systematic approach 

to applying basic ethical principles and theories to any particular situation. One can create an ethics 

algorithm that, if consistently applied to planning for any particular kind of emergency, at least can provide 

reasonable confidence that ethical issues raised by an emergency were well-considered. The ethics 

algorithm might be constructed as follows: 

Debate about which ethical principles and theories to apply and how to prioritize them in a specific 

situation has been going on for millennia. As noted, there are no simple, formulaic schemes for such 

choices. There are, however, ways of thinking about ethical principles and theories that can help 

preparedness planners devise strategies for emergency response. These involve a systematic approach 

to applying basic ethical principles and theories to any particular situation. One can create an ethics 

algorithm that, if consistently applied to planning for any particular kind of emergency, at least can provide 

reasonable confidence that ethical issues raised by an emergency were well-considered. The ethics 

algorithm might be constructed as follows: 

1. Who are all the possibly interested parties? Think broadly -- include not only persons and categories 

of persons but institutions/organizations/professions/communities. 

2. What is the full range of duties and obligations of each potentially interested party, or at least the 

primarily interested parties? Think of parties as not only individuals but also institutions and groups. 

2. What is the full range of duties and obligations of each potentially interested party, or at least the 

primarily interested parties? Think of parties as not only individuals but also institutions and groups. 

3. How might various duties and obligations of each of the various parties clash/conflict? 

4. What might be short-term and long-term consequences, both good and bad, of each possible course 

of action? How confident are you of your predictive accuracy? 

5. What ethical principles are at stake? (Possible ethical principles include respect for persons, 

beneficence, nonmalfeasance, justice, truth telling, liberty, opportunity, and reciprocity.) Which ones 

are in tension? 

5. What ethical principles are at stake? (Possible ethical principles include respect for persons, 

beneficence, nonmalfeasance, justice, truth telling, liberty, opportunity, and reciprocity.) Which ones 

are in tension? 

a. After enumerating the list of principles at stake, work to specify them; refine the meaning of each 

principle involved. Work to bring the broad abstractions down to the level of the specific situation 

being discussed. 

b. Make explicit the strategy for use of the principles. For example, for the situation at hand, must all 

the involved principles be upheld or is the strategy to balance the principles? If a balancing strategy is 

being applied, make explicit which values/ethical considerations are being balanced off and against 

which other values/ethical considerations. 

b. Make explicit the strategy for use of the principles. For example, for the situation at hand, must all 

the involved principles be upheld or is the strategy to balance the principles? If a balancing strategy is 

being applied, make explicit which values/ethical considerations are being balanced off and against 

which other values/ethical considerations. 

6. What might be the intentions of the various players? Evaluate the praiseworthiness or lack thereof, of 

the motives of the people, organizations, and/or institutions involved. 

7. What appears to be the full range of the possible courses of action? 

8. Weed out those possible courses of action that appear not to be justifiable based on potentially bad 

consequences, inability to meet duties and obligations, and/or the ethical soundness, or lack thereof, 

of intentions. 

8. Weed out those possible courses of action that appear not to be justifiable based on potentially bad 

consequences, inability to meet duties and obligations, and/or the ethical soundness, or lack thereof, 

of intentions. 

9. With the possible courses of action that are left, make explicit the justifications for taking each. Then 

vigorously scrutinize whether or not those justifications are ethically robust. 

The sequence in which the analysis called for in numbers 2 through 6 above is conducted may not 

appear to be of major importance. It is necessary, however, to be able to claim convincingly that all 

points have been thoughtfully considered and deliberated, with the discussions and decisions fully 

documented. 

Evan G. DeRenzo, Ph.D., Center for Ethics, Washington Hospital Center, Washington, DC.

Chapter II. Ethical Considerations in Community Disaster Planning 21 
Summary and Conclusions 

This review introduces some of the major, substantive, and competing ethical ideas that 

community disaster planners and managers are likely to find relevant to their efforts. At best, the 

review identifies some of those ideas in the broadest terms and sketches some of the more 

specific issues that each of these perspectives raises. How do you measure good? How far do you 

go to be fair? When are community norms to be respected or overridden? 

In so doing, we argue for making explicit a set of norms that need to apply to how the planning 

process is conducted (see box). 

The arguments for such a process are justifiable by both utilitarian and deontological ethical 

theories. On the deontological or duty-based side, respect for individual autonomy requires that 

citizens subject to the power of government be able to influence how that power is used and be 

protected from its misuse. That can occur through both general political structures and ad hoc 

participatory processes. If considerations of equity are to be respected, special efforts need to be 

made to ensure underresourced and underrepresented segments of the community have their say. 

Corporations and upper-middle-class citizen 

groups will appear at meetings and file comments, 

for example, but what about residents of public 

housing projects? 

What Do Ethics Tell Us About 

What Makes for a Good Process? 

Whether one comes to the planning process with a 

(perhaps unarticulated) philosophical or 

psychological preference for either a utilitarian or 

consequentialist perspective, broad participation and accountability have several potential 

benefits. Local residents may have knowledge and insight about local conditions. Businesses 

know well what resources they might contribute. Front-line disaster responders and their firstlevel supervisors will be painfully aware of gaps in their own training and equipment. 

Maximizing the good across the greatest number and meeting individual and organizational 

duties and obligations will take the contributions of the many. 

o Transparent ethical judgments that confront 

hard choices 

o Involvement and accountability for political 

leadership 

o Broad outreach to the community

Participation and transparency also will help educate citizens and prepare them both to 

participate in and to accept the implementation of plans when a disaster occurs. They will know 

what to do, and because they will have been involved, they will understand and therefore more 

readily will commit to the reasoning behind the plan. They will have more realistic expectations 

and thus will be more prepared both psychologically and practically. 

The process of democratic government, at its best, involves what political scientists call 

“deliberation.” In such conversations, both facts and values are explored, alternatives are 

examined, and meanings are clarified. When done well, deliberation not only produces good 

plans but also enhances a community’s capacity for self-government. Disaster planning offers a 

clear opportunity for advancing such goals. 

Chapter II. Ethical Considerations in Community Disaster Planning 22 
Finally, it is important to remember that in a disaster, difficult choices will have to be made, and 

that the better we plan, the more ethically sound will be the choices. There is no cookbook for 

combining conflicting ethical ideas. There is no “one-size-fits-all” method of priority setting, but 

community disaster planners need to see the opportunities as well as the difficulties that such a 

situation implies. There is room here for responsibility and choice, for ethical concern and 

technical excellence, for process skills and scientific expertise. It is surely worth doing and worth 

our best efforts to do it well. 

Practice Applying Ethical Principles to the Preparedness Planning Process 

Emergency preparedness planning is, or should be, an iterative process. When preparedness planning 

groups habituate themselves to the discipline of thorough ethical analysis, they become increasingly 

skilled at conducting vigorous moral deliberations. Life is full of emergencies, and public institutions 

responsible for emergency preparedness and response can use any emergency that occurs anywhere 

to increase their knowledge base for their ongoing planning efforts. An agency that is responsible for 

emergency response, for example, can take the opportunity of any emergency that has recently 

occurred to test its own ethical analysis skills. An agency can use a recent emergency as an exercise 

to see if its own preparedness planning process would have yielded similar or different ethical 

judgments about response strategies that could have been used. Such post hoc activities allow 

preparedness planning groups to practice the ethical analysis skills necessary to apply ethical 

principles and theories to the planning process meaningfully.

Chapter II. Ethical Considerations in Community Disaster Planning 23 
Chapter II. Ethical Considerations in Community Disaster Planning 24 
Chapter III. Assessing 

the Legal Environment Concerning 

Mass Casualty Event Planning 

and Response 

AUTHOR 

James G. Hodge, Jr., J.D., LL.M., Associate Professor, Johns Hopkins Bloomberg School of Public Health 

 Executive Director, Center for Law and the Public’s Health, Georgetown and Johns Hopkins Universities 

This chapter examines an array of legal issues involved in planning 

for mass casualty event (MCE) responses. The chapter discusses 

relevant laws and their potential impact on the ability of community 

planners to allocate resources when supplies are limited. Community 

planners are encouraged to partner with members of the State and 

local legal community to identify specific legal issues and solutions 

before and during an MCE. 

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 25 
Introduction 

Laws at all levels of government are a critical part of emergency responses and allocation 

decisions involving scarce resources in mass casualty events (MCEs). For the purposes of this 

chapter, scarce resources broadly include physical items (e.g., medical supplies, drugs, beds, 

equipment), services (e.g., medical treatments, nursing care, palliative care), and health care 

personnel (e.g., physicians, nurses, lab technicians, other essential workers in health care 

settings). Constitutional provisions, statutes, administrative regulations, cases, compacts, mutual 

aid agreements, and public health or emergency management policies or plans are each 

implicated in an assessment of the legal environment for MCE responses. 

This chapter discusses an array of legal issues concerning allocations of scarce resources 

organized through a series of major legal themes in emergency responses, including: 

 The changing legal landscape during emergencies. 

 Balancing individual and communal interests. 

 Suspending existing legal requirements. 

 Interjurisdictional legal coordination. 

 Medical licensure reciprocity. 

 Liability and other protections for healthcare workers and volunteers. 

 Property management and control. 

 Making allocation decisions in real time: legal triage. 

Within each of these themes are discussions of relevant laws and their potential impact (both 

positive and negative) on the ability of community health planners to allocate resources when 

supplies are limited. In some instances, distinctions between public- and private-sector entities 

are raised when relevant to the application of the law. 

The purpose of this chapter is to frame common legal issues that State and local community 

health planners may need to address. This chapter is not meant to provide specific legal advice 

in any jurisdiction. Legal advice on issues identified in this chapter is necessarily fact-specific 

and may vary depending on State or local law and the specific circumstances involved. 

Community planners are encouraged to work closely with their State Office of the Attorney 

General or local counsel to identify specific legal issues and solutions before and during MCEs. 

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 26 
The Changing Legal Landscape During Emergencies 

Since September 11, 2001, and the ensuing anthrax attacks, Federal, State, Tribal, and local 

governments have focused on crafting an appropriate legal environment for public health 

emergencies.2

 They assessed their emergency authorities and amended or enhanced their legal 

infrastructure where needed, a process that is still ongoing. The current legal framework for 

emergency responses presents differing standards for the declaration of an emergency and vests 

various powers at all levels of government. States or local governments may feature a 

comprehensive set of government powers arising from the declaration of a public health 

emergency.3 Other States predicate their emergency powers on the declaration of a general 

emergency or disaster, which may include any event that threatens the public’s health or 

safety.4 Some States allow for the dual declaration of public health emergencies and general 

emergencies, which can lead to legislative confusion and duplication of efforts that may detract 

from the implementation of efficient emergency management functions.5

 The Federal 

Government also has emergency declaration powers that operate independently or in 

conjunction with State and local emergency response efforts.6

 These emergency powers are 

summarized below. 

For community health planners, the importance of an emergency declaration at any level of 

government lies in its effect on their operations. Emergency declarations do more than 

announce a state of emergency in an affected local, State, Tribal, or national population; they 

essentially change the legal environment to facilitate emergency responses for the duration of 

the declaration.7

 By reshaping the legal landscape to effectuate emergency responses, multiple 

legal options arise that would not be possible in nonemergency events. 

PUBLIC HEALTH EMERGENCIES. Many State legislatures and health departments have amended 

State statutes and regulations to reflect modern principles of public health emergency 

preparedness based, in part, on the Model State Emergency Health Powers Act (MSEHPA) 

drafted in fall of 2001 by the Center for Law and the Public’s Health at Georgetown University 

and The Johns Hopkins University.8

 MSEHPA presents State and local governments with a 

template for reviewing existing emergency declaration laws and developing legislative or other 

regulatory reforms to facilitate an effective public health response.9

 While this chapter refers to 

MSEHPA to explain common provisions that are featured in many States’ emergency 

preparedness laws, MSEHPA is not law unless a State has enacted it. According to the Center, 

more than 35 States have enacted laws based in whole or part on MSEHPA since the Act’s 

completion.10 These laws vary across jurisdictions and may be interpreted differently depending 

on a host of factors. 

The Act sets a high threshold for what may constitute a public health emergency, defined as: 

“an occurrence or imminent threat of an illness or health condition that (1) is believed to be 

caused by any of the following: (i) bioterrorism (ii) the appearance of a novel or previously 

controlled or eradicated infectious agent or biological toxin (iii)[a natural disaster], and (iv) [a 

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 27 
chemical attack or accidental release] or (v)[a nuclear attack or accident]; and (2) poses a 

high probability of any of the following harms: (i) a large number of deaths in the affected 

population, (ii) a large number of serious or long-term disabilities in the affected population, or 

(iii) widespread exposure to an infectious or toxic agent that poses a significant risk for 

substantial future harm to a large number of people in the affected population.”11

Once a state of public health emergency has been declared, MSEHPA grants State and local 

public health agencies (and their public and private sector partners) a number of extraordinary 

public health powers.12 This includes the ability to waive State professional licensing and 

certification requirements for volunteer health professionals participating in emergency 

response efforts,13 14 liability protections for medical personnel, and expedited procedures to 

acquire essential supplies and personnel.15 These powers are discussed further throughout the 

themes below. 

GENERAL EMERGENCIES AND DISASTERS. Although many jurisdictions do not define public health 

emergency or a like term, every State and many local governments have developed a legal 

structure for declaring a general emergency or disaster and related emergency management 

functions. A state of emergency or disaster typically may be declared in response to any natural 

or manmade event or occurrence that threatens the public’s health or safety. The processes in 

many States or local governments for declaring a general emergency or state of disaster 

resemble those for declaring a public health emergency through MSEHPA. Thus, a figure with 

significant political accountability (e.g., Governor, State health commissioner, local mayor, 

county commissioner) is vested with responsibility for declaring an emergency under specific or 

more generalized standards, depending on the laws in the jurisdiction.16

DUAL DECLARATIONS. Community health planners must be prepared to respond to emergencies 

under a new legal framework consistent with a state of emergency, disaster, or public health 

emergency. Assessing responses can be complicated, however, particularly when jurisdictions 

issue conflicting declarations of emergency. For example, as occurred in Louisiana in responses 

to Hurricane Katrina in 2005, a State governor may declare a general state of emergency 

initially (because the standard for such a declaration is often broader) and declare a public 

health emergency later as specific facts unfold. Two major problems arise from dual 

declarations: (1) the flow of specific powers and protections from emergency declarations vary 

depending on the type of declaration, and (2) responsibility and authority for emergency 

responses may become convoluted when differing State or local agencies are legislatively 

assigned to coordinate responses.17 In some States, public health authorities are responsible for 

managing a public health emergency while public safety or emergency management authorities 

handle general emergencies.18 Although advance emergency planning at State and local levels 

may limit potential conflicts, murky issues of governmental responsibility and authority can 

cloud key decisions in allocating scarce resources. 

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 28 
FEDERAL DECLARATIONS. The Federal Government also has the power to declare an emergency 

or disaster. The President may declare a national emergency pursuant to the National 

Emergencies Act of 1976.19 The Robert T. Stafford Disaster Relief and Emergency Assistance 

Act (Stafford Act)20 also grants presidential declarations of an emergency or major disaster and 

vests the President with various powers to coordinate and implement disaster response 

assistance measures. The President may authorize emergency assistance “to save lives and to 

protect property and public health and safety, or to lessen or avert the threat of a catastrophe in 

any part of the United States” at the request of a State governor or when the emergency is 

primarily a Federal responsibility.21 Under the Stafford Act, depending on whether the event is 

an emergency or a major disaster, the Federal Government has differing powers to assist in 

response efforts.22 For example, Federal disaster assistance is only available on the request of 

the State Governor for major disasters, including natural catastrophes, fires, floods, or 

explosions, “of such severity and magnitude that effective response is beyond the capabilities of 

the State and the affected local governments....”23 

24 In addition, pursuant to the Public Health Service Act, the HHS Secretary is authorized to 

declare a public health emergency.25 This declaration authorizes a host of Federal actions. At 

any time, the Health and Human Services (HHS) Secretary may deploy members of the Public 

Health Service or intermittent disaster response personnel to assist in meeting surge capacity in 

health care facilities nationwide. 

Balancing Individual and Communal Interests 

An important theme in emergency responses for community health planners making critical 

decisions concerning allocations of scarce resources is the balance between individual and 

communal interests. Emergency laws can support these decisions, particularly when communal 

interests are at stake in public health emergencies. Other legal requirements, however, also may 

impact these decisions. Constitutional principles may limit how the government may allocate 

resources. For example, allocation decisions that (1) are based on unwarranted discrimination 

against protected classes (e.g., race, ethnicity, national origin, religion, sex), (2) lack any 

meaningful justification, or (3) deny individuals any opportunity to be heard may violate 

constitutional principles of equal protection and due process or corresponding civil rights 

statutes. Legal causes of action to stop the enforcement of these decisions may be brought even 

during emergencies. 

26 Disability laws, such as the Americans with Disabilities Act (ADA) or State or local 

equivalents, may require certain protections for persons with disabilities during emergencies. 

Some States and some localities bar discrimination under much broader “human rights” laws.27

State and local governments legally may require the prioritization of their own workforce over 

the general population concerning specific medical interventions to ensure the stability of 

government and continued efforts to protect the public’s health. Similar decisions by health care 

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 29 
entities to protect their essential personnel when resources are scarce also may be legally 

supportable.28

Federal or State agencies may prescribe specific laws or guidance concerning the prioritization 

of vulnerable populations in making decisions involving distribution of scarce resources. For 

example, during the 2004–2005 influenza season, flu vaccines ran short because of 

manufacturing problems with a major supplier. The Centers for Disease Control and Prevention 

(CDC) issued guidance concerning distributions of available vaccine that prioritize infants, the 

elderly, and pregnant women. Many States legally incorporated CDC guidance into their own 

State allocation decisions.29 These types of legal actions prior to and during emergencies 

demonstrate how laws can facilitate allocation decisions (literally by dictating a specific 

outcome), but also how they may interfere with local decisions of community health planners 

(who may not agree always with lawmakers and policymakers concerning specific allocations). 

Suspension of Existing Legal Requirements 

One facet of declared states of emergency that is designed to facilitate response efforts is the 

ability of government to suspend specific legal requirements temporarily that would apply in 

nonemergencies otherwise. During a state of public health emergency pursuant to MSEHPA, for 

example, the governor may suspend the provisions of any regulatory statute prescribing 

procedures for conducting State business, or the orders, rules and regulations of any State 

agency, to the extent that strict compliance with the same would prevent, hinder, or delay 

necessary action (including emergency purchases) by the public health authority to respond to 

the public health emergency, or increase the health threat to the population.30

Similar statements allowing suspensions of existing provisions of law (except constitutional 

norms) exist in most Federal, State, and local emergency laws. Their use during an emergency 

can affect allocation decisions profoundly. 

Interjurisdictional Legal Coordination 

Emergencies tend to tax the existing capacities of governments and health care entities quickly 

in any locality, necessitating additional resources. Emergency responses require moving people 

and property between jurisdictions efficiently. Difficult legal questions arise. When can 

personnel or property be transferred between jurisdictions at the same or different levels of 

government during an emergency? Can States seize existing resources from counties or other 

municipalities? When must community health planners relinquish control or decisionmaking 

over specific resources? Does liability arise from the sharing of resources across boundaries? 

These and other interjurisdictional legal concerns require coordination of activities and 

resources across local, State, and Federal boundaries before, during, and after emergencies. The 

Center for Law and the Public’s Health has developed a Public Health Emergency Legal 

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 30 
Preparedness Checklist on Interjurisdictional Legal Coordination to help community health 

planners and others work through these issues.31 As explained in the Checklist, 

interjurisdictional coordination may arise horizontally between similar jurisdictions (e.g., 

between adjacent counties) or vertically between different jurisdictions (e.g., between local and 

State, local and Federal, and State and Federal governments). Though complicated by 

contrasting Federal, State, and local laws, several legal tools may facilitate interjurisdictional 

exchanges of resources. 

As noted in the sections above, emergency declarations may authorize interjurisdictional 

coordination efforts or suspend laws that may interfere with such coordination during the 

emergency. Formal mutual aid agreements between States (e.g., the Emergency Management 

Assistance Compact [EMAC32]), local governments (e.g., Illinois Public Health Mutual Aid 

System Agreement33), and foreign countries (e.g., International Emergency Management 

Assistance Compact between several New England States and Canadian provinces34) facilitate 

many exchanges of resources in real time during emergencies under specific conditions and 

protocols. Compacts like the Mid-America Alliance Mutual Assistance for Public Health 

Preparedness (among 10 Midwestern States)35 authorize resource exchanges in exigent 

circumstances that do not require an emergency declaration. 

Medical Licensure Reciprocity 

Acquiring or exchanging property during emergencies to replenish dwindling supplies is one 

thing; the legality of acquiring additional medical personnel or others to meet patient surge 

capacity is another. During MCEs involving Federal or State declarations of emergency, the 

potential for significant losses of existing health care personnel coupled with hundreds or 

thousands of new patients presents an immediate need for additional trained health care 

providers.36 These may come from other in-State facilities or through out-of-State places. 

During Hurricane Katrina, thousands of volunteer health personnel (VHPs) streamed to the 

affected Gulf Coast States to provide assistance.37 Many of these volunteers came through 

coordinated governmental programs (e.g., State-based Emergency Systems for the Advance 

Registration of VHPs, local Medical Reserve Corps units) or private-sector efforts (e.g., 

American Red Cross, Salvation Army, hospital systems).38 In addition, HHS hired certain 

VHPs as temporary, uncompensated employees.39 

In nonemergencies, licensed non-Federal practitioners in one State cannot practice medicine or 

public health services in another State, absent applied waivers of State licensure requirements or 

other exceptional circumstances (e.g., Good Samaritan provisions). Federal health care 

providers need only to be licensed in one State to perform their official duties in any State. 

During emergencies, States have created several legal approaches to circumvent normal 

licensing requirements for VHPs. Some States provide waivers of professional licensure 

requirements during declared emergencies. Licensure reciprocity also may be promulgated via 

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 31 
40 executive order or invoked pursuant to interstate agreements, such as EMAC. These 

provisions allow volunteer health providers to practice for the duration of the emergency as if 

they were licensed in the jurisdiction, subject to restrictions on the scope of practice set forth by 

the State or political subdivision. 

Though the paths to recognizing a VHP’s out-of-State license are many, each is tied to specific 

legal interventions. For example, VHPs who are deployed via EMAC automatically qualify for 

licensure reciprocity. Others may have to rely on whether the host jurisdiction has invoked 

licensure reciprocity through emergency declarations or other legal routes. Medical practitioners 

with needed skills still may be rejected because their license to practice is conditional or 

nonactive (e.g., the practitioner may be retired from medical practice) or they fail to meet 

emergency credentialing or privileging standards. Licensure reciprocity provisions must be 

clearly communicated during emergencies to ensure that VHPs are available to participate in 

emergency response efforts. 

Beyond VHPs, patient family members, neighbors, or others within the community may be 

needed to provide palliative or other medical care or offer essential support for medical 

personnel. While a State-based declaration of an emergency typically does not authorize 

nonmedically trained individuals to engage in systematic medical care of patients, their 

supervised participation in the care of relatives or companions is essential. Just as in 

nonemergencies, such activities are legally warranted in many cases. Persons lacking medical 

training also may provide key support services in the delivery of medical care to patients 

without legal impediments, provided that they do not actually treat patients. Screening patients 

through the administration of basic services by nonmedical personnel is legally permissible 

during emergencies; diagnosing patients, deciding their treatment, or prescribing their 

medications is not, pursuant to a host of Federal, State, and local laws. 

Liability and Other Protections for Health Care Workers and 

Volunteers 

One of the premier concerns of health care workers and VHPs, as well as the health care entities 

that host them, is their risk for civil liability for negligent or intentional actions that may result 

in harm to patients during emergencies. The uncertainties of emergency environments, the need 

to work within standards appropriate to the situation,41 and the unpredictability of harms to 

some patients (especially during emergencies) raise liability fears. Still, there may be some 

liability protections for these actors depending on the circumstances. Immunity from civil 

liability for harms to patients may be available through multiple legal sources, including (1) 

governmental sovereign immunity (if the worker or volunteer is a government employee or 

agent),42 43 44 (2) Federal and State volunteer protection acts, (3) Good Samaritan statutes, (4) 

State emergency health powers statutes, and (5) mutual aid compacts such as EMAC.45 For 

example, State officers or employees providing aid via EMAC during emergencies are protected 

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 32 
from civil liability as agents of the requesting State so long as they act in good faith and without 

“willful misconduct, gross negligence, or recklessness.”46 

Despite significant protections for individual actors, fewer liability protections exist for the 

entities (e.g., private hospitals, medical clinics) that respond to emergencies. The Federal 

Volunteer Protection Act of 1997, for example, provides immunity for volunteers of nonprofit 

entities but not for the entities themselves.59 Other State laws mimic this approach. As a result, 

hospitals and other health care entities are open to more potential liability for their acts (or 

failures to act) during an emergency.47 An emerging State model law (e.g., the Uniform 

Emergency Volunteer Healthcare Services Act) provides some liability protections for entities 

coordinating or hosting VHPs.48

A different type of harm for which liability may arise involves the workers or volunteers 

themselves. Under what circumstances may government or the private sector compensate these 

individuals for the injuries (e.g., physical or mental) incurred in responding to the emergency? 

In the employment context, workers are often protected from these harms through worker’s 

compensation programs that cover individuals injured or killed at work.49 The cause or fault of 

the employee is not a factor; worker’s compensation pays regardless. These benefits typically 

cover public- and private-sector employees during emergencies, but what about VHPs? 

Volunteers are not typically viewed as employees and thus do not benefit automatically from 

worker’s compensation coverage. 

There are legal solutions to this dilemma. For example, volunteers deployed as Federal or State 

agents may be covered by governmental workers compensation plans. VHPs deployed through 

EMAC are automatically eligible for State workers compensation benefits. Some States, like 

Michigan, have legally extended their workers compensation programs to registered VHPs 

providing services in the State during an emergency.50 Some employers as well have worked 

out contractual agreements with their workers’ compensation carriers to continue to cover 

employees who volunteer to respond to an emergency outside the employment setting. 

Property Management and Control 

At the core of resource allocation issues involving nonpersonnel is the need to manage and 

control public and private property. This includes real property (e.g., land, buildings, 

establishments) and personal property (e.g., medical supplies, drugs, beds). 

As part of their day-to-day legal power to abate public health nuisances, public health 

authorities are able to condemn, remove, or destroy any property (public or private) that may 

harm the public’s health.51 For example, if a private office building is contaminated with 

anthrax spores (as happened in Florida in fall 2001), State or local governments may require the 

facility to be shut down until it is safe for human occupancy. Of course, the power to abate 

public nuisances exists during emergencies as well. 

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 33 
Uses of real or personal property by State or local government or the private sector during 

emergencies depend on the type of emergency declared. Some common legal premises, 

however, permeate most declared states of emergency. Emergency management officials or 

public health authorities may designate public property instantly (e.g., State or local government 

buildings) for emergency uses and require an inventory and reallocation of available supplies. 

State or local governmental authorities are also empowered to seize private property for public 

use that is reasonable and necessary to respond to the emergency. This includes the ability to 

use and take temporary control of certain private-sector businesses and activities that are of 

critical importance to emergency responses. 

During a public health emergency pursuant to MSEHPA, for example, a State department of 

health may designate a private facility (e.g., hotel, convention hall, private meeting place) to 

serve as a clinic for vaccination or other public health services. Similarly, health care facilities 

may be governmentally controlled to treat patients, although governments typically seek to 

partner with (and not commandeer) such facilities. Privately held medical supplies may be 

acquired quickly via the government to meet its own needs or the needs of the population.52

Whenever governmental authorities take private property to use for public health purposes, 

constitutional law requires that the property owner be provided just compensation.53 That is, the 

government must compensate the owner of any facilities or materials temporarily or 

permanently procured for public use during an emergency. Most emergency laws require 

payment not instantaneously but rather at some point after the state of emergency has rescinded. 

When public health authorities must condemn and destroy any private property that poses a 

danger to the public, however, no compensation to the property owners is constitutionally 

required. 

Other permissible property control measures include restricting certain commercial transactions 

and practices such as price gouging to address problems arising from the scarcity of resources. 

MSEHPA specifically allows public health officials to regulate the distribution of scarce health 

care supplies and control the price of critical items during an emergency.54 In addition, public 

health authorities may seek the assistance of health care providers to perform medical 

examination and testing services. Maryland emergency laws actually compel health care 

workers to provide medical services (although this legal approach is not common).55

These legal interventions can be a double-edged sword for community health planners. Laws 

may help community health planners meet critical resource needs by making available essential 

supplies or personnel or prohibiting price gouging but also may require planners to share their 

own resources in the interests of protecting the public’s health. Standards for making critical 

choices in allocating scarce resources will help community health planners and their Federal, 

State, or other partners make guided decisions that work to the benefit of the community. 

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 34 
Making Allocation Decisions in Real Time: Legal Triage 

Laws can help (and hinder) community health planners’ decisions concerning the allocation of 

scarce resources. A key question is how to use the law as a positive tool during an emergency. 

One of the fundamental observations discussed in this chapter is the extent to which the legal 

landscape changes during emergencies. Normal processes, rules, and regulations may not apply 

fully. Expedited uses of public health or other governmental powers coincide with community 

health planners’ need to make decisions in real time. Assessing the legality of specific choices 

(even when protections or requirements are neatly spelled out in emergency law) is difficult 

when the legal environment itself is changing.56 The potential for some planners to act without 

significant regard for the legal ramifications or, conversely, to fail to act because of their legal 

apprehension sustains the need for advance consideration of the legal consequences. 

Community health planners must align with their local legal community to clarify emergency 

legal issues in their jurisdictions. Addressing legal issues that underlie the allocation of scarce 

resources is an essential part of emergency plans. Begin with a series of legal questions that 

have been uniformly answered in prior emergencies. Does local government have sufficient 

home rule to declare an emergency? If so, under what authority? What types of emergencies can 

be declared? What powers flow from the declaration? What nonemergency legal provisions may 

be suspended? Additional questions may be derived from the checklist, Local Government 

Public Health Emergency Legal Preparedness and Response, developed by the Center for Law 

and the Public’s Health.57

CHECKLIST FOR PLANNERS

A useful checklist on local government public health emergency legal preparedness and response is 

available at http://www.publichealthlaw.net/Resources/BTlaw.htm. 

Tougher questions should be specified and addressed. What emergency provisions directly 

impact the allocation of scarce resources? Who is legally responsible for making critical 

decisions at the State or local level? How much authority will a particular entity be given to 

make critical choices? When can the government challenge that entity’s decisions? When is that 

entity, its employees, or its volunteers legally accountable for these decisions? 

Advance planning and issue identification are essential, but they alone are not enough. Just as 

medical personnel must triage patients according to need during emergencies, legal practitioners 

in the public and private sectors must be prepared to prioritize relevant legal issues in real time. 

Legal triage refers to the efforts of legal actors to construct a favorable legal environment 

during emergencies through a prioritization of issues and solutions that facilitate legitimate 

public health responses and allocation decisions.58 

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 35 
Community health planners should partner with members of the local legal community who are 

prepared during emergencies to (1) identify legal issues that may facilitate or impede allocation 

decisions as they arise; (2) monitor changing legal norms during emergencies; (3) communicate 

with lawmakers and policy officials in government and the private sector; (4) develop 

innovative, responsive legal solutions to reported barriers to allocation decisions; (5) explain 

legal conclusions through tailored communications to planners and affected persons; and (6) 

revisit consistently the utility and efficacy of legal guidance related to allocation decisions. 

Only through the skilled, knowledgeable, and coordinated efforts of legal practitioners and 

community health planners via legal triage during emergencies can some allocation decisions be 

made with legal confidence. 

Endnotes

Hodge JG Jr. Bioterrorism law and policy: critical choices in public health. Journal of Law, Medicine, & Ethics. 2002;30:254-255. 2 

3Center for Law and the Public’s Health. Model State Emergency Health Powers Act (MSEHPA) art. V-VI 2001. Available at: 

http://www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf. Accessed April 15, 2006. 

4 Center for Law and the Public’s Health, Health Resources and Services Agency. Emergency System for Advance Registration 

of Volunteer Health Professionals (ESAR-VHP) – Legal and Regulatory Issues. 2006:23. 

5 Ibid. 2006:25-26. 

6 University of Maryland Center for Health and Homeland Security. Maryland Public Health Emergency Preparedness Legal 

Handbook. 2005:31. 

7 Hodge JG Jr. Legal triage during public health emergencies and disasters. Administrative Law Review. In press.

8 Center for Law and the Public’s Health. Model State Emergency Health Powers Act (MSEHPA) art. V-VI (2001). Available at: 

http://www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf. Accessed April 15, 2006. 

9 Gostin LO, Sapsin JW, Teret SP, Burris S, Mair JS, Hodge JG Jr., Vernick JS. The Model State Emergency Health Powers Act: 

planning for and response to bioterrorism and naturally occurring infectious diseases. JAMA. 2002;288:622. 

10 As of July 15, 2006, MSEHPA has been introduced in whole or part through bills or resolutions in 44 States, the District of 

Columbia, and the Northern Mariana Islands. Thirty-eight (38) States and the District of Columbia have passed bills or 

resolutions that include provisions from or closely related to the Act. For more information, see Center for Law and the Public’s 

Health. MSEHPA State Legislative Activity Table. July 15, 2006. Available at: http://www.publichealthlaw.net/MSEHPA/MSEHPA 

%20Leg%20Activity.pdf. Accessed November 27, 2006. Center for Law and the Public’s Health. MSEHPA Legislative 

Surveillance Table, July 15, 2006. Available at: http://www.publichealthlaw.net/MSEHPA/MSEHPA%20Surveillance.pdf. 

Accessed November 27, 2006. 

11 Center for Law and the Public’s Health. Model State Emergency Health Powers Act (MSEHPA). § 104(m). Proposed Draft for 

Discussion 2001. Available at: http://www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf. Accessed April 15, 2006. Italicized 

language indicates optional language for consideration by States. 

12 Gostin LO, Sapsin JW, Teret SP, Burris S, Mair JS, Hodge JG Jr, Vernick JS. The Model State Emergency Health Powers Act: 

planning for and response to bioterrorism and naturally occurring infectious diseases. JAMA. 2002;288:622. 

 Center for Law and the Public’s Health. Model State Emergency Health Powers Act. § 608 (2001). Available at: 13

http://www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf. Accessed April 15, 2006. 

 Ibid. § 804 (2001). 14

 Ibid. §§ 505-507 (2001). 15

16 Hodge JG Jr, Gable LA, Calves S. The legal framework for meeting surge capacity through the use of volunteer health 

professionals during public health emergencies and other disasters. Journal of Contemporary Health Law and Policy. 2006;22:5-

71. 

 Ibid. 17

18 Hodge JG Jr. Delaware Public Health Emergency Law - Review, Recommendations, and a Blueprint for Reform. Dover, DE: 

Delaware Department of Health and Social Services; 2004;1-62. 

19 50 U.S.C. §§ 1601(b) (2006). 

 The Robert T. Stafford Disaster Relief and Emergency Assistance Act, 42 U.S.C. §§ 5121-5206 (2002). 20

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 36 
 

 Ibid. §§ 5122(1), 5191 (2002). 21

 Ibid. §§ 5120-5206 (2002). 22

23 Ibid. §§ 5170, 5191 (2002) (requiring that, prior to requesting Federal assistance from the President, the State Governor must

utilize State resources to respond to the emergency, including the activation of the State emergency management plan). 

24 Public Health Service Act, 42 U.S.C. § 201 et seq. (2006). 

 Public Health Security and Bioterrorism Preparedness and Response Act of 2002, 42 U.S.C. § 247d. 2003. 25

 The Americans with Disabilities Act of 1990. Pub. L. No. 101-336. 26

 The New York “Human Rights Law,” New York Executive Law Art. 15 §290 et seq. 27

28 Hodge JG Jr. Bioterrorism law and policy: critical choices in public health. Journal of Law, Medicine & Ethics. 2002;30:254-

255. 

29 Hodge JG Jr, O’Connell J. The legal environment underlying influenza vaccine allocation and distribution strategies. Journal of 

Public Health Management and Practice. 2006;12(4):340-348. 

 Center for Law and the Public’s Health. Model State Emergency Health Powers Act § 403(a)(1) (2001). Available at: 30

http://www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf. Accessed April 15, 2006. 

31 Center for Law and the Public’s Health. Public health emergency legal preparedness checklist on interjurisdictional legal 

coordination. 2004. Available at: http://www.publichealthlaw.net/Resources/BTlaw.htm. Accessed November 27, 2006. 

 Emergency Management Assistance Compact (EMAC), Pub. L. No. 104-321. 32

33 Intergovernmental Mutual Aid Agreement for the establishment of the Illinois Public Health Mutual Aid System. 

Available at: http://www.idph.state.il.us/local/mutualaidagree_9.30.04.pdf. Accessed November 27, 2006. 

34 Fox P. Cross-border assistance in emergencies: the New England/eastern Canadian model. New England Journal of 

International Contemporary Law. 2004;11:75. 

 Mid-America Alliance: Mutual Assistance for Public Health Preparedness (2005). Available at: 35

http://app1.unmc.edu/midameria. Accessed November 27, 2006. 

36 Hodge JG Jr. Legal issues concerning volunteer health professionals and the hurricane-related emergencies in the Gulf Coast 

region. Public Health Report. 2006;121:205-207. 

 The White House. The Federal Response to Hurricane Katrina: Lessons Learned. 2006:58. Available at: 37

http://www.whitehouse.gov/reports/katrina-lessons-learned/ 2006:58. Accessed November 27, 2006. 

38 Hodge JG Jr. Legal issues concerning volunteer health professionals and the hurricane-related emergencies in the Gulf Coast 

region. Public Health Report. 2006;121:205-207. 

 Ibid. 39

 Emergency Management Assistance Compact (EMAC), Pub. L. No. 104-321, art. V, 100 Stat. 3877, 3880. 1996. 40

41 Agency for Healthcare Research and Quality. Altered Standards of Care in Mass Casualty Events., AHRQ Publication No. 05-

0043. April 2005. Available at: http://www.ahrq.gov/research/altstand/. Accessed November 27, 2007. 

 42 U.S.C. § 5148 (2000). 42

43 Federal Volunteer Protection Act of 1997. Pub. L. No. 105-19, § 4, 111 Stat. 218, 219 (1997), 42 U.S.C. § 14503 (2000); Ala. 

Code. § 6-5-336(d)(1) (LexisNexis 2005); Miss. Code Ann. § 95-9-1(3) (LexisNexis 1972). 

 Massachusetts General Laws Annals. ch. 112, § 12B, ch. 111C, § 20 (West 2003). 44

 Emergency Management Assistance Compact (EMAC), Pub. L. No. 104-321. 45

 Emergency Management Assistance Compact (EMAC), Pub. L. No. 104-321, art. VI, 100 Stat. at 3880. 46

47 Hodge JG Jr, Calves S, Gable LA, Meltzer E, Kraner S. Risk management in the wake of hurricanes and other disasters: 

Hospital civil liability arising from the use of volunteer health professionals during emergencies. Michigan State University Journal 

of Medicine and Law. In press. 

 The Uniform Emergency Healthcare Services Act § 7(c). In press. 48

49 Hodge JG Jr. The intersection of Federal health information privacy and State administrative law: the protection of individual

health data and worker’s compensation. Administrative Law Review. 1999;51:117-144. 

 M.C.L. §§ 418.161(g), 30.411 Sec. 11(1)(b)-(c). 50

 Gostin LO. Public Health Law: Power, Duty, Restraint. Berkeley: University of California Press; 2002:263-265. 51

52 Gostin, LO, Hodge JG Jr. The Model State Emergency Health Powers Act – A Brief Commentary. Seattle: Turning Point 

Statute Modernization Collaborative, 2002; 1-42. Available at: 

http://www.publichealthlaw.net/Resources/Modellaws.htm#MSEHPA. Accessed November 27, 2006. 

 Gostin LO. Public Health Law: Power, Duty, Restraint. Berkeley: University of California Press; 2002:265. 53

 Center for Law and the Public’s Health. Model State Emergency Health Powers Act §§ 505-507 (2001), Available at: 54

http://www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf. Accessed April 15, 2006. 

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 37 
 

 Md. Code Ann., Public Safety §§ 14-3A-03(c), 14-3A-08 (Supp. 2004). 55

 Hodge JG Jr. Legal triage during public health emergencies and disasters. Administrative Law Review. In press. 56

57 Center for Law and the Public’s Health. Checklist on local government public health emergency legal preparedness and 

response. Available at: http://www.publichealthlaw.net/Resources/BTlaw.htm. Accessed November 27, 2006. 

 Hodge JG Jr. Legal triage during public health emergencies and disasters. Administrative Law Review. In press. 58

Chapter III. Assessing the Legal Environment Concerning Mass Casualty Event Planning and Response 38 
Chapter IV. Prehospital Care 

AUTHORS 

Edward Gabriel, M.P.A., AEMT-P, Lead Author, Director of Crisis Management, Walt Disney Corporation 

Peter Pons, M.D., Professor of Emergency Medicine, Department of Surgery, University of Colorado Health Sciences Center 

George Foltin, M.D., Associate Professor of Pediatrics and Emergency Medicine, Bellevue Hospital 

Richard Serino, EMT-P, Chief, Boston Emergency Medical Services 

Paul Maniscalco, M.P.A., EMT-P, Assistant Professor, Homeland Security Policy Institute, George Washington University 

This chapter discusses the unique context in which the U.S. 

emergency medical services (EMS) systems operate, and the issues 

that will need to be addressed in the case of a mass casualty event 

(MCE). It presents the challenges to planning and coordination 

posed by the fragmented nature of EMS training, guidelines, and 

response capacity and offers recommendations for allocating scarce 

resources to respond to a catastrophic MCE. It highlights specific 

issues that planners need to consider to maximize EMS response 

capacity, offers recommendations for successful EMS MCE planning, 

 and presents ideas and resources for EMS planners based on realcase scenarios and planning efforts. 

Chapter IV. Prehospital Care 39 
Prehospital Care Issues and Recommendations At A Glance 

MAJOR CHALLENGES AFFECTING EMS MCE PLANNING 

Lack of: 

o Consistency in EMS training and credentialing 

o Coordination and communication among EMS services and with public safety, public health, 

hospitals, trauma centers, and 9-1-1 dispatchers 

o Readiness preparedness among EMS providers and systems 

o Disaster training in EMS curricula 

o Financial and staff resources 

o An evidence base for EMS care

RECOMMENDATIONS FOR EMS PLANNERS

o Develop partnerships with Federal, State, and local stakeholders to clarify roles, resources, and 

responses to potential MCEs. 

o Improve communication and coordination strategies and backup plans. 

o Exercise, evaluate, modify, and refine MCE plans. 

o Model EMS responses to MCEs. 

o Develop public education plans to provide information on when and where to obtain care. 

o Ensure a cadre of EMS leaders. 

o Plan and implement strategies to maximize to the extent possible: 

- Use and availability of EMS personnel 

- Transport capacity 

- Role of dispatch and public safety answering points (facilities that receive 9-1-1 calls) 

- Personal protection for EMS personnel 

- Patient triage and evaluation 

- Destination choices. 

o Use natural opportunities to exercise disaster planning. 

o Use existing case examples and best practices. 

o Develop strategies to identify large numbers of young children who may be separated from parents 

and cannot give information that would help them to be reunited with their parents.

Context of EMS Systems and Challenges for MCE Planning 

In the event of a catastrophic MCE, it is the EMS systems that will be called on to provide firstresponder rescue, assessment, care, and transportation and access to the emergency medical 

health care delivery system. Emergency medical services in the United States are provided 

through a complex system composed of highly variable organizational structures. Nearly half of 

Chapter IV. Prehospital Care 40 
all EMS are delivered through local fire departments. Others are structured within municipal or 

county governments, police departments, health departments, or private companies (e.g., 

hospital-based, for-profit ambulance services) or are volunteer-based.59

The variability of EMS response systems is further exacerbated by important differences in 

EMS preparedness training, guidelines, and response capacity – posing significant coordination 

and communications challenges for EMS leaders and planners. Two recent reports from the 

Institute of Medicine (IOM), Emergency Medical Services: At the Crossroads and Hospitalbased Emergency Care: At the Breaking Point,

60,61 highlight constraints and challenges that 

will impede the capacity of the nationwide EMS systems to respond to a catastrophic MCE.

They include the following:

LACK OF CONSISTENCY. A criticism of the existing state of EMS preparedness is that there is no 

single oversight agency responsible for ensuring consistency in training, certification, or 

guidelines for disaster response, the use of personal protective equipment (PPE), or the 

coordination of EMS response and operations. There is wide variation in the design of EMS 

systems across States and local areas. Similarly, there is no coherent compliance program to 

ensure that EMS preparedness initiatives are integrated, sustainable, and exercised regularly to 

test for efficacies and vulnerabilities. In their recent report cited above, the IOM recommends 

that all institutions responsible for the training, continuing education, and credentialing and 

certification of professionals involved in emergency care (including medicine, nursing, EMS, 

allied health, public health, and hospital administration) incorporate disaster preparedness 

training into their curricula. 

LACK OF COORDINATION. No central command and control entity coordinates assets and ensures 

communication among EMS response systems. Often EMS agencies are unable to communicate 

with each other because of incompatibilities in their communication systems. There is also a 

lack of communication and coordination among prehospital EMS and 9-1-1 dispatchers, public 

safety agencies, public health, air medical providers, hospital centers, and trauma centers – 

especially when emergencies cross jurisdictional lines. 

LACK OF READINESS PREPAREDNESS. EMS representation in disaster planning at the Federal level 

has been limited, according to the IOM report. In addition, most EMS systems are not trained in 

the National Response Plan. Thus, they have little or inconsistent knowledge with its incident 

command and its tenets for supporting operational requirements. Likewise, EMS systems may 

not be fully aware of the Federal response capability, such as the provisions of the Homeland 

Security Presidential Directive/HSPD-5, the National Disaster Medical System (NDMS), use of 

Disaster Medical Assistance Teams, the Incident Command System, Occupational Safety and 

Health Administration (OSHA) PPE guidelines, and OSHA Hazard Materials Operations 

regulations. As a result, there is risk that requests for resource augmentation will be misdirected 

Chapter IV. Prehospital Care 41 
– possibly overlooking potential sources of support, command and control, communications, 

and interoperability from other Federal departments and agencies. 

EXAMPLES OF FEDERAL RESPONSE RESOURCES

Homeland Security Presidential Directive HSPD-5: 

http://www.whitehouse.gov/news/releases/2003/02/20030228-9.html

NDMS: http://www.ndms.fema.gov

Disaster Medical Assistance Teams: http://oep-ndms.dhhs.gov/dmat.html 

OSHA PPE Guidelines: http://www.osha.gov/SLTC/personalprotectiveequipment/index.html

OSHA Hazard Materials Operations Regulations: 

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10099 

LACK OF STANDARDIZED DISASTER TRAINING IN EMS CURRICULA. At this time there is no 

standardized requirement for education (and continuing education) regarding disaster training, 

special incident, or catastrophic response, and thus most EMS personnel have not been 

consistently trained to respond to acts of terrorism, natural disasters, or other potential MCEs. 

As a result, EMS responders will be called to situations in which they may be overwhelmed and 

unprotected. Some of these issues are being addressed by the Federal Interagency Committee on 

EMS, which was created to provide the EMS community with a mechanism for ongoing Federal 

coordination of EMS programs. The Committee and its supporting Federal agencies are focused 

on the development of National EMS Education Standards. 

DEVELOPING A NATIONAL MODEL FOR EMS TRAINING

To address the lack of consistency in EMS training and credentialing, the National Highway Traffic 

Safety Administration (NHTSA) has been developing a national model to aid States in adopting a 

common scope of practice for EMS personnel, with State licensing reciprocity. Together with the 

Health Resources and Services Administration and other Federal Agencies, NHTSA is focused on the 

development of National EMS education standards and on providing leadership and coordination of 

comprehensive, evidence-based emergency medical services and 9-1-1 systems. 

More information is available at 

http://www.nhtsa.dot.gov/portal/site/nhtsa/menuitem.2a0771e91315babbbf30811060008a0c/.

LACK OF FINANCIAL RESOURCES. Many EMS response agencies do not have the financial 

resources to extend themselves beyond the demands of daily operations. Large-scale disasters 

often require unique resources and response capabilities, which are outside the scope of normal 

operations and far exceed agency budgets. 

Chapter IV. Prehospital Care 42 
LACK OF STAFF. EMS response organizations are confronted with a severe recruitment and 

retention problem nationwide. EMS systems often are not attributed the same professional 

regard as other health professionals, and their salaries are often lower than those of police 

officers, fire fighters, and nurses. Many prehospital providers also hold other jobs; for example, 

volunteer emergency medical technicians (EMTs) in most communities have other employment, 

and their availability during an MCE may be limited. In addition, many personnel have more 

than one EMS employer or other obligations such as participation in the NDMS or military 

service. 

LACK OF AN EMS EVIDENCE BASE. Research on prehospital care and response is limited, raising 

concerns that some practices may be inappropriate (e.g., field intubation of children) and 

clinical care questions remain unanswered. These challenges make it difficult for EMS response 

agencies to ensure a uniform culture of preparedness. As a result, there is an increased risk that 

without careful and concerted pre-event planning, the response to an MCE will be disjointed 

and less effective than it could be and will lead to avoidable deaths or injuries of both affected 

civilians and EMS responders themselves. 

EMS in an MCE: Expected Shortages and Needs 

In the case of an MCE, many health care resources at the local and regional levels will be 

overwhelmed or eliminated. Those EMS response agencies that are able to remain operational 

likely will encounter a demand for services that will outstrip the supply and available resources. 

EMS systems will confront: 

 Personnel shortages. 

 Breakdowns in supply chains. 

 Lack of coordination and information sharing among diverse EMS providers, public safety, 

hospitals, trauma center, and public health. 

 Breakdown of logistic support for operational sustainability, including such things as fuel 

shortages; inadequate availability of transport vehicles; and shortages in supplies, equipment, 

and pharmaceuticals. 

 Overloading of hospital emergency departments and associated services such as intensive 

care capabilities; specialty services such as burn care or decontamination units; and specialized 

equipment such as ventilators, PPE, or negative pressure rooms. 

 Breakdowns in local “burden sharing” strategies (mutual aid agreements) due to 

overwhelming demand and lack of surge capacity. 

 The need to implement modified treatment protocols to meet the extraordinary conditions of 

the MCE that may be limited to reasonable life-sustaining activities where appropriate. 

Chapter IV. Prehospital Care 43 
Recommendations for planners 

There are several important actions that planners should take prior to an MCE to help maximize 

the response capacity of prehospital EMS services. Those actions include the following: 

“Emergency management is really about building 

relationships, whether you are in the public or private 

sector. And in building those relationships, it is 

important to remember not to tell, but to talk.” 

Edward Gabriel

Walt Disney Corporation 

FORGING PARTNERSHIPS AT ALL LEVELS. Building relationships and partnerships is a critical 

component of emergency management planning. The need to coordinate and allocate scarce 

prehospital resources in the case of a catastrophic MCE requires the development, 

implementation, exercising, and 

refinement of partnerships between 

Federal, State, and local government 

response agencies, as well as between 

public and private entities. These 

relationships need to clearly define the 

roles, responsibilities, capabilities, 

oversight, command, communications, 

logistics, and response resources each will 

bring to bear in an MCE. Involvement of senior leadership from all response agencies is 

essential for success and actual progress. 

Examples of partnerships could include the establishment of mutual aid agreements or interstate 

compacts to address issues such as the acquisition and deployment of extra transport vehicles or 

licensure and indemnification matters regarding responders. Similarly, memoranda of 

understanding (MOUs) could be developed among public and private ambulance services to 

coordinate response to potential MCEs. 

MEMORANDA OF UNDERSTANDING (MOUS) 

Further information on developing MOUs is available from the Center for Law and the Public’s Health at 

http://www.publichealthlaw.net/Research/Katrina.htm. Click on Memo 3. 

IMPROVING COMMUNICATION AND COORDINATION. Planners must develop integrated and 

interoperable communications and data systems that can link EMS agencies to hospitals, trauma 

centers, public safety departments, emergency management offices, and public health agencies. 

Communication discipline is one of the keys to effective incident management, and ideally, 

these systems would be centralized through established Incident Command System (ICS) 

channels. There also should be a plan for backup or redundant communication strategies in case 

there are failures in primary communication methods. Similarly, other backup procedures for 

Chapter IV. Prehospital Care 44 
actions that can be taken when systems fail should be planned, tested in advance, and integrated 

into the planning process. 

CONTINUALLY MODIFYING AND REFINING PLANS. Practical planning is essential and should include 

concrete implementation steps with training and exercise goals for each step. Each component 

of the response should be taught, exercised to the point of failure, evaluated, modified, 

rewritten, and tested once again. Exercises should simulate actual casualties, as well as 

management of the “worried well” – individuals calling for EMS resources who actually do not 

need them. Exercises should include response partners from public, private, community, and 

governmental agencies. This iterative process allows for continuous modifications and 

improvements. 

MODELING MCE RESPONSES. Modeling responses to a catastrophic MCE may take the form of 

tabletop exercises, actual but smaller events, or computer simulations and can provide examples 

of difficulties which may be faced during such an event. Such modeling efforts should start 

using small numbers of casualties as a starting point and then use rising victim number 

scalability models; i.e., plan for 100, then 1,000, then 10,000, and then 100,000. Planners 

should consider the use of models such as the Large Scale Emergency Response (LASER) 

Program at New York University (NYU), which includes the following components: computer 

modeling of large-scale events, risk communication, legal aspects, workforce support, and 

community-based response issues. 

MODELING LARGE-SCALE DISASTER SCENARIOS

The LASER program at NYU uses a computer model of New York City to simulate possible 

catastrophic disasters according to a range of prescribed parameters. It can simulate the National 

Incident Management System and assess its integration at the local level to test in detail the 

effectiveness of various emergency response strategies. It also highlights factors such as 

communications strategies for providing risk and emergency information to the public that could 

decrease fatalities. Further information is available at http://www.nyu.edu/ccpr/projects/laser.html. 

EDUCATING THE PUBLIC. Planners need to develop, implement, exercise, and refine efforts to 

provide for comprehensive public education. This may include such things as scripted messages 

that provide specific directions to the public on actions they should take or public information 

programs that specifically outline whether to call 9-1-1 for assistance. 

PROVIDING AND ENSURING LEADERSHIP. Leadership training should be provided for mid- and 

upper-level EMS supervisory staff members to ensure that in case of major illness, injuries, or 

deaths, there will be individuals who can take on the role of EMS medical director or 

leadership. The determination also should be made in advance regarding who in the 

Chapter IV. Prehospital Care 45 
organization would be able to adjust standard operating procedures and the scope of practice of 

EMTs to the needs of the situation. 

Case Study: Preparation for the 2004 Democratic National Convention 

in Boston, MA 

For more than a year before the 2004 Democratic National Convention, Massachusetts’s public health 

agencies planned and drilled for a variety of potential emergency and disaster scenarios. Following are 

examples of the key preparatory steps they took. 

o EMS agencies and organizations in the Boston area developed a mapping database with current 

information on emergency exits, emergency medicine locations, and routes to hospitals and clinics to be 

used in GIS mapping systems and for planning purposes. 

o The Massachusetts Emergency Management Team (MEMT), composed of liaisons from more than 70 

agencies and organizations, met and trained together on a monthly basis. The MEMT served as the 

coordinating agency for the State Emergency Operations Center (SEOC). More than 30 Federal, State, 

local, private, and volunteer agencies and organizations staff the SEOC on a 24/7 basis. 

o The MEMT prepared and tested a plan for integrating business and industry into the emergency support 

function. Designated liaisons from area businesses and industries helped the MEMT prepare to use their 

assets and expertise and to communicate with business and industry leaders. 

O A Consequence Management Subcommittee met to develop response and coordination plans for the 

various EMS organizations. The subcommittee considered how information should be collected and 

shared among the large number of command and/or operations centers and explored ways to connect 

these centers to Washington and all the other command and/or operations centers. 

 

Approaches to the allocation of scarce resources

In the face of a catastrophic MCE, there likely will be scarcities and mismatches regarding EMS 

personnel, transport capacity, and destination availabilities for patient treatment. As a result, 

creative strategies will need to be implemented for coordinating and maximizing the use of 

available staff members and resources. Ideally, these strategies should be considered, tested, 

and refined prior to the MCE. Legal and ethical advisors should be included in discussions (see 

Chapters II and III of this guide). Approaches to the allocation of scarce resources to be 

considered should include, but not be limited to, the following: 

MAXIMIZE THE AVAILABILITY OF EMS PERSONNEL through modified or extended shifts, deployment 

of no more than two providers per vehicle, and use of one-person response vehicles for “patient 

evaluation” prior to dispatch of transport resources. Staff members also may be shifted so that 

non-EMT personnel serve as drivers; fire, police, or volunteer EMT personnel provide 

assistance during transport; and other medical personnel (e.g., physicians, nurses, nurse’s aides) 

help staff casualty treatment sites to permit EMS personnel to provide transport services. “JustChapter IV. Prehospital Care 46 
in-time” programs to train nonmedical volunteers to provide basic medical care such as direct 

pressure for hemorrhage control also should be developed. 

MAXIMIZE THE USE OF AVAILABLE EMS PERSONNEL. Some medical protocols may be suspended 

(e.g., base contact for certain interventions) to allow for greater efficiency and flexibility in 

patient management. EMS personnel may be used in nontraditional settings (e.g., alternative 

care sites, hospitals, pharmaceutical distribution centers) for field triage, treatment, or transport. 

Their scope of practice may be extended to provide vaccinations or medications or to deliver 

nontraditional medical care at the scene or in the home. 

MAXIMIZE TRANSPORT CAPABILITY. Public and private ambulance services should be coordinated 

and steps taken to ensure that they do not self-dispatch to MCEs. Paramedic-initiated alternative 

transport mechanisms also should be put into place (e.g., buses, taxis, privately owned 

vehicles). Mutual aid agreements should be in place and implemented to deploy and use 

available transportation assets, staff members, and staging locations. Transport assets should be 

loaded to their full capacity and patients taken to the closest appropriate hospital or care site. 

Air transport should be used to take patients to distant facilities (unless the incident presents 

contamination risks). Noncritical calls should be batched by geographic area. Bypass, diversion, 

or closure rules could be suspended to promote equitable distribution of patients and to try to 

avoid the overloading of any one hospital. Secondary transport needs should be anticipated so 

that patients can be transferred from overloaded hospitals or care sites to those that are less 

affected. 

COMMUNITY EMERGENCY RESPONSE TEAMS (CERTS) 

The CERTs program educates people on disaster preparedness for hazards that may impact their 

area and trains them in basic disaster response skills, such as fire safety, light search and rescue, 

team organization, and disaster medical operations. Using the training learned in the classroom and 

during exercises, CERT members can assist others in their neighborhood or workplace following an 

event when professional responders are not immediately available to help. CERT members also are 

encouraged to support emergency response agencies by taking a more active role in emergency 

preparedness projects in their community. Further information is available at 

http://www.citizencorps.gov/cert/about.shtm.

MAXIMIZE THE ROLE OF PUBLIC SAFETY ANSWERING POINTS AND DISPATCH. Call screening 

strategies should be in place to determine the level of urgency required to respond to calls. 

Maximal response strategies involving multiple responders (e.g., engine company, ambulance, 

law enforcement) used in standard EMS response should be avoided. 

Prearrival instructions should be scripted and tailored to the incident at hand with formal 

recommendations regarding the use of alternative methods of transport and alternative care 

Chapter IV. Prehospital Care 47 
sites. Nontransporting vehicles with a single responder may be dispatched to evaluate calls and 

the need for onsite care and ambulance transport. 

MAXIMIZE PERSONAL PROTECTION FOR PERSONNEL. Universal precautions should be used for 

every patient encounter, if at all possible. To minimize the number of responders exposed to 

pathogens or chemicals, specialized protections should be used to the extent possible and 

adjusted to the nature of the incident (e.g., distribution of antibiotics, vaccines, or antidotes to 

staff and family members). In the case of chemical incidents, decontamination needs must be 

evaluated and addressed prior to transportation to preserve transport capability. Similarly, 

security personnel should be assigned to protect EMS response operations, logistics centers, and 

stockpile depots. 

MAXIMIZE PATIENT TRIAGE AND EVALUATION. Specific triage systems should be in place prior to 

an incident, and personnel should be trained and exercised in their use. Examples of triage 

systems include the START and JUMPSTART triage systems. 

START/JUMPSTART 

A combined START/JUMPSTART triage algorithm for patients from birth to age 14 years is available 

at miemss.umaryland.edu/emscwww/pdfs/startjumpstartq.pdf. 

Simple triage methods include rapid separation of the critical from the noncritical (i.e., 

“Everyone who can walk should get on this bus”). The overarching principle for triage is “the 

most good for the most people.” The differentiation of “expectant” patients from those who 

likely will survive should be performed in consultation with or by the EMS Medical Director or 

designee. Selected triage systems should include palliative treatment for casualties deemed to 

have little likelihood of survival. Although such patients may be categorized as lower priority 

for transport, appropriate comfort measures, including pharmacologic treatment, should be 

provided as available. 

NATIONAL FIELD TRIAGE CRITERIA

The Terrorism Injuries: Information, Dissemination and Exchange (TIIDE) Project convened a meeting in 2005 

to begin to develop national field triage criteria that can be used in mass casualty events. The TIIDE grantees 

consist of six emergency medicine organizations who are leading an effort to review the available evidence 

on mass casualty triage and develop a position paper on the subject that will be endorsed by the TIIDE partner 

organizations. Planners can find further information about the TIIDE Project at 

http://www.acep.org/webportal/membercenter/sections/ems/cdcmodelcommunities.htm.

Chapter IV. Prehospital Care 48 
MAXIMIZE DESTINATION CHOICES. A centralized coordination of patient transport should be in 

place to minimize hospital overloading and maximize the use of other available resources, such 

as primary care providers, alternative care sites, medical evaluation centers, or triage centers. 

Indeed, it is likely that the vast majority of victims of an MCE may end up being most 

appropriately managed in the home setting, either because their illness or injury is not severe 

enough to warrant institutionalized care or because the successful outcome of such inpatient 

treatment in the setting of scarce and limited resources would be considered futile and 

potentially wasteful. 

Many view the community hospital as a “safe haven,” a place to go for food, shelter, protection, 

and medical attention. However, particularly in the event of a transmissible infectious disease in 

which hospitalized patients represent the sickest patients in the community, the concept of “safe 

haven” may not be applicable. In fact, it may be more dangerous to be in the hospital setting 

than to remain at home. It is important for community planners to highlight the concept of the 

home as a “safe haven” in their risk communication strategies and develop measures to support 

this concept. Emergency planners, therefore, must incorporate the likelihood of home care 

delivery in all aspects of their planning efforts. This planning must focus on the possibility that 

some rudimentary degree of medical care will need to be delivered in the home setting, often 

with limited outside professional assistance. 

Incorporating Home Care Into Emergency Planning: Issues to Consider 

o Register patients being cared for in the home setting with a local emergency management 

 agency and the public health department to ensure access to relevant information. 

o Ensure adequate stock of routine, chronic care medications. 

o Ensure adequate stock of basic first aid supplies, including but not limited to bandages, 

antipyretic medications (acetaminophen, ibuprofen), oral electrolyte solutions, and 

thermometers. 

o Ensure that backup utility support is in place if warranted (particularly for those patients requiring

 electricity support for medical devices). 

o Establish a “sick room” in the home for the primary management of ill household members, 

 particularly in the event of a transmissible infectious disease. 

o In the event of caring for patients with advanced symptoms “too sick” for hospital care, 

coordinate symptom palliation with a home care team coordinated by local public health 

authorities. 

o Ensure the availability of a bedside commode or bedpan. 

o Ensure the availability of a bedside humidifier, if possible.

Chapter IV. Prehospital Care 49 
Planners also need to make sure to include the ambulatory care system as part of the MCE 

planning process. Many people look to their primary care provider first for information on 

health care issues. Primary care providers would play a critical role in MCE situations, 

particularly that of influenza pandemic, for example, in determining which patients need to go 

to the hospital and which patients can be cared for at home. Planners therefore should regard 

primary care providers and their local ambulatory care system as an important component of a 

system to keep the hospitals from being overwhelmed. Given their role as critical sources of 

health care information and assistance for communities, planners should incorporate ways to 

maximize the ambulatory care system appropriately as part of the overall MCE response. 

Whenever possible, specialized patient treatment requirements should be matched to the most 

appropriate destinations. Information services systems that provide ongoing updates of hospital 

bed status and capabilities should be in place and implemented to inform EMS about destination 

choices and to help coordinate patient distribution. This includes local, regional, statewide, and 

national systems such as the National Hospital Available Beds for Emergencies and Disasters 

(HAvBED)62 national hospital bed availability tracking initiative. 

HAVBED SYSTEM 

The HAvBED System explores the feasibility of a national real-time hospital-bed tracking system to 

address a surge of patients during an MCE. This demonstration model is funded by the Agency for 

Healthcare Research and Quality and has been developed by Denver Health. A report describing the 

development, implementation, and evaluation of HAvBED is available at 

http://www.ahrq.gov/research/havbed.

Casualty treatment areas can be established on site, near the disaster scene, or at alternative care 

sites (depending on the nature of the incident) to address the volume of casualties, provide 

triage, assess transport needs and choices, and serve as a treatment site to which supplies will be 

deployed. Home health care should be used according to predetermined triage protocols to 

prevent unnecessary use of EMS transport and hospital resources (e.g., provision of primary 

care, vaccines, antiviral medications). 

 Using Case Examples and Best Practices 

Cities have natural opportunities to exercise their disaster planning by using special events such 

as marathons, major sports/cultural events, or large national conventions as “planned disasters.” 

Special events inevitably result in large crowds, more accidents and injuries than usual, and a 

strain on EMS resources. Thus, they present a prime opportunity to prepare for MCEs and test 

MCE equipment and protocols. This approach is supported by the U.S. Department of 

Homeland Security in their Lessons Learned Information Sharing electronic database, which 

Chapter IV. Prehospital Care 50 
provides updates and examples of community response plans, lessons learned from actual 

disaster events, developments of MOUs and other planning tools, best practices, and stories of 

successes. 

The more EMS agencies are able to take advantage of opportunities such as special events and 

to invest in drills and training, the better prepared they will be when actual disasters arise. For 

example, the effective emergency response to the July 2005 London public transport bombings 

was a direct result of extensive training. Planners should take the time to write and read afteraction reports, as they serve as useful tools for better understanding what has and has not 

worked and they can provide the basis for necessary improvements to be made to response 

capabilities. 

Learning from others – other nations or other U.S. or international agencies – is a critical 

component of being prepared. Although EMS agencies in the United States rarely deal with 

MCEs, for certain countries, such as 

Israel, and agencies such as the U.S. 

Agency for International Development’s 

(USAID) Office of Foreign Disaster 

Assistance, responding to medical 

disasters is more common. Thus, much 

may be learned by examining ways in which other nations respond to large-scale emergency 

events (e.g., bombings, natural disasters, disease outbreaks) with limited resources. 

Case examples of disaster relief from USAID 

can be found at 

http://www.usaid.gov/our_work/humanitarian_as

sistance/disaster_assistance/. 

LESSONS LEARNED INFORMATION SHARING (LLIS) 

Lessons Learned Information Sharing (LLIS) contains the following types of original content: 

Lessons Learned: Knowledge and experience – positive or negative – derived from actual incidents 

such as the 1995 Oklahoma City bombing and the 9/11 attacks as well as observations and historical 

study of operations, training, and exercises. Best Practices: Peer-validated techniques, procedures, 

good ideas, or solutions that work and are solidly grounded on actual experience in operations, 

training, and exercises. Good Stories: Exemplary – but non-peer-validated – initiatives implemented 

by various jurisdictions that have shown success in their specific environments and that may provide 

useful information to other communities and organizations. Access to LLIS is restricted to verified 

emergency response providers and homeland security officials. 

 The content is available at http://www.llis.gov. 

Chapter IV. Prehospital Care 51 
Endnote

59 Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Emergency Medical 

Services: At the Crossroads. Washington: National Academies Press; 2006. 

 Ibid. 60

61 Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Hospital-based 

Emergency Care: At the Breaking Point. Washington: National Academies Press; 2006. 

62 Agency for Healthcare Research and Quality (AHRQ). National Hospital Available Beds for Emergencies and Disasters 

(HAvBED) System: Final Report. AHRQ Publication No. 05-0103. Rockville, MD: AHRQ; December 2005. Available at: 

http://www.ahrq.gov/research/havbed/. Accessed July 18, 2006. 

Chapter IV. Prehospital Care 52 
Chapter V. Hospital/Acute Care 

AUTHORS

John L. Hick, M.D., Lead Author, Assistant Professor, Emergency Department, Hennepin County Medical Center 

Gabor Kelen, M.D., Director, Office of Critical Event Preparedness and Response, Johns Hopkins University 

Daniel O’Laughlin, M.D., Assistant Professor of Emergency Medicine, University of Minnesota/Abbott Northwestern Hospital 

Lewis Rubinson, M.D., Ph.D., Health Officer, Deschutes County Health Department/Bend Memorial Clinic 

Richard Waldhorn, M.D., Distinguished Scholar, Center for Biosecurity, University of Pittsburgh Medical Center 

Dennis P. Whalen, Executive Deputy Commissioner, New York State Department of Health 

Some of the most difficult decisions about providing an appropriate 

standard of medical care when resources are inadequate to meet 

event-driven demands will be made in hospitals. This section presents 

an overview of recommended systems and processes for planning and 

implementing the allocation of scarce hospital and acute care 

resources during a mass casualty event (MCE). It offers planners 

recommendations on developing integrated and coordinated response 

systems and ways to make the operational decisions for stretching 

and allocating scarce resources during a catastrophic MCE.

Chapter V. Hospital/Acute Care 53 
Hospital/Acute Care Issues and Recommendations At A Glance 

MAJOR ISSUES AND CHALLENGES

o Hospitals already at or near capacity for emergency and trauma services 

o Meeting needs for basic and specialized equipment 

o Coordinating competing health care systems 

o Incompatibilities in communications systems 

o Lack of on-call specialists and other essential staff (e.g., nurses) 

o Need for security and protection 

o Issues regarding professional licensing; verification; and supervision, both intra-and interstate 

RECOMMENDATIONS PRIOR TO AN MCE 

o Develop an integrated incident management system. 

o Establish interhospital compacts and mutual aid agreements. 

o Establish a jurisdictional Emergency Operations Center; ensure that the hospital knows how it is 

represented there. 

o Designate a “trusted source” to serve as the hospital’s resource and policy representative at the 

local or regional emergency response level. 

o Develop a planning framework for allocating scarce resources, ideally based on existing Federal 

or State guidances, which articulates the integration of response strategies and tactics across 

facilities/agencies. 

o Regionalize disaster response, through Multi-Agency Coordination (MAC) planning. 

o Establish a Joint Information Center (JIC) or other centralized method to link communications 

regarding incident and response at the local, regional, and State levels. 

o Use expert panels or planning groups to develop decisionmaking protocols or guidance for 

allocating scarce resources in the case of an MCE. 

o Put into place an institutional and State position on how scarce resources would be allocated to 

health care workers. 

RESPONDING TO AN MCE 

o Increase space capacity within the hospital through rapid patient discharge and transfer, addition 

of beds/cots, facilitation of home-based care, and use of alternative care sites. 

o Increase staff capacity through schedule changes, staff sharing, promotion of home care, and the 

use of advance registered and credential-verified health professional volunteers. 

o Increase access to supplies through contacts/agreements with commercial vendors. 

o Institute administrative changes to facilitate processes, reimbursements, reassignment of the 

staff, and schedules. 

o Institute clinical changes to a level appropriate to the available resources. Base triage and 

allocation decisions on existing guidance, if possible. 

o Ensure security for the staff and supplies. 

o Plan for mass mortuary needs. 

o Develop strategies to identify large numbers of young children who may be separated from 

parents and cannot give information that would help them to be reunited. 

Chapter V. Hospital/Acute Care 54 
Hospital and Acute Care in the Context of a Catastrophic MCE 

The overall goal of hospital and acute care response in an MCE is to meet the reasonable care 

needs of as many patients as possible while also meeting at least minimal obligations for 

comfort to each patient.63 In the case of a catastrophic MCE, however, hospitals will not have 

access to many needed resources (e.g., manual resuscitation bags to provide ventilation in 

response to a pandemic influenza, supply of antitoxin in the case of mass botulism poisoning). 

Thus, difficult decisions will have to be made regarding the allocation of available resources. 

During an MCE, Federal and State agencies might be able to offer policy guidance, nationally 

sanctioned decision tools, and event-specific relief of certain regulatory obligations. However, 

the operational decisions regarding limited resource allocation (and the liability related to such 

policies) will be the responsibility of individual hospitals, communities, and regions. Thus, it 

will be incumbent on these localities and entities before an event occurs to establish and test 

plans for operational incident management systems that can be applied to respond to an MCE. 

Challenges for MCE Planning 

Much of the hospital-based response to an MCE will rely on planning, protocols, and actions 

that should be put into place and tested well ahead of time. In order to address those planning 

needs, however, planners must take into account the critical challenges that hospitals will face 

in responding to catastrophic events.64 Those challenges include the following:

SURGE CAPACITY ISSUES. A recent report on hospital-based emergency care from the Institute of 

Medicine2 reveals that many hospital emergency and trauma services are already at or near full 

capacity and thus not equipped to respond to the increased demand and decreased resources that 

would occur in an MCE. Interhospital agreements have the potential to alleviate overcrowding 

by transferring existing inpatients to other facilities, for example, but evidence from a Centers 

for Disease Control and Prevention study indicates that only 46 percent of hospitals have 

agreements of this type.65 

INADEQUATE SUPPLIES. Lack of sufficient supplies, particularly of specialized equipment such as 

personal protective equipment, ventilators, and negative pressure rooms, will be a challenge for 

most hospitals.

NEED FOR COORDINATION, COOPERATION, AND CONSISTENCY BETWEEN HEALTH CARE SYSTEMS 

THAT ARE IN COMPETITION WITH ONE ANOTHER. Public health and State government may have 

certain authorities to make decisions during an emergency, but the scope of their powers often 

does not extend into health care facilities. Thought should be given to approaches to facilitating 

or enhancing cooperation between diverse, and potentially competing, entities. 

COMMUNICATION BARRIERS. In order to respond at a level appropriate to the incident, critical 

information must be shared and processed across systems to give an overview of the event, 

Chapter V. Hospital/Acute Care 55 
guide the mobilization of necessary resources, and inform the development of strategies and 

tactics at the hospital and community levels. The fragmented nature of emergency care systems 

leads to incompatibilities in communications and data systems between EMS systems, hospitals, 

trauma centers, public safety services and public health agencies. 

LACK OF SPECIALISTS AND OTHER ESSENTIAL STAFF MEMBERS. Even in the current emergency and 

trauma care system, the supply of on-call specialists and other essential staff members (e.g., 

nurses) is not great enough to meet demand – a gap that will be greatly exacerbated in an MCE. 

NEED FOR SECURITY PRESENCE AND PROTECTION. Hospital staff members, supplies, and assets 

will need to be protected in the case of an MCE, which naturally will result in scarcities and the 

potential for fear, theft, or violence. 

Recommendations Related to Advance Planning 

In the event of a catastrophic MCE, decisions and policies regarding resource allocation within 

hospitals will have to occur at multiple levels, ranging from the State down to local 

communities and institutions. Ideally, these decisions and policies should be crafted in advance 

of the event and should reflect nationally sanctioned guidance. 

Hospital administrators and local and State elected officials must work to ensure that the 

framework for such decisionmaking is in place and that a public conversation is held that 

ensures understanding of the resources and limitations of the health care system. 

They must be prepared to defend this planning to State agencies and government and help them 

to understand the implications of resource allocations. Local and regional legal issues must be 

raised and defined, and solutions must be determined. 

PLANNING TEMPLATE FOR HOSPITALS

To help stimulate discussion and planning for MCEs within hospital facilities as well as at the local and 

regional levels, a Mass Casualty Disaster Plan Checklist for Health Care Facilities has been 

developed by the Center for the Study of Bioterrorism and Emerging Infections and the Association for 

Professionals in Infection Control and Epidemiology, Inc. It is available at 

http://www.gnyha.org/eprc/general/.

Ideally, hospitals should be able to follow guidance and decision support tools to make resource 

allocation decisions (e.g., who should receive mechanical ventilation) that are sanctioned and 

approved at the Federal level and are distributed by the State. Even with the support of these 

tools or policies, however, it is the hospital that will have to take on the role of implementing 

them. 

Chapter V. Hospital/Acute Care 56 
To plan for addressing the hospital and acute care needs following an MCE prior to an event, 

hospitals and their partners should do the following: 

DEVELOP AN INTEGRATED INCIDENT MANAGEMENT SYSTEM. In order to respond to the demands 

and scarcity of resources that would be brought on by an MCE, hospitals must have in place a 

system of coordination with other local hospitals, public health departments, incident 

commanders, public safety, and EMS systems to provide care. 

Thus, integrated incident management is critical to preparing for an MCE and must be 

developed prior to any catastrophic event.66

INCIDENT MANAGEMENT SYSTEM CURRICULUM

The complexity of incident management, coupled with the growing need for multiagency and 

multifunctional involvement in incidents, has increased the need for a single standard incident 

management system that can be used by all emergency response disciplines. The Incident Command 

System, originally designed in California to respond to wildfires, has been adopted as the National 

Incident Management System, a national training curriculum for public and private sector users that 

can be applied to multihazard and planned event situations. Information on the training curriculum is 

available at http://www.nimsonline.com/ics_training/index.htm.

The Institute of Medicine report on hospital-based emergency care recommends that 

coordination and incident management require the following components:67

 The establishment of hospital coalitions, compacts, and mutual aid agreements to create a 

common platform for planning and response. This may be facilitated by the use of an existing 

program, such as the former Hospital Emergency Incident Command System, which has been 

revised and renamed the Hospital Incident Command System (HICS). HICS is a wellinstituted and nationally recognized approach to disaster management. 

 The establishment of a jurisdictional Emergency Operations Center. Each hospital should 

be familiar with its local office of emergency preparedness and know how it is represented 

there, whether through assignment of direct liaison, the public health department, a hospital 

association, the EMS system, or another mechanism. 

 The designation of a particular hospital or local public health agency as a “trusted source” 

to serve as the hospital’s resource and policy gateway within the region during a major 

multijurisdictional event. 

Chapter V. Hospital/Acute Care 57 
HICS 

HICS applies the principles of incident management to health care facilities. The system helps 

coordinate emergency response between hospitals and other emergency responders with a system 

based on a predictable chain of management, defined responsibilities, prioritized response 

checklists, clear reporting channels for documentation and accountability, and a common 

nomenclature to facilitate communications. Further information is available at 

http://www.emsa.ca.gov.

DEVELOP A PLANNING FRAMEWORK FOR ALLOCATING SCARCE RESOURCES. This framework should 

be transparent and shared with key stakeholders in the health department, attorney general’s 

office, and governor’s office as well as with the community, both in advance of and during an 

MCE. The framework should establish ways to do the following: 

 Define or project the resource shortfalls and the impact on clinical care. 

 Identify the facilities and area to be affected. 

 Request additional resources, facilitate the transfer of patients out of the affected area, or 

facilitate alternative strategies for patient care (e.g., offsite care, home care). 

 Develop and disseminate supportive policy and clinical guidance (e.g., triage and treatment 

recommendations, decision tools) – ideally ones that have been nationally sanctioned or 

federally approved and disseminated. Sources of expertise may include the academic, private, or 

public medical care system. Clinical guidance or decision aids should reflect any available 

Federal guidance and ideally be flexible enough to allow hospital and clinician discretion in 

making resource allocation decisions, as deemed medically justified. 

 Provide guidance for liability relief for providers in good-faith compliance with such 

policies and guidance. 

 Include guidance on the equitable management and allocation of scarce resources. For 

example, prior to an MCE both government and private institutions should know the extent to 

which they can commandeer equipment or information about remaining supplies and to allocate 

resources. 

 Articulate the integration of response strategies and tactics across facilities and agencies at 

the local and regional levels (see Figure 1). Use a tiered approach, ranging from the smallest 

unit, the individual health care facility (HCF) or group of providers (Tier 1); through health care 

coalitions (Tier 2) and jurisdictional incident management systems (Tier 3); to broader State, 

interstate, and Federal response levels (Tiers 4–6). Resource coordination needs that overwhelm 

the lower tiers spill over onto the higher tiers either to meet the resource needs or to make 

policy decisions to cope with the lack of resources. 

Chapter V. Hospital/Acute Care 58 
Figure 1. The Decisionmaking Process for Resource Allocation and Policy Guidance 

Federal response

(regional and national)

Federal response

(support to State and locals) Tier 6

Interstate regional coordination

(management coordination

and mutual support) Tier 5

State response and coordination

of intrastate jurisdictions 

(management coordination and 

support to jurisdictions)

Tier 4

Jurisdiction incident 

management (medical IMS 

and emergency support—

EOC)

Tier 3

Healthcare “coalition” (info 

sharing, cooperative 

planning, mutual aid) Tier 2

Healthcare asset management

(EMP+EOP using

incident management)

Tier 1

State A State B

State A

Jurisdiction I

(PH/EM/public safety)

Jurisdiction II

(PH/EM/public safety)

Medical

Support

HCF A HCF B HCF C Non-HCF 

providers

HCF A

EMP = Emergency Management Program

EOP = Emergency Operations Plan

PH = Public Health

EM = Emergency Management

 

Source: Medical Surge Capacity and Capability: A Management System to Integrate Medical and Health Resources During 

Large-scale Emergencies. CNA Corporation, under contract to HHS (August 2004). Available at 

http://www.hhs.gov/ophep/publications.html. Accessed November 27, 2006. 

Coordinating Community and Regional Planning of Hospital/Acute 

Care MCE Responses 

Regional Planning 

The State health department has the overall responsibility for projecting health resource 

needs in the event of a major health-related emergency and for allocating scarce resources to 

meet those needs. Some States have intrastate regional coalitions (clearinghouse 

hospitals, regional coordinating hospitals), which can assist the State health department in 

managing resource allocation within their area. This arrangement establishes a more effective 

span of control for the State, with only a few regions rather than multiple individual facilities, 

reporting data and resource needs. It also allows for plans to consolidate inventories of supplies, 

epidemiological data, medical response, communications, and command and control. These 

intrastate regional coalitions, where they exist, should be incorporated into regional MultiAgency Coordination (MAC) planning and response (see Figure 2). Planners should expect that 

Chapter V. Hospital/Acute Care 59 
there will be issues with communication, coordination, and overlapping responsibilities, and 

thus it is important to practice all elements of the State, regional, or local interface in advance. 

Such advance practice would enable planners to find ways to account for and adapt to the 

variability in relationships among local emergency operations centers, hospitals, regional 

MACs, and the State. 

Figure 2. MAC Model 

Hospital A

Hospital B

Hospital C

Clinical 

Coordination

Health 

System

Regional Hospital 

Coordinating Center

Multi-Agency 

Coordination Center

EM EMS PH

A

B

C A B C

A

B

C

Jurisdiction

Emergency

Management

Public Health 

Agencies

EMS Agencies

Hospital A

Hospital B

Hospital C

Clinical 

Coordination

Health 

System

Regional Hospital 

Coordinating Center

Multi-Agency 

Coordination Center

EM EMS PH

A

B

C A B C

A

B

C

Jurisdiction

Emergency

Management

Public Health 

Agencies

EMS Agencies

Lines illustrate relationships within the MAC. Communication and coordination should not be strictly limited to these channels 

of connection.

68 

Source: Based on Metropolitan Hospital Compact MAC model – Minneapolis/St. Paul, Minnesota. 

Interstate regional coordination is another means of managing allocation of scarce resources. 

Interstate agreements and cooperation help promote sharing of assets across State lines. These 

types of agreements also help ensure consistency of response (e.g., National Capital Region) 

where inconsistencies between State plans could prove problematic. This level of interstate 

cooperation is difficult to achieve but is one of the most important ways to maximize resource 

allocation. The development of national-level clinical decision tools to address commonly 

limited resources (e.g., dialysis, mechanical ventilation) would be very valuable in helping to 

facilitate greater interstate cooperation. 

Chapter V. Hospital/Acute Care 60 
PLANNING RESOURCES

The Minnesota Department of Health MAC Plan has been developed to facilitate health-related 

policy coordination and resource allocation decisions among multiple jurisdictions and health-related 

entities to provide for the safe, rapid, and coordinated response to a health-related emergency. 

Information is available at 

http://www.health.state.mn.us/oep/planning/allhazards.html#macresponserecovery.

A Patient Care Coordination Planning Guide, also developed by the Minnesota Department of 

Health, is available on CD by request to MDH Office of Emergency Preparedness at 

http://www.health.state.mn.us/oep.

Coordination and communication 

The State, rather than local jurisdictions, should take responsibility for overall risk 

communication management. This includes information provided to hospitals and health care 

systems, as well as the provision of public information releases and information for providers or 

members of the public that are posted through telephone, the Internet, the media, and other 

access points. A JIC should be established as well as other ways to link communications at the 

local, jurisdictional, and State levels to establish mechanisms for media message development. 

Communications strategies must be established and practiced ahead of time to ensure that 

messages will come from accurate sources in a timely and consistent manner. These strategies 

should include the use of risk communication, regular media releases, and press conferences. 

JOINT INFORMATION CENTER (JIC)

A JIC is a centralized communication hub for handling emergency events. It serves to gather incident 

data, analyze public perceptions of the event, and give the public or special targeted audiences 

accurate and comprehensive incident and response information. Planning for the JIC should be 

undertaken in advance, including processes, procedures, and staff training. This allows communities to 

be more proactive in their response to the information needs of the public, industry, and government. A 

full description of the JIC model is available from the U.S. National Response Team Web site at 

http://www.nrt.org/production/nrt/nrtweb.nsf/allattachmentsbytitle/A55jic/$file/jic.pdf?openelement. 

Using expert panels or planning groups 

At this time, no current predictive model is sufficient to serve as a decision framework for 

determining the allocation of critical care resources (e.g., ventilators, intensive care therapies). 

One valuable strategy for examining the allocation of scarce resources, however, is to convene a 

Chapter V. Hospital/Acute Care 61 
balanced expert panel that can bring in multiple viewpoints and establish decisionmaking 

guidelines. The panel must be inclusive of relevant stakeholders who reflect the jurisdictional 

area and its demographics, in addition to recognizing border issues with adjoining States. The 

composition, functions, and operational role of these groups must be carefully considered. 

CONVENING AN EXPERT PANEL TO ADDRESS THE ALLOCATION OF SCARCE RESOURCES: THE 

EXAMPLE OF NEW YORK STATE

In March 2006, the New York State Task Force on Life and the Law (TFLL), in partnership with the 

State’s Department of Health, convened a workgroup to consider clinical and ethical challenges in 

the allocation of mechanical ventilators in a public health crisis. The group includes experts in the 

areas of law, medicine, policymaking, and ethics. Its goal is to develop clinical and ethical guidance 

for local health care systems that will promote the just allocation of ventilators in an influenza 

pandemic. The panel considered a range of policy options necessary to support such an allocation 

system, including the development of recommendations for laws or regulations in areas including 

liability and appropriate standards of care. Further information on the TFLL is available at 

www.health.state.ny.us/nysdoh/taskfce/index. 

Issues of resource allocation ideally would be addressed by expert panels or groups as part of 

MCE planning. An ad hoc expert panel may be called on to address an unexpected event to 

determine which factors will be used for decisionmaking based on a particular situation and the 

specific resource in short supply. The community member panels that allocated scarce 

hemodialysis resources in the city of Seattle during the 1960s can serve as an historic example 

of this process. 

USING COMMUNITY PANELS TO HELP ALLOCATE SCARCE RESOURCES: THE EXAMPLE OF 

HEMODIALYSIS IN SEATTLE

When hemodialysis was first introduced in 1960, it was available only in limited supply. In order to 

decide which patients would receive this life-prolonging treatment, the city of Seattle established a twocommittee decisionmaking process. The first committee was comprised of physicians and the second 

made up of a cross-section of community representatives. The physician committee took into account 

medical and psychiatric criteria, while the community group weighed factors such as age, future 

potential, and other intangible measures of personal and community value. 

Chapter V. Hospital/Acute Care 62 
Some questions that States should consider when developing an expert panel include: 

 Is the group considered an advisory body or a policy development body for the 

health department? If it is advisory, what internal process within the department is followed to 

develop and approve the policy? 

 What is the liability of the members of the group (if any) for their decisions? 

 What is the expectation of the group during an event? How often will they meet? What will 

be their sources of information? Is there enough redundancy in the group in case of illness or 

absence? 

 Would the composition of the group need to be modified based on the type of MCE? If so, 

who would decide? 

How does the group convene, develop consensus and recommendations, and modify them as 

needed? 

The recommendations of the expert panel should be vetted and shared with larger, more diverse 

groups to allow feedback and further modifications. Those groups might include physicians or 

other health care professionals, palliative care providers, ethicists, State health officers, 

representatives from the Office of Emergency Preparedness, community leaders, and others. 

Any guidelines or decisionmaking framework developed should be circulated between facilities 

and jurisdictions prior to an event. 

Increasing System Capacity During an MCE 

During an MCE, the capacity of the health care system should be expanded according to an 

incident management system-directed mobilization of physical space, personnel, and material 

resources – sometimes referred to as “space, staff, and stuff.” For example, in advance of an 

MCE, hospitals should establish a preference list of supplemental providers to expand staff 

capacity. These providers might include local hospital staff, clinic staff, and health professional 

volunteers who have registered with and had their credentials verified by one of the State 

Emergency Systems for Advance Registration of Volunteer Healthcare Professionals (ESARVHP), Medical Reserve Corps, National Disaster Medical System teams, trainees, patient 

family members, military members, Community Emergency Response Teams, and lay 

volunteers. Policies should be in place in advance to credential staff members and manage 

deployment of nonhospital personnel at community and hospital levels, and there should be a 

plan for managing spontaneous volunteers. 

Another critical component of increasing system capacity during an MCE is informing the 

public. It is important to provide the public with information on two fronts: information about 

ongoing events and how to care for themselves, as well as information that will enable them to 

make appropriate decisions about their own personal health care situation. This information 

Chapter V. Hospital/Acute Care 63 
process will help limit or slow the spread of disease while engaging the public in the allocation 

of scarce resources. 

The goal of informing the public can be achieved through a two-pronged approach: the use of 

effective media campaigns to educate and inform most of the public, supported by enlisting the 

assistance of established community health call centers (poison centers, nurse advice lines, 

public health hotlines) to help address the public’s additional concerns and questions. This 

approach should enable most people to care for themselves, and at the same time, will help to 

lessen demands on the healthcare system. 

Short-term strategies 

Short-term strategies may be applied to increase healthcare facility capacity in cases where 

resource shortages can be expected to be resolved relatively quickly (within hours or days). 

These strategies usually do not require a systematic assessment of the standard of care being 

provided. They may include the following: 

Increase space capacity with: 

 Rapid discharge of emergency department (ED) and other outpatients who can continue 

their care at home safely 

 Rapid discharge of inpatients who can safely continue their care at home (or at alternate 

facilities if they are available) 

 Cancellation of elective surgeries and procedures, with reassignment of surgical staff 

members and space 

 Reduction of the usual use of imaging, laboratory testing, and other ancillary services 

 Expansion of critical care capacity by placing select ventilated patients on monitored or 

step-down beds; using pulse oximetry (with high/low rate alarms) in lieu of cardiac monitors; or 

relying on ventilator alarms (which should alert for disconnect, high pressure, and apnea) for 

ventilated patients, with spot oximetry checks 

 Conversion of single rooms to double rooms or double rooms to triple rooms if possible 

 Designation of wards or areas of the facility that can be converted to negative pressure or 

isolated from the rest of the ventilation system for cohorting contagious patients; or use of these 

areas to cohort those health care providers caring for contagious patients to minimize disease 

transmission to uninfected patients 

 Use of cots and beds in flat space areas (e.g., classrooms, gymnasiums, lobbies) within the 

hospital for noncritical patient care 

 Transfer of patients to other institutions in the State, interstate region, or nationally. 

Chapter V. Hospital/Acute Care 64 
 Facilitation of home-based care for patients in cooperation with public health and home care 

agencies 

 Establishment of mobile or temporary evaluation and treatment facilities in the community 

to supplement usual clinic locations. These locations also may be used to screen those with mild 

symptoms when medications are available and must be taken early in the course of illness to be 

effective. 

Expand staff capacity with: 

 Call-in of appropriate staff members 

 Changes in staff scheduling (e.g., duration of shifts, staffing ratios, changes in staff 

assignments) 

 Requests for supplemental staff members from partner hospitals through the use of 

Emergency Systems for Advance Registration of Volunteer Health Professionals (ESAR VHP), 

clinics, the Medical Reserve Corps (MRC), the local American Red Cross, public health, public 

works, schools, or other agencies and State and Federal sources as applicable. 

STATE COORDINATION OF VOLUNTEER RESOURCES: EMERGENCY SYSTEMS FOR ADVANCE 

REGISTRATION OF VOLUNTEER HEALTH PROFESSIONALS 

State Emergency Systems for Advance Registration of Volunteer Health Professionals (ESAR-VHP) 

systems are statewide mechanisms for recruiting, registering, and verifying credential information of 

potential health volunteers in a State. These systems should support and include information about 

volunteers involved in organized efforts at the local level (such as MRC units) and the State level (such 

as National Disaster Medical System [NDMS] teams). The ESAR-VHP systems also will coordinate 

broader Statewide recruitment and registration of health professionals who would be willing to serve in 

an emergency, but are not interested in being a part of a trained, organized unit structure such as MRC 

or NDMS. State ESAR-VHP systems provide a single, centralized source of volunteer information to 

facilitate intrastate, State-to-State, and State-to-Federal transfer and mobilization of volunteer health 

professionals. 

More information about the national effort to develop State ESAR-VHP systems, including information 

about the legal protections offered to volunteers in each State and Territory, and links to State systems 

is available at http://www.hrsa.gov/esarvhp.

Chapter V. Hospital/Acute Care 65 
THE MEDICAL RESERVE CORPS (MRC) 

The mission of the MRC is to organize medical, public health, and other volunteers in support of existing 

programs and resources to improve the health and safety of communities and the Nation. MRC units 

provide personnel to support and supplement the existing emergency and public health agencies in the 

community. MRC leaders are encouraged to adopt an all-hazards approach and more broad-based public 

health initiatives, including a focus on increasing disease prevention efforts, and enhancing emergency 

preparedness. Medical Reserve Corps volunteers include medical and public health professionals such as 

physicians, nurses, pharmacists, dentists, veterinarians, and epidemiologists. During the 2005 Hurricane 

Season, MRC members provided support for American Red Cross health services, mental health and 

shelter operations. MRC members also supported Federal response efforts by staffing special needs 

shelters, Community Health Centers and health clinics, and assisting health assessment teams in the Gulf 

Coast region. For example, The Southside (Boydton, VA) MRC organized, conducted, and supervised a 

local food relief and water collection site for Hurricane Katrina victims. In all, 53,000 pounds of food and 

water were shipped to Lamar County, Mississippi. The Rhode Island MRC, along with the Rhode Island 

DMAT team, was largely responsible for staffing a weeklong clinic that received 105 evacuees from 

Louisiana. The clinic averaged 26 visits per day with daily blood pressure checks provided. Further 

information on MRC is available at http://www.medicalreservecorps.gov.

 Promotion of home care and discouragement of the “worried well” from seeking hospital 

evaluation and care through the use of media campaigns and access to community health call 

centers 

 Establishment of guidelines and public messaging describing how to evaluate symptoms, 

what treatment can be safely delayed, and how to care for themselves at home 

 Sharing of small numbers of specialized staff members (e.g., burn nurses, pediatric critical 

care staff members) with hospitals in need 

 Activation of memoranda of understanding (MOUs) with regional and distant hospitals, 

health systems, or State disaster medical assistance teams. 

Increase access to supplies by: 

 Activation of MOUs with commercial companies for supply chain continuity. 

If these strategies are not sufficient to meet the demands of the incident and no immediate relief 

is available, then a systematic evaluation of the level of care being provided must be conducted. 

These surge strategies should be reviewed and revised based on the available resources. 

Chapter V. Hospital/Acute Care 66 
The Spectrum of Adaptation: From Administrative to Clinical Change 

In the case of a longer-term resource shortage, strategies for meeting the event-generated 

demands of an MCE can be classified along a spectrum that includes two categories of changes: 

administrative adaptations and clinical adaptations, as shown in Figure 3 below. 

Figure 3. Administrative and Clinical Adaptations to Resource Poor Situations 

Usual patient

care provided

Austere patient

care provided

Incremental changes to standard of care

Administrative Changes Clinical Changes

to usual care to usual care

Triage set up in 

lobby area

Meals served by 

non-clinical staff

Nurse educators 

pulled to clinical 

duties

Disaster 

documentation forms 

used

Significant reduction 

in documentation

Significant changes in 

nurse/patient ratios

Use of non-healthcare 

workers to provide 

basic patient cares 

(bathing, assistance, 

feeding)

Cancel most/all 

outpatient 

appointments and 

procedures

Vital signs checked 

less regularly

Deny care to those 

presenting to ED with 

minor symptoms

Stable ventilator 

patients managed on 

stepdown beds

Minimal lab and x-ray 

testing

Re-allocate ventilators 

due to shortage

Significantly raise 

threshold for 

admission (chest pain 

with normal ECG goes 

home, etc.)

Send select patients to 

alternate care site

Allocate limited 

anti-virals to select 

patients

Low impact

Administration changes

High-impact

Clinical changes

Need increasingly exceeds resources

ADMINISTRATIVE ADAPTATIONS are designed to increase provider availability for patient care. 

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. 

Chapter V. Hospital/Acute Care 67 
Administrative changes generally can be implemented with minimal discussion by hospital 

administration or nursing personnel, but such changes require preplanning. Examples of 

administrative changes may include the following: 

 Changes to reduce provider documentation, billing and coding, registration, and other 

administrative policy burdens. These should be discussed in advance with the State and Federal 

agencies that oversee public health insurance programs and with private payers. 

 Cancellation of elective procedures. 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. 

 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 within each department as needed 

to cope with the impact of the event. 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. 

SURGE CAPACITY RESOURCES 

The Joint Commission on Accreditation of Healthcare Facilities Report Surge Hospitals: Providing Safe 

Care in Emergencies is available online at 

http://www.jointcommission.org/PublicPolicy/surge_hospitals.htm. 

Seamless Emergency Medical Logistics Expansion System (SEMLES) promotes the development of 

collaborative relationships between public and private entities and between local and regional partners 

to expand surge capacity. Information on SEMLES is available at 

http://www.disasterhelp.net/resources. 

One important staffing issue to consider 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 a threat 

to themselves or their family members from contamination by biological or radiological agents. 

Certain States have provisions to delicense or otherwise sanction (or even arrest, in the State of 

Maryland) providers who do not report for duty during a declared disaster. It is important, to 

remember, however, that although health care providers have a duty to act and may have been 

supported in their training by Federal dollars, there are real concerns about the “duty to family” 

and issues of child care, among others, which may not be solved easily. 

Careful determination of priority groups and essential personnel as well as facilitation of child 

care, providing adequate PPE, providing housing apart from family for workers who request it, 

Chapter V. Hospital/Acute Care 68 
and other “carrots” need to accompany the regulatory “sticks” designed to ensure that health 

care workers are able to work (and work safely) during a disaster. 

CLINICAL ADAPTATIONS represent the allocation of scarce resources or services based on the 

ethical principles outlined in Chapter 2. 

Examples of clinical adaptations include the following: 

 Triage of patients to home care, acute care sites, or other offsite locals who would otherwise 

be treated as inpatients 

 Assignment of limited resources (e.g., ventilators, radiographs, laboratory testing) to those 

most expected to benefit 

 Provision of specialty care (e.g., burn or intensive care) by nonspecialty trained staff 

members (ideally with supervision by appropriately trained staff members). 

Implementing Clinical Changes to Respond to an MCE 

EXAMPLES OF POSSIBLE RESPONSE PROCESSES

 The incident commander recognizes the need for systematic clinical changes. 

 The planning chief gathers any guidelines, information, and resources. 

 A clinical care committee (predetermined members and designees for toxic, infectious, and 

trauma situations) is convened. Members may include a hospital administrator, a hospital 

attorney, nursing supervisor, a respiratory care supervisor, a hospital ethicist, a community 

representative, and representatives from clinical departments. 

 The clinical care committee reviews existing strategies/protocols and determines: 

● Methods to meet patient care needs, location of care, assignment of resources 

● Additional changes in staff responsibilities to redistribute specialized staff and incorporate 

other health care providers, lay providers, or family members 

● A mechanism to reassess local/regional hospital efforts and needs and recommend 

changes on a regular basis. 

 Information is disseminated to inpatient services, outpatient services, the regional hospital 

coordination point, and State and local health departments. 

 Security and behavioral health response plans are implemented. 

 Triage plan is implemented to determine ED/outpatient screening of patients, patient 

discharge, removal from therapy, and bed assignments. 

 Just-in-time training or education is implemented for health care workers, patients, and family 

members. 

Chapter V. Hospital/Acute Care 69 
The hospital should be able to follow State guidance regarding clinical triage decisions. If no 

guidance exists, it will be incumbent on the hospital to have a plan or strategy for bringing 

together the appropriate personnel who can make the best decisions possible and reevaluate the 

situation during each planning cycle (e.g., each shift a day). When there is little advance 

evidence to guide allocation decisions (for example, not knowing how different age groups with 

pandemic influenza respond to mechanical ventilation), good clinical judgment by experienced 

clinicians will be the final common denominator to justify resource allocation decisions. The 

decisionmaking process, based on ethical judgments that include maximizing good 

consequences across the many while meeting at least minimal duties and obligations to all, 

should be shared openly with staff members, patients, and the public and should be as consistent 

as possible across facilities. 

The goal is to adjust clinical care to a level appropriate to the resources available and to do so in 

as smooth, transparent, consistent, and incremental a fashion as possible. There are no clear 

“trigger” or “trip” points to indicate when the shift from reactive, mostly administrative changes 

to proactive, clinical changes must occur. Communities and regions should coordinate as much 

as possible. Situational awareness by the Incident Commander and Planning Section Chief can 

help anticipate or recognize resource bottlenecks that may require intervention. 

Allocating Scarce Resources 

Patient assessment 

The American Medical Association (AMA) has identified five important criteria to consider 

when the allocation of scarce resources is required: likelihood of benefit, change in quality of 

life, duration of benefit, urgency of need, and amount of resources required. According to the 

AMA guidance, all five of these criteria must be considered. If there is no differentiation in the 

criteria between patients, then resources should be allocated on a “first come, first served” basis. 

At a minimum, patient assessment should include the following factors: 

 The patient’s need for the resource 

 Potential to return to the baseline state 

 Overall acute resource needs of the patient 

 Age and functional assessment (e.g., Quality Adjusted Life Years or other tools when 

significant functional differences are present between patients) 

 Underlying health and prognosis related to an underlying disease(s) 

 Event-specific or injury-specific prognostic factors. 

Chapter V. Hospital/Acute Care 70 
Patient triage 

There are three basic types of triage. Primary triage is the first triage of patients into the medical 

system (it may occur prehospital), at which point patients are assigned an acuity level based on 

the severity of their illness/disease. Secondary triage is the reevaluation of the patient’s 

condition after initial medical care (see box).69 This may occur at the hospital following EMS 

interventions or after initial interventions in the ED. Tertiary triage is the reevaluation of the 

patients’ response to treatment after further interventions and is ongoing during their hospital 

stay. This is the least practiced and least well-defined type of triage. 

Historically, triage has involved four levels of priority for traumatic injuries: 

 Green – delayed treatment – has minor injuries or illness and should not pose a threat to life 

or limb. 

 Yellow – intermediate – has injuries or 

illness that may result in death or disability but 

pose no immediate threat to life or limb. 

It is important to note that criteria such as gender, 

race, ability to pay, social worth, perceived 

obstacles to treatment, patient contribution to 

 Red – critical – has injuries or illness that 

will result in death within the hour unless 

interventions occur. 

illness, or past use of resources are not 

appropriate criteria for determining the allocation 

of scarce resources. Age may be considered only 

as it relates to underlying  Black – expectant or deceased – is 

expected to die because of severity of illness or 

injuries or has died. 

organ function and prognosis. 

An experienced health care provider should be involved in any decision to classify a patient as 

“black” during a disaster. As described in Chapter VII, all such patients should have access to 

palliative care (analgesia, sedation, physical and behavioral cares) to the extent possible under 

the circumstances. Expectant patients should be reassessed regularly for comfort, for 

improvements in their situation, or in case resources become available unexpectedly. 

Studies have shown that experienced health care providers are generally very accurate at 

assigning triage levels in the ED on a daily basis,70 though there are no studies to determine to 

what degree this is true in disasters. 

An example of an existing triage tool is the Emergency Severity Index (ESI), perhaps the beststudied hospital ED approach to triage. While highly predictive of resource use within the ED, 

the ESI was not designed, however, for disaster situations per se. Simple Triage and Rapid 

Treatment triage may be used for traumatic injuries, but it is perhaps too simplistic for 

application in the ED setting and has not been validated. 

Chapter V. Hospital/Acute Care 71 
THE EMERGENCY SEVERITY INDEX (ESI) 

The ESI is a five-level ED triage algorithm that provides clinically relevant stratification of patients into 

five groups, from 1 (most urgent) to 5 (least urgent), on the basis of acuity and resource needs. The 

ESI Implementation Handbook is available at http://www.ahrq.gov/research/esi/esi1.htm. 

Overall illness severity and mortality prediction scores (Mortality Probability Model II, 

Sequential Organ Failure Assessment) and organ system-specific mortality predictors 

(oxygenation index – FiO2 x mean airway pressure / pO2 has predictive value in pediatric 

patients, for example) may be used to provide quantitative estimates of survival or severity. 

These prediction scores present limitations, however, in that they are validated on cohorts, not 

individuals, and generally require data obtained from laboratory or other invasive measures.71,72

An example of a secondary triage decision tool is the American Burn Association table of 

mortality graphed against age and percent body surface area burns, which allows a burn surgeon 

to make immediate rough determinations of the resource needs and projected mortality of a 

given patent and allocate, when needed, limited resources available. 

Select Operational Considerations 

In addition to allocating scarce resources, an MCE will require that hospitals also address many 

operational considerations, including security and mass mortuary. 

Security 

Disasters that require systematic changes in the provision of health care are likely to have had 

similar pronounced effects on the community at large. Civil unrest due to supply line 

disruptions, infrastructure damage, and resource scarcity are not uncommon in such situations. 

Resources in short supply may be subject to hoarding or internal pilfering (e.g., of vaccine, of 

antibiotics). Any changes in usual clinical care that result in resources not being available to all 

patients who may need them may increase the potential for violence against health care 

facilities and providers. 

Hospitals should work with their community law enforcement agencies and security staff 

members to develop a security assessment and vulnerability analysis and a plan for augmenting 

hospital security during a widespread disaster, when demands on law enforcement may be 

extreme. This plan should prioritize hospital assets for protection and rely, when possible, on 

physical and technological, rather than human solutions. Proactive communication with the 

public can reduce the potential for civil unrest and should be part of community and 

institutional strategies. 

Chapter V. Hospital/Acute Care 72 
Security measures that hospitals may wish to consider in an MCE include: 

 Increased security personnel 

 Increased monitoring of hospital premises and surroundings 

 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) 

 Single or few designated entrances 

 The limit of a single visitor (or no visitors) per patient 

 Metal detectors and security screening at entry points 

 Augmented law enforcement presence (must have mutual aid agreements in place ahead of 

an event; consider uniformed peace officers or National Guard personnel) 

 Equipping and training hospital security personnel with less-than-lethal methods of 

behavioral control (if not already so equipped) with appropriate policies and oversight (e.g., 

batons, pepper spray, TASER electroshock guns or similar electric-current immobilizer 

devices). 

 Other deterrents at entrances (presence of canine officers, increased uniformed security 

presence). 

Mass Mortuary 

Hospitals should understand clearly the community plan for management of excess casualties. 

In some cases, hospital responsibilities for record keeping and reporting will change in a 

disaster. Temporary facility morgue locations may be required, and regional processing sites 

may be needed. The role of the medical examiner’s office versus that of public health should be 

clearly defined. This should include situations such as pandemic influenza, which normally 

would not involve the medical examiner’s office. 

Provisions should be made for appropriate solutions to barriers presented by culturally based 

funeral and burial practices. Every effort should be made to preplan 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 that the minimum level of disruption to usual 

cultural practices and the maximum level of dignity are afforded the deceased and their 

families. 

Chapter V. Hospital/Acute Care 73 
CONDUCTING PATIENT TRIAGE 

NEW ORLEANS INTERNATIONAL AIRPORT – HURRICANE KATRINA

Three Disaster Medical Assistance Teams (DMATs) were faced with the task of providing medical care 

to tens of thousands of patients at New Orleans International Airport who had been evacuated or 

rescued from their homes, nursing homes, and hospitals. Approximately 300 of these patients were 

stretcher bound. Few had acute injuries, but many had complex medical problems exacerbated by 

dehydration, infections, and lack of medications. 

There was essentially no ability to communicate externally, nor was there an identified command 

element to request additional resources and evacuation assistance in the first 24 hours of the 

operation. Standard triage tags were used for nonambulatory patients, and they were prioritized for 

care and evacuation. Approximately 50 extremely sick patients were tagged as “expectant” due to the 

lack of clinical resources and transferred to a separate area of the airport. Many of these were elderly 

with complex underlying health problems and unstable vital signs, coma, or other poor prognostic signs 

– and were expected by the clinician to die within the next 24 hours. As staff members and resources 

became available, some of these individuals were reclassified as “red” and provided care. Ultimately, 

only 26 of these patients died, thanks to the efforts of the DMATs, who also treated hundreds of other 

critical and serious patients. A Herculean evacuation effort over the subsequent several days and the 

arrival of additional staff members and resources prevented further deaths. 

Endnotes

63 Society of Critical Care Medicine Ethics Committee. Consensus statement on the triage of critically ill patients. JAMA. 

1994;271:1200–1203. 

 Institute of Medicine. Hospital-based Emergency Care: At the Breaking Point. Washington: National Academies Press; 2006. 64

Niska RW, Burt CW. Bioterrorism and mass casualty preparedness in hospitals: United States, 2003 65 . Advance Data. 

2005;364:1–11. 

66 Barbera J, Macintyre A. Medical and Health Incident Management System: A Comprehensive Functional System Description 

for Mass Casualty Medical and Health Incident Management. Washington: George Washington University Institute for Crisis, 

Disaster, and Risk Management; December 2002. Available at: www.gwu.edu/~icdrm. Accessed November 16, 2003. 

 Institute of Medicine. Hospital-based Emergency Care: At the Breaking Point. Washington: National Academies Press, 2006. 67

 Based on Metropolitan Hospital Compact MAC model–Minneapolis/St. Paul, MN. 68

69 Saffle JR, Gibran N, and Jordan M. Defining the ratio of outcomes to resources for triage of burn patients in mass casualties. 

Journal of Burn Care & Rehabilitation. November/December 2005;26(6): 478-482. 

70 Lemeshow S, et al. Mortality probability models based on an international cohort of intensive care unit patients. JAMA. 

1993;270:2478–2486. 

71 Herridge MS. Prognostication and intensive care unit outcome: the evolving role of scoring systems. Clinics in Chest Medicine. 

2003;24(4):751–762. 

72 Pettila V, Pettila M, Sarna S, Voutilainen P, Takkunen O. Comparison of multiple organ dysfunction scores in the prediction of

hospital mortality in the critically ill. Critical Care Medicine. August 2002;30(8):1705–1711. 

Chapter V. Hospital/Acute Care 74 
Chapter VI. Alternative Care Sites 

AUTHORS 

Stephen Cantrill, M.D., Lead Author, Associate Director, Department of Emergency Medicine, Denver Health Medical Center 

Carl Bonnett, M.D., Emergency Medical Services Fellow, Department of Emergency Medicine, Denver Health Medical Center 

Dan Hanfling, M.D., Director, Emergency Management and Disaster Medicine, Inova Health System 

Peter Pons, M.D., Professor of Emergency Medicine, Department of Surgery, University of Colorado Health Sciences Center 

This chapter discusses the issues surrounding non-Federal, 

non-hospital-based alternative care sites (ACSs). It describes 

different types of ACSs as well as critical issues and decisions 

that will need to be made regarding these sites during mass casualty 

event. Potential barriers are addressed, 

and examples of case studies are included. 

Chapter VI. Alternative Care Sites 75 
Alternative Care Sites (ACS) Issues and Recommendations At A Glance 

MAJOR CHALLENGES TO SUCCESSFUL ACS PLANNING AND ESTABLISHMENT

o Lack of regional and State planning with clear delineation of responsibilities and authority 

o The requirement that multiple groups work together who traditionally have not done so, including 

health care providers with conflicting institutional allegiances, hospitals, emergency managers, 

regional planners, and local and State health departments 

o Lack of financial inducements to create, drill, and execute the plan 

o Issues regarding professional licensing; verification; and supervision, both intra-and interstate 

o Funding and compensation issues 

RECOMMENDATIONS FOR ACS PLANNERS

o Ensure that all communities have an integrated mass casualty event (MCE) plan in place to provide 

for expansion of health care services into ACSs when existing health care providers and institutions 

become overwhelmed. 

o Constitute a planning and implementation committee comprised of, at a minimum, emergency 

managers, planners, public health departments, health care providers and institutions, local and 

regional government representatives, and appropriate private partners. 

o Ensure that a concept of operations (CONOPS) document is prepared to define in advance the 

anticipated role that the ACS facility will serve. 

o Identify and assess potential sites for implementation of an ACS prior to an incident. Whenever 

possible, put in place agreements to permit such use. 

o Obtain, stockpile, and store supplies, equipment, and pharmaceuticals sufficient to meet the 

anticipated role for the ACS as defined in the CONOPS in a fashion that will permit rapid deployment 

to a selected site. 

o Prepare a plan for personnel staffing sufficient to meet the anticipated role for the ACS as defined in 

the CONOPS. 

o Anticipate and plan for operational and logistic support of the ACS. 

o Plan for the needs of pediatric patients. 

Background 

The impact of an MCE of any significant magnitude likely will overwhelm – and indeed may 

render inoperable – hospitals and other traditional venues for health care services. This situation 

will necessitate the establishment of ACSs for the provision of care that normally would be 

provided in an inpatient facility, including acute, subacute, and chronic care. 

The concept of providing medical care in a nonhospital ACS has been demonstrated throughout 

history: during the Civil War, the aftermath of the San Francisco earthquake of 1906, the 

influenza pandemic of 1918–1919, and more recently the aftermath of Hurricane Katrina. 

During the Cold War in the 1950s and 1960s, this concept was developed and formalized by the 

U.S. Civil Defense Agency in cooperation with the Department of Health, Education and 

Welfare as “Packaged Disaster Hospitals” (PDHs). These PDHs consisted of modularized, 

predeployed units for 50, 100, or 200 beds. In 1972, Congress discontinued its support funding 

Chapter VI. Alternative Care Sites 76
for the PDH concept. The 2,500 deployed units were declared to be surplus and were discarded 

over the next decade. More than three decades later, however, we find ourselves in the 

interesting position of rediscovering, resurrecting, and refining the concept of ACSs. 

ACSs in the Context of an MCE 

The focus on catastrophic bioterrorism over the past decade has resulted in some key efforts in 

the development of the concept of ACSs. The most widely recognized effort has been the 

development of the Acute Care Center (ACC) and Neighborhood Emergency Health Center 

(NEHC) concepts by the U.S. Army Soldier and Biological Chemical Command (SBCCOM). 

NEHC AND ACC CONCEPTS

Under the auspices of the Department of Defense and the Domestic Preparedness Program, the 

Biological Weapons Improved Response Program developed the Modular Emergency Medical System 

(MEMS) to provide systematic, coordinated, and effective medical response in the event of a largescale biological terrorism incident. MEMS strategy established a framework for which outside medical 

resources could be used to enhance local response efforts in two types of expandable patient care 

modules: the NEHC and the ACC. The NEHC is designed to function as a high-volume casualty 

reception center, performing victim triage and dispensing medicines and information. The ACC is 

designed and equipped to treat patients who need inpatient treatment but do not require mechanical 

ventilation and those who are likely to die from an illness resulting from an agent of bioterrorism. 

Sources: Acute Care Centers: A Mass Casualty Care Strategy for Biological Terrorism Incidents (December 2001), 

and Neighborhood Emergency Help Centers: A Mass Casualty Care Strategy for Biological Terrorism Incidents 

(May 2001). Both documents prepared in response to the Nunn-Lugar Domestic Preparedness Program by the 

Department of Defense. See http://www.nnemmrs.org/surge.html. 

The innovative body of work surrounding the development of the ACC and NEHC concepts has 

addressed several key issues related to the delivery of care outside of established hospitals, 

including: 

 The level and scope of care to be delivered 

 The physical plant required for the establishment of such facilities 

 Staffing requirements for delivery of such care 

 Medical equipment and supplies requirements 

 The incident management system required to integrate such facilities with the overall 

delivery of health care in the context of a disaster. 

Chapter VI. Alternative Care Sites 77
In the aftermath of the September 11, 2001, attacks, more concerted focus was placed on the 

definition and development of public health and medical surge capacity. A distinction was 

drawn between health care facility surge capacity and community surge capacity, with the 

understanding that community surge capacity strategies were focused on the creation of out-ofhospital solutions to the delivery of health care, closely mirroring the ACC concept.

This understanding led to the emergence of a new definition of ACS, one that included a 

location for the delivery of medical care that occurs outside the acute hospital setting for 

patients who, under normal circumstances, would be treated as inpatients. In addition, the ACS 

has come to be viewed as a site to provide event-specific management of unique considerations 

that might arise in the context of catastrophic MCEs, including the delivery of chronic care; the 

distribution of vaccines or medical countermeasures; or the quarantine, cohorting, or 

sequestration of potentially infected patients in the context of an easily transmissible infectious 

disease. 

Surge Capacity 

Further conceptual development of surge capacity was conducted by the Joint Commission on 

Accreditation of Healthcare Organizations (JCAHO) and focused on the establishment of “surge 

hospitals.” The JCAHO identified three types of surge hospitals: 

 FACILITIES OF OPPORTUNITY, which are 

defined as nonmedical buildings which, 

because of their size or proximity to a 

medical center, can be adapted into surge 

hospitals 

Planners may download the guide, Surge 

Hospitals: Providing Safe Care in Emergencies,

from www.jointcommission.org.

 MOBILE MEDICAL FACILITIES, which are mobile surge hospitals based on tractor-trailer 

platforms with surgical and intensive care capabilities 

 PORTABLE FACILITIES, which are mobile medical facilities that can be set up quickly and are 

fully equipped, self-contained, turnkey systems usually stored in a container system and based 

on military medical contingency planning. 

All three types of contingencies were used and deployed in the aftermath of Hurricane Katrina. 

Challenges to Successful ACS Planning and Implementation 

While recent experiences with Hurricanes Katrina and Rita clearly demonstrate the need for 

ACSs to provide medical care at the time of an MCE, there are multiple impediments to 

successful ACS planning and establishment. The most significant challenges include: 

 Lack of regional and State planning with clear delineation of responsibilities and authority 

Chapter VI. Alternative Care Sites 78
 The requirement that multiple groups work together who traditionally have not done so, 

including health care providers with conflicting institutional allegiances, hospitals, emergency 

managers, regional planners, and local and State health departments 

 Lack of inducements to create, drill, and execute the plan 

 Issues regarding health professional licensing; verification; and supervision, both intra- and 

interstate 

 Funding issues.

Key Issues in ACS Planning 

To respond effectively to an MCE, advance planning is critical. Community planners (from 

municipal agencies, including public safety, public health, and emergency management as well 

as representatives from local health care organizations or institutions) must conceive of a plan 

for how the ACSs would deliver wide-ranging medical services to the population in need. This 

planning must be done with existing health care facilities (hospitals, outpatient clinics, and 

multispecialty group offices) and home care entities. Planners must delineate the specific 

medical functions and treatment objectives that the ACS facility would need to accomplish. 

This approach assumes that an organized mechanism exists for triage of patients into highacuity, moderate-acuity, low-acuity, and expectant/expired categories, so that patient needs are 

matched with available medical resources. The division of patients also must identify those 

patients for whom no manner of medical intervention is likely to result in a positive outcome 

and are therefore candidates for palliative care. Such planning also assumes that the most 

severely ill or injured high-acuity patients can receive medical care commensurate only with 

what would be expected within the setting of a hospital facility or an ACS that is outfitted to 

serve as an acute care hospital, which is unlikely. 

The biggest challenge, however, is the fact that most communities will not be able to procure 

the amount and complexity of resources or the level of staffing required to extend hospital 

facilities into designated ACSs. For this reason, most ACSs will be located in “buildings of 

convenience.” It is imperative for planners to establish clear operational definitions of what can 

and cannot be accomplished in the setting of an ACS. 

Chapter VI. Alternative Care Sites 79
Getting Started with an ACS 

WHAT TO DO?

The most important step in attempting to overcome the challenges to successful ACS planning and 

implementation is to begin the planning process. 

HOW TO DO IT?

A single individual or group must recognize that planning for ACS is a mandatory part of all hazards 

preparedness and identify or establish an administrative structure to begin the planning process. 

WHO SHOULD BE INVOLVED?

Participants in this process should include emergency managers, community planners, public health 

(local and State), public safety, emergency medical services (EMS), area health care facilities, and 

health care providers. 

The development of ACS plans will not be accomplished in a vacuum. Key planning issues to 

consider include the following: 

 Local health care and emergency management systems all should be involved not only in 

the ACS planning process but in the commitment of financial support as well. 

 Any regional health care alliance that is formed to plan for response to disasters must 

integrate ACSs into their operating plans. As such, these facilities must fit within the broader 

spectrum of medical and health care incident management. Community planners must identify 

the logistical support necessary for establishing such ACSs. 

 Community planners should identify and create protocol-driven patient management 

objectives, based on assumptions about the types of patients that would be treated in such ACS 

facilities. 

Chapter VI. Alternative Care Sites 80
Different Uses of an ACS 

ACS facilities ultimately may be developed to serve different purposes depending on the 

circumstances requiring their use. An ACS might be designed to serve as one of the following: 

o A primary triage point, helping decide which patients require hospitalization, can be managed at 

home, might benefit from observational care and minimal interventions available at the ACS, or 

require palliative care which also might be available at an ACS. Such a facility might be reasonably 

expected to cohort a group of patients who were exposed to certain infectious agents but do not need 

more than continued observation and minimal, if any, medical intervention. 

o A community-focused ambulatory care clinic that serves as a point of distribution for 

medications, vaccinations, or other medical interventions that must be delivered to a wide population. 

o A low-acuity patient care site to permit the offloading of stable patients from hospitals to 

enhance their internal patient care capability or as primary sites for the care of stable low-acuity 

patients. 

Key Issues in ACS Establishment and Operation 

The successful establishment and operation of an ACS is, by its very nature, a complex 

undertaking, with a variety of issues to be addressed. As is the case with all aspects of 

preparedness, these issues are best vetted and investigated well before an event that necessitates 

their implementation. Several of the points discussed below also will apply to the situation 

where a locale is not setting up its own ACS but rather is operating in a supportive role of a 

Federal Medical Station (FMS) ACS. 

FMSs are designed to provide surge medical capacity (equipment, material, pharmaceuticals) to 

communities overwhelmed by mass casualties. They can provide rapidly deployable health and 

medical care to those patients who have nonacute medical, mental health, or other health-related 

needs that cannot be accommodated or provided for in a general shelter population. They also 

provide health and medical care for patients with needs such as: 

 Conditions that require observation, assessment, or maintenance. 

 Chronic conditions which require assistance with the activities of daily living but do not 

require hospitalization. 

 Medications and vital sign monitoring, particularly for patients who are unable to do so at 

home. 

Chapter VI. Alternative Care Sites 81
“Ownership,” command, and control of the ACS 

The single most important issue for the successful establishment of an ACS is the determination 

of ownership, command, and control of the ACS. These issues should be decided at a local or 

regional (as opposed to institutional) level and must involve the identification of the 

individual(s) with the authority to decide whether, when, and where an ACS should be opened 

and the authority to operate the site. 

The most effective way to make such decisions is to use and build on the organizational and 

governance structure that is already functioning in the region or State. The administrative 

structure for operation of an ACS should follow the basic concepts of the hospital incident 

command system discussed earlier in this guide and reviewed below. 

The Hospital Emergency Incident Command System (HEICS) was developed in the early 1990s 

to provide an emergency management system for hospitals for use during a medical disaster, but 

the concept has been adapted to other areas of emergency response as well and certainly lends 

itself to providing structure and organization to the operation of an ACS. Indeed, many ACSs 

that were set up during Hurricanes Katrina and Rita used the basic concepts of HEICS, which 

were then altered to fit the unique aspects of the ACS. HEICS, now known as HICS, provides 

an emergency management system that provides a logical, flexible management structure with a 

clear chain of command and is compliant with the National Incident Management System. 

Hospital Incident Command System* Management Structure 

The Incident Command Section provides overall coordination of the response and is the central 

communication point. 

The Operations Section is responsible for clinical duties including triage and treatment and directs all 

patient care resources. 

The Logistics Section is responsible for providing facilities; services, including food service and 

communications; and materials. 

The Planning Section determines and provides for the achievement of each medical objective and 

manages human resources. 

Finance and Administration is responsible for maintaining accounting records, issuing purchase 

orders, and stressing facility wide documentation. 

*Hospital Incident Command System is the new name for the revised Hospital Emergency Incident Command System. Planners 

are encouraged to view the updates posted at www.emsa.ca.gov . 

Chapter VI. Alternative Care Sites 82
Recommended Approaches to the ACS Planning Process 

1. Ensure that all communities (local and regional) have an integrated MCE plan in place to provide for 

expansion of health care services to ACSs when health care providers and institutions are overwhelmed. 

2. Convene a planning and implementation committee comprised, at a minimum, of emergency 

managers, planners, public health departments, health care providers and institutions, local and regional 

government representatives, and appropriate private partners. 

3. Ensure that a concept of operations (CONOPS) document is prepared to define in advance the 

anticipated role that the ACS facility will serve. 

4. Identify and assess potential sites for implementation of an ACS prior to an incident. Whenever 

possible, put in place agreements to permit such use. 

5. Obtain, stockpile, and store supplies and equipment sufficient to meet the anticipated role for the ACS 

as defined in the CONOPS in a fashion that will permit rapid deployment to a selected site. 

6. Prepare a plan for obtaining or stockpiling pharmaceuticals sufficient to meet the anticipated role for 

the ACS as defined in the CONOPS. 

7. Prepare a plan for personnel staffing sufficient to meet the anticipated role for the ACS as defined in 

the CONOPS. 

8. Anticipate and plan for operational and logistic support of the ACS, including, at a minimum: 

communications, internal and external with redundancy, security, transport of patients to and from the 

ACS, mechanisms for documentation of services, food services, resupply, staff rotation and rest, laundry 

services, and storage capacity. 

Any ACS should be operationally integrated into a community-wide, unified command. It also 

should be integrated into the local Health Alert Network, which will allow for consistent 

approaches of care to the various medical problems that will be encountered (e.g., pandemic 

influenza, acute radiation syndrome). 

HEALTH ALERT NETWORK (HAN)

The HAN is a nationwide program that establishes the communications, information, distance learning, 

and organizational infrastructure for a new level of defense against health threats. The HAN will link local 

health departments to one another and to other organizations critical for preparedness and response. 

The Centers for Disease Control and Prevention (CDC) is leading HAN development, working in 

partnership with other health organizations. Currently, HAN is providing health information and the 

infrastructure to support the dissemination of that information at the State and local levels. See 

www.phppo.cdc.gov/han.

Chapter VI. Alternative Care Sites 83
Decision to establish and open an ACS 

This usually will be collaboration among local emergency managers, regional planners, health 

care workers responsible for operating the facility, county and State health officials, and any 

institutions that will participate in the staffing or logistical support of the ACS. 

Scope of care to be delivered and patient population to be served 

Although the target patient population and scope of care to be delivered at an ACS may be 

event specific, some general guidelines are outlined in Table 1. Depending on the specific 

situation, the ACS may be used to: 

 Provide delivery of ambulatory or chronic care 

 Offload less ill patients from nearby hospitals, thereby increasing the hospitals’ surge 

capacity 

 Provide primary victim care at a standard appropriate for the austere situation 

 Provide quarantine, sequestration, or cohorting of “exposed” patients 

 Provide palliative care. 

Table 1. ACS Scope of Care

Objectives 

of ACS Implementation 

Scenario 

Type Scope of Care Facility Type 

1. Delivery of ambulatory/chronic 

care/special medical needs 

Decompression of medical 

shelters; decompression of 

emergency departments 

All ACS 

2. Receiving site for hospital 

discharge patients (non-oxygen 

dependent) 

Decompression of acute care 

hospital inpatient beds 

All ACS 

3. Inpatient care for moderate-acuity 

(non-oxygen-dependent) patients 

Used instead of acute care 

hospital inpatient beds 

All ACS 

4. Sequestration/ cohorting of 

“exposed” patient population 

Protection of acute care hospitals 

from exposure to potentially 

infectious patients 

Pandemic 

influenza 

Home 

ACS 

Bio event 

5. Delivery of palliative care Used instead of acute care 

hospital inpatient beds 

All Home 

ACS 

Chapter VI. Alternative Care Sites 84
One of the key decision points in the delivery of out-of-hospital care at an ACS is the ability to 

provide oxygen and respiratory therapy, particularly the ability to provide mechanical 

ventilation. The logistics and expense of sustaining oxygen delivery systems in an ACS setting, 

however, is extremely complex and prohibitively expensive. The exception to this may be the 

use of nursing homes and long-term care facilities in the role of alternative care facilities, given 

their existing medical gas supply. 

Tentative sites are best identified in advance, 

and the mechanism of approval for use as an 

ACS should be investigated. As a rule, 

permission to use municipal buildings will be 

easier to obtain, and it will be easier to get 

MOUs to use existing staff members. Possible 

structures of opportunity are outlined in Table 

2. Each will have advantages and 

disadvantages, depending on the type of MCE. 

Table 2. Buildings of convenience 

Although site selection is usually a local 

function, State partners should be asked early 

in the planning process whether potential 

shelters or ACSs have been designated at a State or regional level. If the ACS must supply 

ambulatory patient care, it may help to locate it near a victim shelter to support victims with 

chronic medical needs in that shelter. A list of requirements for an ACS has been converted to a 

matrix tool to assist with ACS site selection (in the table at the end of this chapter). 

Adult detention facilities Military facilities 

Aircraft hangers National Guard 

ACS SELECTION TOOL

The selection of a potential building to use as an ACS is an imprecise science and may vary based on 

the nature of the event. Using a consensus process, a group of hospital engineers, facility personnel, 

and health care providers developed and refined a list of infrastructure requirements for ACSs based 

on some initial work by the Department of Defense. These characteristics were then converted into a 

matrix tool to assist in site selection with each characteristic being assigned a relative weight from 0 to 

5 (see the table at the end of this chapter). The values for each structure under consideration then can 

be added up giving a relative rank order of the suitability of each building. This tool is most 

appropriately used in advance of any event, so a list of potential buildings for use as ACSs can be 

developed and maintained. The tool is available at http://www.ahrq.gov/research/altsites.htm. 

Supplies and equipment 

Another issue that requires advance planning is the availability of supplies for the adequate 

operation of an ACS. Routine supply chains will be stressed or not operational during an MCE 

Churches armories 

Community/recreation Same-day surgical 

centers/clinics centers 

Convalescent care Schools 

facilities Shuttered hospitals 

Fairgrounds Sports 

Government buildings facilities/stadiums 

Hotels/motels Trailers/tents 

(military or other) Meeting halls 

Chapter VI. Alternative Care Sites 85
of any magnitude or duration. Although the degree of need for certain supplies may be event 

specific (e.g., increased need for masks during a pandemic), the need for many basic supplies 

can be accurately forecasted. This is especially true for basic durable medical equipment (cots, 

IV poles, wheelchairs, etc.). These supplies may be stored as portable caches, which then may 

be transported to the ACS for use. 

Caches can vary from a bare minimum cache (“Level I”) for institutional augmentation to the 

very complete cache (“Level III”) as defined for the ACC by the Soldier and Biological 

Chemical Command (SBCCOM). Certain supplies have a limited shelf life and therefore will 

require product rotation or replacement. As noted above, the ability to supply supplemental 

oxygen to patients in the ACS is problematic, with no simple solution. Some potential partial 

solutions to this problem are offered below. 

THE CHALLENGE OF SUPPLEMENTAL OXYGEN

The use of an ACS for patients who require supplemental oxygen is highly problematic from a logistical 

point of view. Options to supply supplemental oxygen run from a home fill unit (10L/min maximum, less 

than $1,000) to deployable oxygen generation or liquid oxygen storage and distribution system 

(multiple patients, high technology, upwards of $480,000). Given the variables of cost, general 

availability, ease of use and sustainability, the most promising options for supplying supplemental 

oxygen would be either a bank of 10L/min home fill units or a rack of eight interconnected “H” oxygen 

cylinders, each supplying 7,000 liters of oxygen for a cost of approximately $13,000. Even this rack 

setup is severely limited, however, as the eight “H” cylinders could supply only 50 patients 

at 2 liters of oxygen per minute for 8 hours. This would necessitate three refills per 24-hour period and 

would require the rapid installation of a rudimentary gas distribution system. Support for ventilated 

patients would increase the rate of oxygen consumption significantly, further complicating 

this issue, and most likely would not be possible. 

Sources: 

Agency for Healthcare Research and Quality (AHRQ). Rocky Mountain Regional Care Model for Bioterrorist Events: Locate 

Alternate Care Sites During an Emergency. Available at http://www.ahrq.gov/research/altsites.htm. Accessed July 21, 2006. 

Anthony Rizzo, USAF, MC, SFS, Chief, Operations Division NORAD-USNORTHCOM/SG. Deployable Oxygen Solutions for 

FEMA briefing. Available at http://www.ahcpr.gov/research/altsites/alttool3.htm.(Appendix A). Accessed July 21, 2006. 

Caches of supplies should be stored in a modular fashion in units supporting 50–100 patients, 

allowing an ACS to be set up in stages. 

Experience with the FMS for victims of Hurricane Katrina demonstrated the need for 

wheelchairs, walkers, and canes in an ACS. Local or regional resources are not likely to be 

sufficient to deal with this requirement. Questions also were raised about the appropriateness of 

Chapter VI. Alternative Care Sites 86
using cots in an ACS, which require staff members to bend over constantly and are inadequate 

for dealing with obese patients. This problem may be solved by purchasing oversized cots. 

Expensive diagnostic and monitoring equipment (e.g., portable x-ray machines, ultrasounds, 

cardiac monitors), in most cases, will be beyond the scope of an ACS. Advances in point-ofcare clinical laboratory testing, however, may allow some basic laboratory tests to be performed 

at an ACS. 

Supply Caches 

The following sources provide excellent guidance for planners in terms of establishing supply caches for 

different levels of ACS: 

o Agency for Healthcare Research and Quality. Rocky Mountain Regional Care Model for Bioterrorist 

Events: Locate Alternate Care Sites During an Emergency. Available at 

http://www.ahrq.gov/research/altsites.htm. Accessed July 21, 2006. 

o Hick JL, Hanfling D, Burstein JL, DeAtely C, Barbisch D, Bogdan G, Cantrill S. Healthcare facility 

and community strategies for patient care surge capacity. Annals of Emergency Medicine. 

2004;44:253–261. 

o Skidmore S, Wall W, Church J. Modular Emergency Medical System Concept of Operation for the 

Acute Care Center: Mass Casualty Strategy for a Biological Terror Incident. Soldier and Biological 

Chemical Command; May 2003. Available at http://www.nnemmrs.org/documents. Accessed 

June 12, 2006. 

Pharmaceuticals 

Pharmaceuticals are an especially problematic issue, as they require a degree of environmental 

storage, stock rotation, and legal control. In certain events, the Strategic National Stockpile may 

be of assistance in supplying pharmaceuticals, but this is not guaranteed and should not be 

depended on as a sole solution. Pharmaceuticals fall into two major categories: those needed for 

the acute care of a patient and those needed for chronic diseases and ongoing maintenance of a 

patient’s current condition. Basic pharmaceuticals will be required for the management of a 

wide variety of medical conditions within the context of the ACS’s limited scope of practice. 

The specific categories of medications that should be available include those related to: 

 Acute respiratory therapy 

 Acute hemodynamic support 

 Pain control and anxiolysis 

 Antibiotic coverage 

 Behavioral health 

Chapter VI. Alternative Care Sites 87
 Chronic disease management. 

Patients requiring drugs used for Advanced Cardiac Life Support response, as well as those 

used in the management of worsening respiratory status, necessarily will be transferred from the 

ACS to a hospital inpatient setting, if at all possible. 

Although it might be anticipated that stable patients, even those being observed after a possible 

exposure, would have few specific needs, most such patients have existing medical conditions 

that require ongoing pharmaceutical therapy. Medications for the care of chronic diseases and 

conditions all will be necessary. Planners must address in advance the issues of obtaining, 

storing, controlling, and dispensing both controlled and noncontrolled medications. 

Staffing 

Many aspects of staffing may depend on the specific type of event. Medical staff volunteers 

probably would be more abundant for a geographically limited noninfectious MCE, for 

example, than for a geographically generalized (pandemic) infectious MCE. Even in situations 

where there will be adequate staffing, the issues of verification, credentialing, supervision, and 

command and control will exist. Development of the Emergency Systems for Advance 

Registration of Volunteer Health Professionals (ESAR-VHP) will help address these issues. The 

ESAR-VHP structure of verified health professional credential levels increases health system 

personnel capacity by providing a standardized way to identify significant numbers of 

credential-verified health professionals across a State. In addition to providing State-based 

advance registration, verification, and credentialing of medical volunteers, the system should 

enable interstate sharing of volunteers. Further development of the Medical Reserve Corps 

(MRC), with their local units of medical volunteers, including paramedics if available, also may 

help address some of these staffing issues. In 2005, more than 1,500 MRC members were 

willing to deploy outside their local jurisdiction on optional missions to hurricane-affected areas 

with their state agencies, the American Red Cross, and HHS. 

Although some staffing levels for ACSs can be proposed in advance (see Table 3, next page), 

unique staffing requirements tend to be event and population specific. The level of patient 

acuity certainly will have an impact on staffing needs. 

One option is that in situations in which the ACS is used to decompress hospitals, only those 

hospitals that contribute staffing would be allowed to send patients to the ACS. Planners should 

consider other staffing options, including the following: 

REGIONAL HOSPITAL ALLIANCES could designate in advance a small number of key staff 

members, including pharmacists, laboratory workers (to be responsible for the point-of-care 

testing), respiratory therapists, and administrators, to help support ACS operations. Given the 

aggregate number of allied health professionals employed per hospital, recruitment of such a 

Chapter VI. Alternative Care Sites 88
relatively small number of staff members 

should not be overly burdensome. 

Table 3. Potential Staffing for a 

50-bed ACS per 12 Hours 

PER 12 HOUR SHIFT: 32.5 

A SINGLE HOSPITAL may adopt an ACS and 

in so doing may be able to provide 

staffing for an entire ACS. 

o Medical Assistant/ 

Phlebotomy [1] 

o Physician [1] 

o Physician Extender 

(PA/NP) [1] o Food Service [2] 

THE FAITH-BASED COMMUNITY AND 

COMMUNITY HEALTH WORKERS also may be 

viable sources of volunteers. 

o RNs or RNs/LPNs [6] o Chaplain/Pastoral [1] 

o Health Technicians [4] o Day Care/Pet Care 

Moreover, in a geographically limited 

MCE, where there is a large possibility of 

volunteers from outside the impacted area, 

academic medical centers may be a source 

of teams of health care workers who could 

assist with staffing needs. This concept 

could be further refined through the 

establishment of partnerships with centers 

outside of the local geographic area in advance of an event. Tapping into the administrative 

structures of large, geographically diverse health care systems also could assist in meeting 

staffing needs. 

o Unit Secretaries [2] o Volunteers [4] 

o Engineering/ 

Maintenance [0.25] 

o Respiratory 

Therapist [1] 

o Case Manager [1] o Biomed [0.25] 

o Social Worker [1] o Security [2] 

o Housekeepers [2] o Patient Transporters [2] 

o Lab [1] 

Despite having staff members from distinct and separate health care organizations, there are 

many more similarities than differences evident in the delivery of medical care, particularly in 

any given region. Planners need to establish guidelines and protocols in advance for the care 

and management of patients treated in an ACS. These guidelines should help to minimize the 

difficulties inherent in bringing a new team of health care professionals to work together for the 

first time. 

Other Staffing-related Issues to Consider 

o The provision of housing for the staff may be an issue. 

o Identification of staff members (and patients and their family members) becomes an issue in the 

rapidly changing environment of an ACS and should be addressed by providing a name badge 

system that could be as simple as stick-on nametags or as complicated as a site-generated photo 

ID. 

o It may be appropriate to negotiate overtime contracts in advance in cases where municipal-owned 

buildings are to be used as ACSs with municipal workers providing support staffing. 

Chapter VI. Alternative Care Sites 89
Operational support 

Actual operation of an ACS will require a host of support services, including meals, sanitary 

services, infrastructure maintenance, and security. Although some of these needs will be driven 

by the nature of the event, much planning can and should be done in advance for many of these 

support issues. 

Documentation of care 

Given the extraordinary conditions that will exist to require the use of ACSs for patient care 

delivery, only modest means for patient care documentation should be expected to be used. 

Electronic medical records are not likely to be available or practicable, particularly given the 

learning curve associated with their use and the dependence on technology that may not be 

operable. Rather, simple paper-based charting will be required. Forms for patient records 

(including nursing notes and flow sheets), patient tracking and discharge planning should be 

prepared in advance; there should be an adequate supply of such forms, as well as clipboards 

and pens. 

SECURITY ISSUES

In the chaos and confusion that accompany any large-scale MCE, security assumes an increased level 

of importance, especially since law enforcement resources will be severely taxed. To this end, planners 

must develop robust security plans. It is helpful if security personnel have previous experience in 

dealing with patients, especially those with behavior disorders. The best potential source of security 

staff would be off-duty hospital security personnel, but these individuals may not be available. Other 

potential sources would include on- or off-duty police officers, activated members of the National Guard, 

or volunteers. 

Communications 

Reliable communications will be required among the ACS and nearby health institutions, EMS 

providers, unified command, law enforcement, suppliers, staff members, and the public. Most 

MCEs, however, result in communication system failures, highlighting the need for redundant 

communication capability, including land lines, cellular phones, and local and regional radio 

communication (including HAM radios). Advance planning and selection of potential ACSs 

may facilitate the establishment of land line communication. 

Relations with EMS 

Any ACS will be dependent on local EMS for transport of patients to and from higher levels of 

care and to assist with patient dispositions. For this reason, local EMS providers should be part 

of the ACS planning process. 

Chapter VI. Alternative Care Sites 90
Rules and policies for operation 

Planners are referred to the following 2006 HHS 

document as an excellent reference for sample 

It became clear during the operation of the FMSs in the aftermath of Hurricanes Katrina and 

Rita that rules of behavior for patients, caregivers, and visitors were necessary for the smooth 

operation of the ACSs. ACS planning should 

include the establishment of such a set of 

rules as well as operating procedures. 

forms (emergency intake, patient assessment, 

etc.), sample rules, and operating procedures: 

After Action Review of Federal Medical 

Station(FMS) Operations During 

Hurricanes Katrina and Rita.

Operating procedures should address incident 

command, staffing, criteria for admission, 

discharge and transfer, clinical roles and 

responsibilities, infection control, pharmacy 

and medication control, safety, security, 

supplies, finances, documentation, staff housing, housekeeping, food services, and other areas 

unique to the event. 

Development of an exit strategy 

Part of the successful operation of an ACS is the decision of when to close the facility. Criteria 

for disengaging the ACS should be established as part of the planning process. The actual 

decision to close the facility should be made in concert with the local emergency managers and 

local or State health officials. 

Exercising the ACS 

Plans for a regional ACS can be fully vetted only through exercises. Ideally, these exercises 

should include the ACS as a stand-alone facility and use the ACS support components to assist 

with the establishment and operation of an FMS. Funding for these exercises can be supported 

with Health Resources and Services Administration 2006 bioterrorism grants and Urban Area 

Security Initiative funding. 

Lessons from Case Studies of ACSs 

The 2005 hurricane season dealt the health care system of the Gulf Coast of the United States an 

unprecedented blow. The enormous number of patients and evacuees in the aftermath of 

Hurricanes Katrina and Rita overwhelmed local health care resources of the Gulf Coast of the 

United States. This afforded emergency managers and clinicians an excellent opportunity to 

witness firsthand the operation of alternative medical care facilities. 

Chapter VI. Alternative Care Sites 91
The near total destruction of the local health care system of the Gulf Coast region and especially 

the New Orleans metropolitan area made it necessary to evacuate thousands of healthy 

evacuees, acute medical patients, and persons with chronic medical conditions and special needs 

to unaffected areas. The concept of receiving casualties in areas which were otherwise 

unaffected by the original disaster has been described as evacuee surge capacity. This term 

differentiates it from the intrinsic surge capacity resources of the impacted location. It is a 

subtle distinction, but it takes into account that the receiving facilities at least have not suffered 

a blow to their infrastructures. Also, from an emergency planning standpoint, it encompasses 

the principle of distributing patients to several different receiving areas so as not to overwhelm 

any single facility. 

The strategy of transferring patients away from the affected Gulf Coast area was used 

extensively in the late summer of 2005. Large ACSs were established in surrounding States, and 

smaller facilities were set up to accept evacuees throughout the United States. A number of 

clinicians and officials involved in EMS and emergency management at several of the locations 

where ACSs were established after Hurricanes Katrina and Rita were interviewed for this 

planning guide. 

Lessons Learned: Key Areas to Consider in ACS Planning 

OPERATIONS

o Regional planning is important. Ensure that patients are distributed across the State(s) efficiently and 

appropriately. 

o Security makes patients and staff members feel safe and keeps out troublemakers. Having uniformed 

people on site, even Reserve Officer Training Corps (ROTC) cadets, makes a real difference. 

o There are distinct advantages to setting up an ACS near a college or university. For example, it provides 

extra manpower (e.g., football team) to carry patients, set up equipment, etc. 

MEDICAL

o Plans must be made to segregate individuals with special medical needs from the general population. 

o Facilities should be laid out in an organized fashion. A grid system allows clinicians to make “rounds” and 

know exactly where to find a patient (e.g., bed A4). 

STAFFING

o There should be extensive use and coordination of volunteers. 

o Acknowledge that volunteers may not want to do certain tasks (e.g., colostomy care, diaper changes). 

Establish who is going to do what. 

o Legal and jurisdictional issues will need to be addressed. 

o It is important to develop an Incident Command System that can help avoid “turf battles” between 

employees of different health systems who are staffing the same facility. 

LOGISTICS

o Public health issues are critical (e.g., safe food and water, sanitation, latrine resources). 

Chapter VI. Alternative Care Sites 92
SPECIAL NEEDS SHELTER CASE STUDY

Converting a Veterinary Hospital in College Station, TX 

In anticipation of Hurricane Rita, emergency planners and officials from the Texas A&M 

Health Sciences Center converted the Large-Animal Hospital at the College of Veterinary 

Medicine and Biomedical Sciences into a medical facility to house special needs patients and 

their caregivers from Houston and Galveston. Officials at the University previously had worked 

out a hypothetical plan to convert the animal hospital into just such a surge hospital during 

times of scarce medical resources. The facility was quickly cleaned and brought online to 

receive patients and remained operational for 1 week. 

A type III Federal Medical Station (later redesigned as a Level IV FMS) was dispatched 

through an HHS-CDC-coordinated effort; this addition supplied two 250-bed caches of 

equipment, which increased the capacity to 1,081 beds. 

U.S. Public Health Service staff eventually assumed medical control of the facility. In total, the 

facility took care of more than 350 patients (many of whom were ventilator or dialysis 

dependent) and housed more than 650 people (including patients’ caregivers). This facility was 

instrumental in allowing the pressure to be taken off the local acute care facility, St. Joseph 

Hospital. 

Lessons learned from this experience include the following: 

 Veterinary hospitals can offer significant advantages in planning for surge capacity due to 

preexisting facilities (e.g., water, lighting, medical gas pipelines). 

 If such vet hospitals are associated with a university medical system, they are easier to 

integrate into the overall medical system. 

 It is important to have a plan for conversion to human use, including plans for care of 

animals. 

MOBILE MEDICAL FACILITIES CASE STUDY

Mobile Field Hospital in Waveland, MS 

During Hurricane Katrina, the Hancock County Medical Center was completely incapacitated, 

with mud covering the entire first floor. The State of Mississippi worked with HHS and the 

State of North Carolina through the Emergency Management Assistance Compact (EMAC) to 

deploy a mobile medical field hospital. The hospital was comprised of the North Carolina State 

Medical Assistance Team (SMAT) together with a tractor trailer from the Carolinas Medical 

Center in Charlotte. 

Chapter VI. Alternative Care Sites 93
In addition to the North Carolina SMAT, two Disaster Medical Assistance Teams from NDMS 

and a U.S. Air Force Expeditionary Medical Support system (EMED + 25) were among the 

many field medicine service providers rendering medical care to local residents of Hancock 

County. The North Carolina SMAT conducted medical operations for more than 7 weeks and 

treated more than 7,500 patients, including some surgeries. More than 500 health care 

professionals from North Carolina were deployed from all over the State to staff this field unit 

during the 2-month deployment. 

Lessons learned from this experience include the following: 

 The use of a self-contained mobile medical facility can be a significant asset in an austere 

environment with essentially no infrastructure; however, that asset must be deployed with 

“wraparound” logistics and must be truly self-sufficient to avoid becoming part of the burden 

on the requesting community. Logistical challenges diminished the intended capability of the 

tractor trailer medical unit. The prototypical unit proved to be less useful than originally 

planned and more than 95 percent of the patients were actually treated outside the unit in a tent 

style environment similar to Disaster Management Assistance Teams or the EMED + 25. 

 A heliport was set up given the fact that the main ground evacuation route was underwater. 

Air medical services played an important role in this instance, highlighting the need to include 

such services in planning efforts. 

 Issues of licensing, jurisdiction, malpractice, and reciprocity need to be addressed at the 

highest levels of government for the successful widespread use of similar mobile medical 

assets. EMACs give protection to assets owned by a State, but similar protection for non-State 

entities is less clear. Local medical assets that wish to deploy outside their jurisdiction must fall 

in line with the State system of emergency management to ensure proper asset placement and 

liability protection. 

Chapter VI. Alternative Care Sites 94
Converting Public Buildings to ACSs: Examples from Hurricane Katrina 

During the response to Hurricane Katrina, there were many instances of converting public buildings to an 

ACS: Some of these are described below: 

Reliant Arena Medical Clinic, Houston – Many thousands of evacuees from the New Orleans Super 

Dome and more than 700 patients from New Orleans hospitals were evacuated to Reliant City 

Astrodome in Houston. Fire department EMS personnel and clinicians from Baylor College of Medicine 

and the Harris County Hospital district oversaw medical operations at the Astrodome and established 

the Reliant Arena Medical Clinic. A triage system was set up to avoid persons directly dialing the 911 

system and potentially overwhelming the Houston hospital system. 

Convention Center Evacuee Medical Clinic, Houston – After the Astrodome reached capacity, a 

shelter was created at the George R. Brown Convention Center. In addition to health care 

professionals from the University of Texas Science Center at Houston, the clinic was staffed with 

volunteers, such as retired physicians from the Harris County Medical Reserve Corps. 

Reunion Arena and Dallas Convention Center (DCC) Medical Unit, Dallas – Reunion Arena in 

Dallas was opened to accommodate more than 700 evacuees. As the Arena filled to capacity, the DCC 

was opened as a large shelter which housed 900-1,800 evacuees a night. A small aid station and 

standing ambulance were set up at the Reunion Arena, but a larger and more substantial medical clinic 

was set up at the DCC, encompassing more than 8,200 square feet of space. This clinic was 

administered by the University of Texas (UT) Southwestern Medical Center at Dallas and staffed by UT 

staff members as well as numerous volunteers. 

Surge Hospital, Louisiana State University (LSU) Basketball Arena, Baton Rouge—The Louisiana 

Department of Health worked with LSU to establish an 800+bed surge hospital at the university’s 

basketball arena and a special needs shelter in an adjacent field house. The surge hospital was an 

acute care center and received patients who had been evacuated by helicopter and ambulance from 

the disaster area and other health care facilities. The center was staffed initially by local Baton Rouge 

physicians and evacuated health care professionals. Additional medical staff members included those 

from the Illinois Medical Emergency Response Team, the New Mexico Disaster Medical Assistance 

Team, the U.S. Public Health Service, and other health care volunteers. 

Shelter for Special Needs Evacuees, Tyler, TX – The Northeast Texas Public Health District worked 

with UT at Tyler to set up a special needs shelter at the university to accommodate special needs 

patients. Medical operations were overseen by the Texas Medical Rangers and additional staff 

members provided by the UT Health Center at Tyler. 

Operation Safe Haven, Evacuee Processing Station and Medical Clinic, Denver – Through an 

EMAC agreement between Colorado and New Orleans, more than 300 displaced evacuees from New 

Orleans were transported to the former Lowry Air Force Base in Denver, now a part of the Colorado 

Community College System (CCCS). Using an ICS, the mothballed buildings were prepared for the 

first planeload of 150 evacuees within 24 hours by volunteers from various agencies, the CCCS, local 

utility companies, and work crews from local prisons for the first plane load of 150 evacuees. Medical 

operations included an initial triage station and a clinic in the evacuee dormitory that operated for 4 

days until the evacuees were integrated into local Denver health clinics. 

Chapter VI. Alternative Care Sites 95
Converting Public Buildings to ACS: Lessons from Hurricane Katrina 

Planning and Coordination - The coordination of logistics, personnel, space, and supplies was 

critical in quickly responding to situational needs. This involved coordinating not just those entities 

responsible for responding to public health emergencies but included colleges, universities, and other 

potential community resources. Planners considered the order in which buildings would be used, first 

using a large arena with another site available if the numbers of evacuees became too large. In 

general, establishing personal relationships among various agencies and branches of government 

before a disaster strikes is critical to operating effectively during an MCE. A well-defined ICS was 

critical to operations in most localities; any agency or volunteer organization that is part of a response 

operation must have a basic understanding of ICS. 

Public Health Considerations – Large arenas and convention centers are not equipped to handle 

evacuees for long periods of time. Shower facilities and other amenities are limited, and planners need 

to consider ways to address this in advance to avoid dangerous public health conditions. Medical staff 

needs for personnel hygiene also need to considered, such as showering and washing providers’ 

clothing. 

Security – In crowded conditions with large number of evacuees, it was important to maintain a sense 

of control and security. Uniformed staff members from area hospitals and other sources of security 

personnel were helpful in maintaining a sense of order. In some centers, National Guard soldiers and 

college ROTC cadets provided security. A safety officer should be designated to coordinate security 

activities in an ACS. 

Transportation – Dedicated ambulances stationed at large evacuee centers helped to reduce 

demand on local EMS, which in turn freed the local EMS to respond to the community’s needs and its 

9-1-1 system. In general, the ACS clinical services helped to prevent local hospital systems from being 

overwhelmed. 

Planning Medical Supplies, Pharmaceuticals, and Food Supplies – Small over-the-counter 

pharmacies in evacuee centers can help address simple pharmacy needs. Planners need to consider 

options and can coordinate with local pharmacies, hospitals, and local businesses to provide 

pharmaceuticals and other supplies. In Houston, arrangements were made with a chain pharmacy and 

local health care system to set up a full pharmacy at the ACS clinic. Ordering of purchased supplies 

should be handled through one person who is a designated purchasing authority to reduce potential 

confusion. Controlling access to the pharmacy and central supply is a critical security issue to be 

addressed in preplanning. In a sustained event, donor-fatigue can set in; mechanisms therefore should 

be considered for coordinating an uninterrupted supply chain and spreading the financial impact of 

volunteer supplies. In Baton Rouge, a resource book of each type of volunteered equipment was 

maintained so that providers had a ready source of information. 

Shelter Expectations for Standards of Operation – Municipalities that contract out the management 

of shelters to outside organizations, such as ARC and faith- and community-based organizations, need 

to establish a set of standards for how shelters will be run. In Dallas, admitting and accommodating the 

immediate medical needs of evacuees at shelters became confusing due to varying admittance 

standards. In addition, planners need to consider how best to accommodate the existing homeless 

population in the shelters that are accepting incoming evacuees.

Chapter VI. Alternative Care Sites 96
Credentialing – Credentialing is an important planning issue due to the potential for rogue clinics and 

medical providers to operate in the early stages of an event. Coordination of staff members under an 

ICS can address this issue. The U.S. Public Health Service addressed screening and credentialing of 

volunteer health care providers in Baton Rouge’s ACS. The Texas Board of Medical Examiners was 

proactive in facilitating credentialing of out-of-State physicians. 

Staff Considerations – Emergency physicians working to triage patients in ACS enabled the internists, 

pediatricians, and other primary care provides to focus on direct patient care. Volunteer health care 

providers play a valuable role, but clinic operations should not be run solely by a collection of 

volunteers. In addition, leaders must assess whether volunteers are being helpful and remove 

individuals who are not contributing to the overall mission. Some ACSs used a volunteer coordinator to 

manage the number of people who came to volunteer. In Dallas, a Web portal was set up to schedule 

physicians and coordinate staff members. Another consideration is that ACS leadership should have 

training in emergency management and disaster medicine; in some instances, it may become 

necessary to rotate some of the leadership positions to include personnel with more hospital 

administration experience. It is important to identify teams of personnel in anticipation of an event, allow 

them to evacuate their families, and provide shelter for the staff at an ACS, clinic, or hospital. Quiet and 

restricted access space needs to be provided to the health care staff so that lack of rest will not have a 

negative impact on the quality of care. 

Patient Tracking and Documentation – Planners will need to consider how to use and coordinate 

patient-tracking data and coordinate across all agencies and organizations, such as the ARC, faithbased and community-based organizations and government-supported ACSs. Some of these 

organizations may have rules regarding information sharing that need to be considered in advance. A 

system for registering and tracking patients helps with making patient flow as efficient and orderly as 

possible. In Baton Rouge, a charge nurse station was established to track each patient and list 

providers that were on duty. A real-time census was performed every 8 hours to maintain accountability. 

In one center, a system of identification tags was useful for tracking patients. 

Communications – In some ACS, HAM radio operators provided helpful supplemental 

communications. Having a number of handheld walkie-talkies also facilitated communications. 

Patient Screening – Initial evaluation of evacuees is important to determine those people whose health 

conditions have deteriorated during travel to the ACS. A medical triage/evaluation station was used in 

Denver to conduct a more thorough screening of evacuees as they were being processed at the 

reception center. 

Pediatric Populations – The involvement of pediatricians with experience in emergency management 

is helpful for planning for the numerous special considerations of pediatric evacuees. Early and accurate 

identification of children is crucial to alleviate confusion and additional suffering for families. It is 

important to keep in mind that children have special considerations in terms of decontamination and 

treatment due to the differences in their body size and metabolism. 

Chapter VI. Alternative Care Sites 97
Chapter VI. Alternative Care Sites 98

Psychiatric Services – Evacuees from a major disaster have suffered a huge mental trauma. Some 

ACSs set up tents so that persons with psychiatric or stress issues could be attended to in a quiet and 

secluded location. The mental health of providers is important as well; in Baton Rouge, provisions 

were made for postincident debriefings and ongoing psychological support for health care providers. 

Special Needs – Patients with special needs were directed to shelters that focused on their care 

instead of a regular shelter. In Texas, patients requiring special needs were redirected to a special 

needs shelter. 

Accessibility – Some ACSs did not have wheelchair access and other accommodations for evacuees 

with disabilities. Temporary ramps and other adjustments can be made and need to be planned in 

advance.

Pets – A number of people arrived at shelters with their pets. Local animal shelters and animal 

response teams were used to register, evaluate, and house pets that arrived. 
Chapter VI. Alternative Care Sites 

Table 4. ACS Selection Matrix 

Aircraft 

Hangers 

Churches 

Community/ 

Recreation

Centers 

Convalescent Care

Facilities 

Convention 

Facilities 

Fairgrounds 

Government 

Buildings 

Hotels/ 

/Motels 

Meeting 

Halls 

Military 

Facilities 

National 

 Guard 

Armories 

Same Day

Surgical 

Centers 

/Clinics 

Shl

Infrastructure Door sizes adequate for gurneys Floors Loading dock Parking for staff and visitors Roof Toilet facilities/showers (#) Ventilation Walls Total Sspace and Layout Auxiliary spaces (Rx, counselors, chapel) Equipment/supply storage area Family area Food supply and prep area Lab specimen handling area Mortuary holding area Patient decontamination areas Pharmacy area Staff areas Utilities Air conditioning Electrical power (backup?) Heating Lighting Refrigeration Water (hot?) Communication Communication (# phones, local/long distance, intercom) Two-way radio capability to main facility Wired for IT and Internet access Other Services Ability to lock down facility Accessibility/proximity to public transportation Biohazard & other waste disposal Laundry Ownership/other uses during disaster Oxygen delivery capability Proximity to main hospital Total Rating/Ranking (Largest # indicates best site) Rating System: 5 = Equal to or same as hospital. 4 = Similar to that of a hospital, but has SOME limitations (e.g., quantity/condition). 3 = Similar to that of MAJOR limitations (e.g., quantity/condition). 2 = Not similar to that of a hospital, would take modifications to provide. 1 = Not similar to that of a hospital, wmodifications to provided. 0 = Does not exist in this facility or is not applicable to this event.
Chapter VII. Palliative Care 100 
Chapter VII. Palliative Care

AUTHORS 

Anne M. Wilkinson, Ph.D., M.S., Co-lead Author, Senior Social Scientist, Palliative Care Policy Center, RAND Corporation 

Marianne Matzo, Ph.D., APRN, BC, FAAN, Co-lead Author, Professor Palliative Care, University of Oklahoma College of Nursing 

Maria Gatto, M.A., APRN, Director of Palliative Care, Bon Secours Health System 

Joanne Lynn, M.D., M.A., M.S., Senior Natural Scientist, RAND Corporation 

This chapter addresses the overarching mass casualty planning issue of 

how to provide optimal support for the dying, those facing life-limiting 

illness or injury, and those caring for them. It defines palliative care and 

explores ways in which this care can be integrated into initial planning 

and response (including health care facilities and alternative care sites) 

for catastrophic events. The goal of this section is to offer 

recommendations and considerations to help community planners address 

palliative care in areas such as decisionmaking, communication, 

 supplies, resources, training, and personnel. 

Chapter VII. Palliative Care 101 
Palliative Care in the Context of a Mass Casualty Event (MCE): Issues and Recommendations 

At A Glance

MAJOR PALLIATIVE CARE-RELATED CHALLENGES

The provision of palliative care in the context of an MCE is a new component of disaster planning; there is a 

lack of understanding of how to incorporate community-based health care, mental health and social service 

professionals into planning efforts. 

RECOMMENDATIONS FOR PLANNERS

Leadership 

o Request aid of disaster planning leadership at a national level to engender a network of leaders in home 

health, palliative and hospice care, and long-term care that will be engaged in disaster planning. 

Incorporating Palliative Care into MCE Planning 

o Incorporate community-based long-term care and palliative care providers in all phases of planning, 

response, and recovery as integral members of the response team. 

o Integrate specific planning for those likely not to live long in all established scenarios (“all-hazards approach”) 

and established response plans. Include pediatric-specific palliative care issues in planning. 

Training 

o Incorporate palliative care training for MCE responders as an integral part of exercises, planning, and 

response, building on existing disaster planning and command and control structures. 

Triage and Treatment Decisions 

o Work with first responder personnel and local and regional disaster response planners (e.g., EMS, fire, 

police, departments of public health, community health clinics, local and regional governmental entities) to 

identify and develop clear guidelines and protocols to address issues of: 

 Triage 

 Alternative care sites (ACSs) for palliative care 

 What levels of care are to be delivered in what settings and by whom 

 Lines of authority and the clear identification of responsible personnel 

Background 

As was demonstrated with Hurricane Katrina, a catastrophic MCE overwhelms all available personnel 

and resources, both locally and regionally. Other large disasters (e.g., major hurricanes, “dirty 

bombs,” pandemic influenza) also have the potential to overload the health care and social service 

systems and disrupt existing services to persons who were already seriously ill. Under conditions of 

massive injury and loss, and even in the face of overwhelming economic and social disruption, human 

beings will be called on to act humanely. In any disaster, the first priority will be to save all those who 

can be saved and to reestablish societal structure. In the event of a catastrophic MCE, it must be 

assumed that some people may survive the onset of the disaster but will have incurred such serious 

illness or injury that they will live only for a relatively short time. In addition, there will be vulnerable 

individuals (e.g., the elderly in the community, those sick in the hospital, those in nursing homes or 

group homes, the disabled, children) who were already ill with severe preexisting conditions and who 

may be negatively impacted by the resulting scarcity of resources. These individuals will suffer harm 

Chapter VII. Palliative Care 102 
“When the needs of the many outweigh the 

disproportionately during or following a catastrophic MCE, because they may not be able to seek 

help, care for themselves, or pursue other survival and recovery strategies pursued by nonvulnerable 

populations. 

needs of the one, what happens to the one?” 

Sally Phillips, R.N., Ph.D., 

Agency for Healthcare Research and Quality 

The goal of an organized and coordinated response 

to a catastrophic MCE should be to maximize the 

number of lives saved. At the same time, the goal 

also should be to provide the greatest comfort and 

minimize the physical and psychological suffering 

of those whose lives may be shortened as a result of either an immediate surge of patients or longterm exposure following a catastrophic event. 

Palliative Care in the Context of an MCE 

Under ordinary circumstances, about 1 to 2 percent of the population lives at home or in long-term 

care facilities with serious illness, facing the last phase of life. 

Most scenarios of catastrophic MCEs would create sudden large numbers of fatally injured or 

critically ill short-term survivors that are at least a few orders of magnitude larger than the existing 

vulnerable populations. Depending on the event, some victims will last only a few weeks (e.g., 

pulmonary injury from airborne chemicals) and some may last for months (e.g., pandemic influenza). 

In many cases, those who survive the onset usually will live for some time – days to months – but will 

not be “expected to survive” due to the event itself or to the ensuring resource scarcities it creates. 

Initial identification of those who might fit into the “not expected to survive” category following a 

catastrophic MCE may include: 

 Those exposed to the event who are expected to die over the course of weeks (e.g., those with 

radiation exposure) 

 The “already existing” palliative care population (e.g., those already enrolled in hospice or 

receiving palliative care in acute care settings) 

 Vulnerable patients (e.g., advanced illness patients in long-term care facilities) whose situation 

will be worsened due to scarcities associated with the event 

 Patients who are triaged as a result of scarce resources. 

Those who are not expected to survive cannot be simply abandoned or ignored; nor should they 

overwhelm hospitals and EMS. By including these populations in existing disaster and MCE 

preparation, response, and management, most communities can ensure humane palliative care for all 

affected by such disasters. 

Chapter VII. Palliative Care 103 
WHAT IS PALLIATIVE CARE? Aggressive management of symptoms and relief of suffering is what 

generally have come to be called “palliative care.” The World Health Organization defines palliative 

care as “an approach which improves the quality of life of patients and their families facing lifethreatening illness, through the prevention, assessment, and treatment of pain and other physical, 

psychosocial, and spiritual problems.” 

 While it is important to understand what palliative 

care is, it is also important to specify what palliative 

care is not. Palliative care is not abandonment of the 

patient or reduction or elimination of treatment. 

Rather, it involves active treatment for symptom 

management and support to address the comfort of 

the patients and their families. Finally, the 

aggressive and appropriate treatment of pain and 

other symptoms is not euthanasia; nor does it 

“hasten death” (See Table 1). The application of 

palliative care principles in an MCE would include: 

Table 1. 

Palliative Care Is: Palliative Care Is Not: 

Evidence-based 

medical treatment 

Abandonment 

Euthanasia 

Vigorous care of pain 

and symptoms 

throughout illness 

Hastening death 

Care that patients want 

 Recognizing that initial prognostication may change if additional resources become available or 

if the situation deteriorates 

 Honoring the humanity of the dying and those who serve them (whether loved ones, 

professionals, or strangers) by providing comfort and social, psychological, and spiritual support. 

In an MCE, standards of care will require 

adaptation, unfamiliar personnel will be providing 

services, supplies will be strained, and command 

and control lines of authority will need to be 

established. In the interest of maximizing good 

outcomes for as many patients as possible, and at 

the very least, providing palliative care to all, 

treatment decisions will have to balance 

utilitarian notions against other ethical values, 

with medical effectiveness as a key determinant. 

Priority access to scarce resources, including 

structural and skilled personnel resources, may be 

applied or moved to those with the greatest 

potential for survival. Thus, services to those 

expected to die soon will fall more heavily on 

people who do not have substantial prior health 

experience and expertise. 

WHAT SERVICES WILL BE NEEDED? The need to care 

The National Consensus Project for Quality 

Palliative Care states that palliative care focuses 

on the relief of suffering and distress for people 

facing serious, life-limiting illness to help them and 

their families to have the best possible quality of 

life, regardless of the stage of the disease or the 

need for other therapies. Palliative care is both a 

philosophy of care and an organized, highly 

structured system for delivering care. Palliative care 

expands traditional disease-model medical 

treatments to include the goals of enhancing quality 

of life for patient and family, optimizing function, 

helping with decisionmaking, and providing 

opportunities for personal growth. As such, it can 

be delivered concurrently with life-prolonging care 

or as the main focus of care. 

Chapter VII. Palliative Care 104 
for the dying in times of calamity has been a small 

part of military medicine for a long time: chaplains 

and morphine are standard issue in field 

operations. In addition, the need to care for the 

dying in routine civilian medical care has come to 

the fore with the advent of large numbers of people 

who live with serious chronic illness and 

increasing disability for a substantial time before 

dying. Optimal support of potential survivors, the 

dying, and those whose vulnerability or frailty will 

be exacerbated by the event itself depends, in part, 

on having done a good job in planning for the inevitability of mass casualties throughout the time of 

the disaster. Crafting services that enable comfort, support longevity, and permit meaningful activities 

and relationships has been a major commitment of modern health care and consolidated under the 

label “palliative and supportive care.” 

“The needs of those who may not survive 

catastrophic mass casualty events and the 

‘existing’ vulnerable populations affected by the 

event should be incorporated into the planning, 

preparation, response, and recovery 

management systems of all regions and 

jurisdictions.” 

Joint Commission on Accreditation of Healthcare 

Organizations, 2004

Major Palliative Care-related Challenges 

Community planners face several significant challenges in the integration of palliative care services 

and personnel into MCE response planning. First, the provision of palliative care in the context of an 

MCE is a new component of disaster planning. As such, there is a dearth of literature and expertise on 

the subject of palliative care in the context of an MCE. Second, palliative care, long-term care, and 

home care are already resource poor; thus, identifying and securing funding for palliative care 

services will be a significant challenge. Third, there is a lack of understanding of the potential utility 

of incorporating community-based health care, mental health, and social service professionals into 

MCE response planning efforts – even by the professionals themselves. Finally, there is a significant 

lack of public awareness regarding the limitations of the health care system under austere 

circumstances. 

Integration of Palliative Care Services into MCE Planning and Response 

The palliative care service aspect of community preparedness is new to disaster planning in the 

United States. Without deliberate planning and direction, stocking up on appropriate supplies, and the 

development of realistic guidelines, supportive care services for the dying in MCEs will be erratic, 

inefficient, disruptive, and potentially indefensible as the basis for social reorganization after the 

disaster. 

In most disaster scenarios, the priority concern is for survivors. In situations of the scale of the 

Oklahoma City or World Trade Center bombings, the local health and social service systems were 

able to respond to the relatively small numbers of seriously injured and modest disruptions to 

supportive care and community services for the existing population. In recent catastrophic events such 

Chapter VII. Palliative Care 105 
as Hurricane Katrina, however, there were massive disruptions to local and regional response 

capabilities, and large numbers of critically ill survivors with few resources to respond to them. 

Recommended Actions and Potential Barriers 

Leadership 

Knowledgeable professionals and organizations (e.g., geriatricians, palliative care clinicians, longterm care providers and organizations, home health providers, hospice providers) should be integrated 

into current local, State, and regional disaster preparedness planning to bring the palliative care 

perspective. 

Recommended actions include: 

 Build on existing relationships 

 Have State and local home health, hospice, and long-term care organizations and professional 

associations contact leaders in their State and regional-area disaster preparedness planning bodies to 

get involved in these activities/processes 

 Have disaster planning leadership at a national level help to engender a network of leaders in home 

health, palliative and hospice care, and long-term care to be engaged in disaster planning, supported 

by appropriate research support and development expertise, so that promising ideas are quickly shared 

and tested and so that cross-region support is available in times of crisis. 

As noted earlier, the barriers to implementing these recommendations involve the fact that palliative 

care, long-term care, and home care are already resource poor; there is a lack of understanding of the 

potential utility of incorporating community-based health care, mental health, and social service 

professionals into planning, even by the professionals themselves; and there is a dearth of literature 

and expertise on the subject. 

Roles of palliative care services in various disaster scenarios 

The role of palliative care and the resources needed to incorporate it into disaster response must be 

anticipated and fully incorporated into the current State and local disaster planning/training 

guidelines, protocols, and activities. 

Recommended actions include: 

 Base planning on lessons learned from previous disasters (including war) 

 Establish practical measures of success in palliative care services in MCEs 

 Conduct “gap analyses” and existing tabletop exercises of how to integrate palliative care services 

into local, State, and regional systems 

Chapter VII. Palliative Care 106 
 Integrate specific planning for those likely not to live long in all established scenarios (“all hazards 

approach”) and established response plans (e.g., link to local, regional, and State plans and agencies 

such as joint field offices and local emergency planning committees; link to the National Incident 

Management System and the National Response Plan) 

 Incorporate community-based long-term care and palliative care providers in all phases of 

planning, response, and recovery as integral members of the response team 

 Encourage attention to the needs of those with expected short survival in all four phases of 

emergency management (prevention, preparation, response, recovery) and in all relevant settings 

(prehospital, acute care hospital, and ACS) 

 Include pediatric-specific palliative care issues in all plans; failure to do so will hamper the ability 

of health care workers to move children into palliative care and develop guidelines for treating them. 

The barriers to integrating palliative care services into MCE planning and response include substantial 

differences of perspective between palliative care providers and other planners; for example, there 

may be differences in perceptions between providing comfort and dignity and enhancing survival, 

even though these are often intertwined. 

Triage and treatment decisions for those likely to die 

A model of triage and response for victims of an MCE and the potential impacts on the prevailing 

health and social service system is depicted in Figure 1. Casualties would fall under three general 

categories: those unscathed by the event or too well to require emergency medical treatment, those 

too sick or injured to survive days or weeks, 

and those deemed appropriate for acute 

medical treatment and transport to an acute 

medical care facility. In addition, the existing 

“vulnerable” population likely will be 

affected by the event or the resulting 

disruption to their support system and may 

become palliative care patients due to the 

scarcity of resources. These patients also 

would be triaged over time to one or more of 

the casualty categories and casualty 

treatment sites, as their condition either 

worsens or improves. 

 Figure 1. 

Catastrophic MCE: Triage and Response 

In the event of a catastrophic MCE, 

casualties will be triaged at the site of the 

incident and again after transport to an ACS. 

Some will be deemed “likely to die” during the extreme circumstances of the catastrophe and 

Chapter VII. Palliative Care 107 
therefore will be triaged not to receive (or not to continue to receive) life-supporting treatment. For 

these casualties, death will be expected within a short period. 

This reality poses substantial challenges for all involved, including the recognition that some people 

who might survive under other circumstances now will die. Given the usual focus of rescue in 

manageable disaster events, most patients, families, and emergency responders are likely to resist this 

designation and attempt to save all, potentially exacerbating an already overwhelmed medical care 

system. Thus, ACS and providers need to be identified and used for this population during 

catastrophic MCEs. 

Recommended actions include: 

 Build smooth links with supportive service organizations and personnel (e.g., home health, longterm care settings, hospice and palliative care providers) for those expected to die as part of 

catastrophic MCE response plans. 

 Work with first responder personnel and local and regional disaster response planners (e.g., EMS, 

fire, police, departments of public health, community health clinics, local and regional governmental 

entities) to identify and develop clear guidelines and protocols to address issues of: 

y Triage 

y ACSs for palliative care 

y Who delivers treatment and support (e.g., spiritual, psychological) and how 

y What levels of care are to be delivered in what settings and by whom 

y Lines of authority and the clear identification of responsible personnel 

y Identification of location and use of stockpiles, supplies, and personal protection equipment 

y Training of providers for the provision of appropriate palliative care at all care treatment sites 

 Disseminating guidebooks for the roles and activities involved 

 Building strong support for triage and standards of care to respond to dire circumstances or scarce 

resources by redefining public expectations and training of palliative care and other health 

professionals. Actions would include: 

y Build in flexible methods of response for revising triage decisions and treatment when 

affected persons are doing better than expected 

y Build in psychological and ethical support for front-line responders 

y Expect anxiety and strong emotions, including mental illness and criminal activity, and having 

security and appropriate medications available 

Chapter VII. Palliative Care 108 
y Establish guidelines and protocols for “just-in-time” training and palliative service delivery of 

secondary providers at all treatment sites (e.g., the location of the event, alternative treatment 

sites, acute care hospitals, secondary referral sites such as nursing homes). 

Barriers include public resistance to the overt rationing of health care resources. It is the role of the 

popular media and public health agencies to enhance public understanding regarding the limitations of 

the health care system under dire circumstances. 

Medical supplies and equipment 

Supply arrangements must be identified as part of the community planning effort not only to ensure 

that all potential palliative care supply sources are included, but to prevent multiple organizations 

from unknowingly relying on the same suppliers. Resources include people, equipment, food, and 

medical supplies. Mutual aid agreements should be made ahead of time with community agencies, 

other health care providers, and backup suppliers to ensure that resource needs for palliative care 

service delivery can be met. 

Recommended actions include: 

 Stockpile palliative care medications in each community for disaster response, including injectible 

morphine and dihydromorphone, injectible haloperidol, subcutaneous butterfly needles, tegaderm, 

antipyretics, steroids, and diuretics 

 Plan for the needs of individuals chronically dependent on dialysis, ventilators, or other special 

supplies such as dressings, splints, syringes and oral droppers, incontinence supplies, beds or 

cushioned surfaces, and personal protective devices. 

Barriers will include the need to stock supplies near the settings of service and preferably distant from 

hospitals and other sites of definitive care for survival. Long-term care facilities, inpatient hospice 

settings, or home nursing care offices are possibilities. Having controlled substances in strong 

lockboxes is probably most naturally sited at nursing homes, where systems are in place and storage 

of these drugs is already set up. Another option would be designated pharmacies. The effectiveness of 

these two options obviously would depend on their proximity to the disaster scene. 

Training 

Training in palliative care must occur prior to an MCE and will involve many layers of education and 

practice. Planners can incorporate experts now working with seriously chronically ill persons to be 

mobilized to serve those who might live and who are seriously ill. Thus, many of the physicians, 

nurses, and therapists who regularly serve the disabled or elderly will be needed to provide lifeextending treatments. Planners could designate in advance certain leadership to remain in place and 

mobilize retired professionals and layperson volunteers. 

Chapter VII. Palliative Care 109 
Communities now provide Community Emergency Response Team training to engage citizens in 

community and family preparedness through public education, outreach, and training. Building on 

existing models of emergency response training, the planning team should identify a variety of 

training methodologies to incorporate palliative care services training for all disaster response 

members. 

Cross-training of personnel from other areas (of expertise as well as from other areas of the country to 

provide “mutual aid” to the stressed community/region) will be important. In addition, laypeople 

should be recruited to serve (e.g., bus drivers, mail deliverers, anyone from the community who is 

willing to attend the training) due to the inevitable surge in demand for assistance that an MCE will 

engender. Moreover, education and training should be competency based, with programming specific 

to the individual’s role in emergency response. 

Recommended actions include the following: 

 Incorporate palliative care training for first responders as an integral part of disaster and MCE 

preplanning and practice of events and response, which will build on existing disaster planning and 

command and control structures. 

 Develop and implement competency-based evaluation and measurement. 

 Identify cross-training opportunities of local and regional first responders along with integrated 

palliative care professionals. 

PALLIATIVE CARE IS A NEW COMPONENT OF MCE PLANNING

Given that the issue of planning for palliative care during an MCE is a new component of disaster planning, 

both professional and layperson education is necessary and likely will take some time and persistence on the 

part of community planners. It may be appropriate to target retired health care professionals and volunteers 

for training. Both generic in-advance training and “just-in-time” curricula will need to be developed. 

 Train all first responders to use oral and injectible morphine to manage pain and symptoms until 

licensed personnel are available to manage these symptoms. These medications should be stockpiled 

in the community as part of basic disaster planning, and the ways to locate and access it should be 

part of emergency response training. 

 Provide personal protection and individual response training that first responders ordinarily receive 

to lay or professional individuals designated as responsible for providing care to those expected to 

die. 

 Provide community and family member education regarding individual response actions and 

personal protection under various disaster scenarios or MCEs. Specifically, people will need to know 

how to protect themselves from contamination while still palliating symptoms for dying patients. 

Chapter VII. Palliative Care 110 
 Ensure that all first responders serving those who are expected to die soon know: 

y How to access the medication stockpile 

y The basics of psychosocial counseling and support for peer-to-peer support and 

provider/patient services in MCE scenarios. 

Recruitment of professional providers and lay volunteers 

With planning, a community could develop a reasonable reserve capacity for serving those who will 

live a short time before dying from a disaster. Palliative care, home health care, and long-term care 

professionals have valuable skills, but they are seldom called on for planning or for response during 

and after large-scale emergencies and disasters. Retired health care professionals often do not have a 

current skill set to be optimally useful in hospital settings, but their skills could be readily sufficient 

for medication and assessment in palliative care settings. 

Furthermore, volunteering to help the dying has a long tradition among older persons and faith-based 

organizations. 

Palliative care and long-term care professionals, retired health care professionals, and lay volunteers 

could be recruited and trained in their “defined roles” in disaster events in advance. Local palliative 

assistance teams could be recruited from a variety of practice settings (hospices, hospitals, long-term 

care, etc.) and disciplines (physicians, nurses, social workers, chaplains, etc.). These teams could be 

developed locally, potentially in conjunction with the Medical Reserve Corps (MRC). Potential 

groups that might serve as sponsors of these teams include senior centers, churches and synagogues, 

hospices, long-term care providers, nurses’ organizations, senior organizations such as AARP, the 

National Hospice and Palliative Care Organization, and the American Academy of Hospice and 

Palliative Medicine as well as local hospitals, hospices, and palliative care programs. 

These teams would be deployed to the site of an MCE, would assist with triaging victims as needed, 

and then would provide palliative care to patients deemed to be expectant (black tag) or in critical 

need of pain and symptom management. These rapid response teams would supplement, not replace, 

local palliative care services. 

Recommended actions include the following: 

 Create specialized rapid response teams made up of palliative care professionals and lay volunteers 

recruited and trained to serve as local, statewide, and regional providers. 

 Consider incorporating these teams under the MRC, and the Community Response Team for 

deployment depending on the nature and scope of an incident. 

 Consider extending the credentialing of palliative care disaster volunteers into the existing disaster 

response Federal/State and local legal/insurance systems in order to expand community capacity 

Chapter VII. Palliative Care 111 
through such mechanisms as the Emergency Systems for Advance Registration of Volunteer 

Healthcare Personnel (see page 87). 

 Develop central registries of local health care providers and lay volunteers in the community who 

can be called on in the event of a disaster. Recruit these volunteers and providers into emergency 

response teams. 

Barriers to implementing these recommendations include identifying sponsors and funding. In 

addition, it may be that some of the people who are dedicated to providing palliative care services in 

normal times may be unwilling to take on these roles under dire circumstances of a catastrophic MCE. 

Mental health and spiritual care services 

Dying, suffering, and death quite reasonably incite strong emotions and responses in patients, family 

members, professional caregivers, and bystanders. Reactions to disasters or MCEs will vary, and 

stress reactions can occur immediately following the disaster or many months later. In addition, 

because the medical community are the primary first responders in a catastrophic event or natural 

disaster, a broad-based mental health and counseling educational and service delivery plan 

(determined by the community that it will serve) for this group is essential. Local mental health 

providers, such as psychologists, chaplains, and health care providers, are a vital resource not only for 

the provision of palliative care services to mass casualties but also for the psychosocial support 

services that they can provide to the response providers. As the volume of patients triaged to palliative 

care expands, so will the strain of providing mass palliative care. These individuals also will need to 

have periodic emotional and psychological relief (e.g., by having them rotate to teams that are doing 

other types of work, such as delivering food); this would be important for the welfare and morale of 

the provider corps as a whole. 

Resources for Planners A number of behavioral, psychological, and 

spiritual response plans have been 

developed and should serve as the basis for 

the planning and delivery of these services 

in an MCE (see box). 

o Standing Together: An Emergency Planning Guide for 

America’s Communities. Joint Commission on 

Accreditation of Healthcare Organizations; 2005. 

While many individuals will die outright as 

a result of an MCE, there may be many 

more that are imminently dying or expected 

to die, in both the short and long terms. In 

times of crisis, many people look to clergy 

and other religious leaders for guidance. 

Spiritual counseling and support regarding 

the effects of the event should be made available to those not expected to survive and their families, 

as well as those expected to survive. 

o Preparing for the Psychological Consequences of 

Terrorism: A Public Health Strategy. Institute of 

Medicine; 2003. 

o Mental Health All-Hazards Disaster Planning Guidance 

(HHS Pub. No. SMA3839) and Mental Health 

Response to Mass Violence and Terrorism: A Training 

Manual (HHS Pub. No. SMA 3959). Both available at 

http://nmhicstore.samhsa.gov/publications/browse.

asp. Accessed November 28, 2006.

Chapter VII. Palliative Care 112 
The potential post-traumatic stress and long-term psychological impacts of such disasters should be 

anticipated for those who are likely to survive and those experiencing the event but unharmed over 

the long term. Recommended actions include ensuring that response planning and activities include 

mental health and spiritual care services, especially for those not expected to survive and the first 

responders and health care professionals serving these populations. Mental health professionals and 

laypeople with training as well as pastoral and spiritual caregivers should be recruited and integrated 

into current disaster planning and response. Reluctance to integrate these nontraditional initial 

response professionals into catastrophic MCE planning and response could pose a barrier. 

Communications and chain of command 

Local and State leaders will have a great deal of influence over the individuals and community’s 

expectations, understanding, and responses to an MCE. The management of the acute situation sets 

the tone for the ways society will respond. The accurate portrayal of ongoing efforts and successful 

forecasting of predictable events will enhance the credibility of authorities and diminish negative 

outcomes such as panic and chaos. 

Two principal goals of communications in disaster events are (1) to establish and maintain a common 

operating picture and (2) to ensure accessibility and interoperability across jurisdictions and 

functional agencies. Establishing the role of communication in the integration of palliative care 

services in an MCE requires understanding how communications are transmitted and planning for 

alternative and backup communications and links. 

Recommended actions include: 

 Integrating information about service capacity in long-term care, home care, and hospice care and 

these professionals and laypersons into public education and disaster response training and activities 

 Ensuring ways to communicate the need to transfer persons needing palliative care to designated 

ACSs as well as to transfer revised classification patients from palliative care treatment sites 

 Ensuring ways for authorities to direct community members to palliative sites. 

Planners should be aware that under the dire circumstances of a catastrophic MCE, training first 

responders either to classify as not expected to survive or to reclassify as expected to survive will not 

be an easy task. In addition, there will need to be clear lines of authority and responsibility for transfer 

to palliative care treatment sites. 

Management of the dead 

Recommended actions include the following:

 Pay attention to and be respectful of varying religious beliefs and approaches to body management. 

Chapter VII. Palliative Care 113 
Disaster Mortuary Operational Response Teams 

(DMORTs) are composed of private citizens, each 

with a particular expertise, who are activated in the 

event of a disaster to deal with the myriad issues of 

victim identification and mortuary services. During an 

emergency response, DMORTs work under the 

guidance of local authorities, providing technical 

 Do all that is possible to document the identity of the dead and the disposition of the body, for the 

benefit of the survivors. Deciding how to 

manage the dead has profound and long-lasting 

consequences for survivors and communities 

and is one of the most difficult features of 

disaster management. Immediately after a 

major disaster, the identification and disposal 

of human remains is typically handled by the 

local community. 

assistance and personnel to recover, identify, and The remains typically pose no immediate 

health risk in the case of a natural disaster but 

may pose considerable risk in the case of an 

epidemic. 

process deceased victims. 

 Address issues such as the supply of body bags, refrigerator trucks, ways to catalog bodies, and 

cremation with local funeral directors prior to an MCE. Communities may decide to purchase and 

stockpile body bags. 

 Include the disaster mortuary operational response team (see box), public health planners, funeral 

directors, and medical examiners in disaster planning and drills. 

Chapter VII. Palliative Care 114 
Discussions with Key Informants 

Given the fact that palliative care issues in the context of an MCE have not benefited from substantial 

prior work, the authors conducted telephone discussions with a sample of key informants from the fields 

of disaster planning and palliative care regarding the relevant issues and requirements for palliative care 

under a catastrophic MCE. General domains experts were asked to discuss: 

1. How should decision guidelines for who receives this care be delivered? How do we handle large 

numbers of people expected to die and those already very sick or disabled? 

2. What services/equipment/providers should be available? How should we use (or reuse) common 

supplies and equipment (e.g., gloves, gowns)? 

3. What skills, materials, and memoranda of understanding are needed to shelter and/or evacuate people 

with supportive/palliative care needs? 

4. What criteria would you suggest to allocate scarce and highly specialized clinical resources concerning 

supportive/palliative resources in the two scenarios? 

5. What differences and similarities are there in the general considerations for the delivery of 

supportive/palliative care in an MCE such as bioterrorism and pandemic flu? 

6. Is the current system given what is needed for shelter and evacuation sufficient, and if not, what if any 

additional support needs to be provided at the State and local levels? 

7. Do you perceive a need for evacuation decisions for the supportive/palliative populations? 

8. What are the vital skills for first responders to have? 

9. How to maintain infection control and safe care environment? 

10. How should we modify documentation standards to ensure enough information to support care and 

obtain legal protection without posing an undue administrative burden? 

11. How to manage excessive deaths and the disposal of their bodies? 

12. What are the clinical algorithms to make decisions regarding allocation of scarce resources? 

13. What are the protocols for those who we need to help die comfortably? 

14. What role does euthanasia play in disaster planning in supportive/palliative care? How do you communicate 

these tough decisions to the public? 

Chapter VIII: Influenza Pandemic Case Study 115
Issues Related to Palliative Care in the Context of an MCE 

1. All disaster planning and response should include plans for patients who will be unlikely to survive 

under catastrophic circumstances (e.g., events with mass casualties and/or long-term scarce 

resources), those already living with short prognosis in the community (since their existing services 

will be disrupted by the event), and those newly dying as a result of the event. 

2. Most skilled professionals who usually serve those with fatal chronic illness may be diverted to active 

treatment settings to treat the medically salvageable, so first responders, less well-trained health 

care personnel, and potentially laypersons may have to fill in to care for the dying. 

3. Health care personnel who are skilled in the principles of palliative care, long-term care, and hospice 

need to be involved in disaster response planning. 

4. Specific palliative care supplies; disaster preparedness equipment; and health, mental health, and 

social service personnel (including volunteer laypersons) must be available and trained to use 

supplies such as narcotics and psychoactive drugs, dressings and splints, supportive surfaces, 

antipyretics or steroids, anti-infectives, and PPE. 

5. Palliative care should be integrated into the case mix of ACSs or special locations: “palliative care” 

treatment sites should be established to treat those not expected to survive. 

6. “First responders” and transport personnel should be trained in appropriate triage of patients so that 

palliative care patients do not overwhelm acute care hospitals. 

7. The patients designated as “too sick to survive” initially should have their pain or other symptoms 

managed at the scene of the event and then should be transported to an ACS for continued palliative 

care services when transportation becomes available. 

8. Locations ordinarily used to care for persons with eventually fatal chronic illnesses (e.g., nursing 

facilities, home health agencies) need to be ready to handle more severe complications. Plans 

should address the prospect of not transferring patients needing ventilator support if they are too sick 

to survive but prepared to provide appropriate palliative care services. 

9. Preplanning for the provision of palliative care following a catastrophic event should not be seen as 

euthanasia or a cause of wrongful death. Managing the ethics interface requires thoughtful training, 

peer support, and extensive public education. 

10. Long-term care providers and palliative care experts are encouraged to become part of all disaster 

planning and response activities. 

11. The challenges of serving people who are frail or in need of palliative care prior to the disaster 

event should be addressed. At a minimum, this would include establishing a way to find and identify 

them. 

12. There must be an honest recognition of death; this will be particularly difficult for certain groups 

such as children. 

Chapter VIII: Influenza Pandemic Case Study 116
Chapter VIII. Influenza 

Pandemic Case Study 

AUTHORS 

Members of all writing teams contributed to this chapter. 

Previous chapters highlighted important issues, concepts and 

strategies that need to be taken into consideration when preparing 

mass casualty event (MCE) response plans. This final chapter of the 

guide pulls much of that information together and applies it to a 

specific MCE case study: the hypothetical scenario of an influenza 

pandemic. This chapter provides an overview of the myriad 

challenges community planners need to consider when faced with the 

allocation of scarce resources as a result of a worldwide outbreak of 

influenza. 

Chapter VIII: Influenza Pandemic Case Study 117
Overview 

Preceding chapters of this report have discussed a broad range of issues that planners need to 

consider when developing their MCE preparedness and response plans. This chapter distills that 

information into a specific case study planning exercise. Specifically, the discussion in this 

chapter explores the implications of planning for a hypothetical MCE: that of an influenza 

pandemic. None has been “mitigated” to date. 

The National Strategy for Pandemic Influenza 

Implementation Plan is available at 

www.whitehouse.gov/homeland/nspi_ 

implementation.pdf.

The Department of Health and Human Services 

Pandemic Influenza Plan is available at 

An influenza pandemic would fall under the category of a developing impact MCE discussed in 

the introduction of this guide. A pandemic poses daunting challenges for planners in that it will 

occur in many areas simultaneously; there will not be a single disaster “site.” Indeed, a 

pandemic will affect a large part of the population across the world and across all age groups, 

including the health care and emergency 

response workforce. The magnitude of the 

pandemic’s impact will be felt in the large 

numbers of patients who quickly overwhelm 

hospitals and emergency departments and 

necessitate the allocation of scarce resources. 

www.hhs.gov/pandemicflu/plu/pdf. The National Strategy for Pandemic Influenza 

Implementation Plan puts the bulk of the 

planning and coordination responsibility on 

States and localities rather than the Federal 

Government. The ubiquitous nature of an influenza pandemic requires such shared 

responsibility. State and local health authorities and community planners, therefore, represent 

the front lines of pandemic preparedness response planning efforts. 

Consistent with the messages from the other chapters of this guide, planners need to create their 

pandemic preparedness plans now, practice and exercise the plans and revise them when 

necessary. The range of issues that planners need to consider as they prepare for an event likely 

to place overwhelming demand not only on each community’s health care system, but on 

essential services as well, is indeed staggering. 

While an important component of all disaster responses, clear communications with the public 

assumes even greater prominence in pandemics. Effective and coordinated risk communication, 

domestically and internationally, before and during a pandemic, is essential to helping the 

public understand the rationale for recommended protective actions and in accepting the 

prioritization of scarce resources. 

Chapter VIII: Influenza Pandemic Case Study 118
Communications activities include the 

identification of credible spokespersons at 

all levels of government to effectively 

coordinate and communicate helpful, 

informative messages in a timely manner. 

In the pre-pandemic period, for example, the 

The National Governors Association primer for 

Governors and Senior State Officials, Preparing 

for a Pandemic Influenza notes that “Managing 

during a pandemic--with considerable loss of staff, 

depleted resources, a struggling economy and a 

nervous public--will be a considerable challenge to 

local and State leadership.” 

The NGA primer is available at www.nga.org

public can be educated about infection 

control behaviors and the specific actions 

individuals likely will be asked to take 

during a pandemic, such as self-isolation and protection of others, if they themselves become ill 

with the flu. 

Preparedness activities that planners need to consider include using available communications 

tools (see box) to develop messages to address the difficult topics discussed in this guide, 

including decisions regarding the uses of scarce resources and caring for the sick at home. 

RISK COMMUNICATIONS TOOLS FOR PLANNERS

Activities are underway to develop training modules to assist communities prepare for all public health 

crises. Training guides, publications, and other risk communications documents are available at 

www.pandemicflu.gov/rcommunication. 

Given the range of issues to be considered and the potential scope of the pandemic’s impact, 

communities are encouraged to identify what resources will be needed, what processes and 

systems need to be put in place and to prepare their plans now to help mitigate the impact of a 

pandemic; decrease the amount of infection; and, by extension, reduce hospitalizations and 

deaths. 

The first sections of this chapter set the stage for our hypothetical case study with an overview 

discussion of influenza and the implications of a pandemic. The succeeding sections of the 

chapter focus on the key concepts and strategies that planners need to consider when faced with 

the challenge of planning for a potential flu pandemic and the requisite allocation of scarce 

resources. 

Background 

Not all influenza strains are alike. Avian influenza, for example, a strain that occurs naturally 

among birds, differs markedly from what we know as the seasonal human influenza that claims 

an average of 36,000 lives annually in the United States (see Table 1). 

Chapter VIII: Influenza Pandemic Case Study 119
While these viruses usually do not infect humans, a lethal strain of avian influenza known as 

H5N1 did appear among humans in Hong Kong in 1997, sending 18 people to the hospital and 

killing 6 people. The H5N1 strain reappeared in Hong Kong in 2003, killing one person. Since 

that time, the virus has extended its geographic reach to other nations in Asia, Europe, and the 

Middle East. According to the World Health Organization, more than 50 percent of the people 

that have been infected with the virus to date have died. 

What is particularly troubling to experts is the knowledge that all influenza viruses are capable 

of mutating. If the current strain circulating were to gain the capacity to spread easily from 

person to person, a worldwide influenza pandemic could ensue. While no one can tell if this 

may happen, experts are concerned about – and are monitoring closely – the evolving H5N1 

virus situation in Asia, Africa, and Europe in preparation for a possible pandemic. 

Despite the uncertainty about whether or when a pandemic will hit, we do have prior experience 

with pandemics. Over the course of the last century, the world witnessed three pandemics: the 

Table 1. How Seasonal Flu Differs from Pandemic Flu 

SEASONAL FLU PANDEMIC FLU 

Outbreaks follow predictable seasonal patterns; 

occurs annually, usually in winter, in temperate 

climates 

Occurs rarely (three times in 20th century – last in 

1968) 

Usually some immunity built up from previous 

exposure 

No previous exposure; little or no preexisting immunity

Healthy adults usually not at risk for serious 

complications; the very young, the elderly and 

those with certain underlying health conditions 

at increased risk for serious complications 

Healthy children and adults, along with other seasonal 

high risk groups, may be at increased risk for serious 

complications 

Health systems can usually meet public and 

patient needs 

Health systems may be overwhelmed 

Vaccine developed based on circulating flu 

strains and available for annual flu season 

Vaccine probably would not be available in the early 

stages of a pandemic 

Adequate supplies of antivirals usually available Effective antivirals may be in limited supply 

Average U.S. deaths approximately 36,000/year Number of deaths could be quite high (e.g., U.S. 1918 

death toll approximately 675,000) 

Symptoms: fever, cough, runny nose, muscle 

pain. Deaths often caused by complications, 

such as pneumonia. 

Symptoms may be more severe and complications 

more frequent 

Generally causes modest impact on society 

(e.g., some school closing, encouragement of 

people who are sick to stay home) 

Sever pandemic may cause major impact on society 

(e.g., widespread restrictions on travel, closings of 

schools and businesses, cancellation of large public 

gatherings) 

Manageable impact on domestic and world 

economy 

Potential for severe impact on domestic and world 

economy 

Source: www.pandemicflu.gov

Chapter VIII: Influenza Pandemic Case Study 120
“Spanish influenza” of 1918, which resulted in a worldwide death toll of more than 50 million 

lives; the “Asian influenza” in 1957, which resulted in one-to-two million deaths worldwide; 

and the “Hong Kong influenza” in 1968, with 700,000 deaths worldwide. 

Given the significant growth in not only the human population but animal populations as well 

since the last pandemic, the current environment may be even more conducive for the 

reassortment between animal and human influenza strains leading to a novel influenza virus that 

spreads between people and could cause a pandemic. The sharp increase in worldwide travel 

over the past 40 years would fuel the rapid spread of the virus even further. Since viruses such 

as avian flu are not usually transmitted to humans, there is little or no immune protection 

against them, so most people are susceptible. The supply of antiviral drugs may be inadequate 

and the development of a vaccine will take a significant amount of time. Moreover, there may 

be a shortage of supplies, equipment, and hospital beds to cope with a pandemic. 

Potential shortages of ventilators could be particularly problematic. In the case of such a 

pandemic, hospitals may not have an adequate supply of reserve ventilators required to treat 

patients suffering from acute respiratory failure. The Centers for Disease Control and 

Prevention (CDC) has a reserve supply of thousands of mechanical ventilators under the 

Strategic National Stockpile, and is planning to procure additional ventilators in 2007. To help 

prepare for a potential pandemic, the American Association for Respiratory Care (AARC) has 

issued a set of guidelines and recommendations (see box). 

Key AARC Ventilator Capacity Recommendations 

 Increase human resources to assist respiratory therapists and physicians and have easy-to-use 

ventilators available in the event the respiratory therapists on the hospital staffs cannot handle 

the volume and noncritical care professionals must be enlisted. 

 Extend ventilator capacity for any mass casualty response, expanding the Strategic National 

Stockpiling Program by 5,000 to 10,000 ventilators. Additional ancillary supplies for ventilator use 

also should be stockpiled.* 

 Develop a distribution plan for ventilators at both the local and national levels. 

 Intubation (placing a breathing tube down the windpipe) is recommended for patients suffering 

acute respiratory failure during a pandemic flu, because ventilation by mask may increase the 

risk for infection to staff and other patients. 

 Prepare for a power outage: each medical center should identify emergency power sources for 

electricity and compressed gas. 

The guidance document is available at www.aarc.org.

* HHS has since allocated $25 million toward ventilator procurements.

Chapter VIII: Influenza Pandemic Case Study 121
The impact of the pandemic will be felt in the closing of schools and businesses, with high 

worker absenteeism as employees remain at home either due to their own illness or to care for a 

sick family member. 

Current State of U.S. Emergency Medicine and Disaster Preparedness 

Pandemic response planning efforts will 

not take place in a vacuum; planners 

need to be aware of the overall 

environment in which any disaster 

preparedness effort will operate. 

Unfortunately, planners will not be 

working necessarily from a position of 

strength in terms of the current state of 

emergency health care and disaster 

preparedness in the United States. 

“It became evident to me that [emergency 

preparedness] was a major part of my responsibility. 

[September 11] has created a need for an even 

deeper inspection of our readiness throughout the 

country. The people of Salina, Kansas weren’t really 

worried about terrorists coming to their town, but they 

have reason to be concerned about a [flu] pandemic.” 

– Michael O. Leavitt, Secretary 

U.S. Department of Health and Human Services 

Many hospitals are already operating at or 

over capacity. Because major hospitals and 

emergency departments are already crowded 

with patients and even may be boarding 

large numbers of inpatients, there is little or 

no surge capacity to absorb a large influx of 

patients from an MCE. 

According to a recently issued Institute 

of Medicine report, Hospital-based Emergency Care: At the Breaking Point, the U.S. 

emergency medical care system is seriously unprepared for a national crisis such as a pandemic 

or terrorist attack. The report concluded that our current emergency medical system is already 

strained to the breaking point and suffers from 

inadequate funding along with weak 

communications and coordination across levels 

and geographic areas, with little if any surge 

capacity to deal with a disaster of the magnitude 

of a flu pandemic or other crisis. 

Hospital-Based Emergency Care: At the 

Breaking Point. Institute of Medicine. June 

2006. 

It is within this context that every community 

must address the daunting task of developing a 

pandemic preparedness response plan. Given the 

current state of emergency medicine, it is 

important to reemphasize the key message of the 

earlier chapters of this guide: advance planning is critical. 

Setting the Stage: Progression of a Hypothetical Flu Pandemic 

For the purposes of this case study, the Expert MCE Working Group devised a hypothetical 

pandemic scenario that can be grouped into four periods. 

PRE-PANDEMIC PERIOD. The pre-pandemic period is the period in which we currently find 

ourselves. A limited number of human cases of avian flu H5N1 have occurred in persons 

Chapter VIII: Influenza Pandemic Case Study 122
having close contact with infected birds or poultry, and only limited human to human 

transmission has occurred. This is the period in which the bulk of the planning effort should be 

completed. Indeed, the discussions throughout this planning guide have emphasized the 

importance of advance planning for an MCE; it is precisely here in this early pre-pandemic alert 

period that most of the advance planning for a potential flu pandemic needs to take place. 

INITIAL PANDEMIC ALERT: NO CASES IN U.S. The next period in our hypothetical case study 

involves the confirmation of an outbreak of sustained human-to-human transmission of a strain 

of H5N1 in a small village in Thailand. The World Health Organization then commits 3 million 

courses of Tamiflu to the region and requests additional donations from industrialized nations 

with stockpiles. Thailand also requests additional countermeasures directly from the United 

States. Other Southeast Asian countries subsequently institute restrictions on movement to 

protect their populations and prevent the disease from spreading further. By the end of the first 

phase, there are 446 cases of the disease and 18 deaths in Southeast Asia. 

PANDEMIC ALERT: GLOBAL SPREAD AND FIRST CONFIRMED CASES IN U.S. The next period of our 

pandemic scenario sees the H5N1 virus spreading beyond Southeast Asia to major 

municipalities, countries, and regions worldwide, with sustained human-to-human transmission. 

The number of reported infections rises to 158,487 cases worldwide and 6,318 deaths. This 

period ends with the appearance of the first flu case from the H5N1 virus in the United States. 

PANDEMIC PERIOD: WIDESPREAD U.S. PANDEMIC. The final period of our hypothetical pandemic 

scenario, the pandemic period, involves increased attention to the worsening conditions in the 

United States, where millions are infected and 2 percent of those infected ultimately die from 

the disease. Workplace absenteeism and disruption in trade and travel begin to take a large toll 

on world economies. Shortages of medical supplies, staff members, and facilities complicate 

treatment of the ill. Over the course of a 7-week period, the number of cases in the United 

States rises from 90 to nearly 5 million and the number of deaths increases from 1 to nearly 

100,000. 

Pandemic Flu Case Study: Important Concepts, Strategies, and Actions 

for Planners 

The following sections detail important concepts, strategies, and actions that planners need to 

incorporate into their preparedness planning. The information is arranged according to the three 

periods of our hypothetical case study described above. Within each period of the pandemic, we 

highlight the important concepts to be considered as well as the strategies and actions to be 

taken within the prehospital, hospital, and alternative care site (ACS) sectors. 

As noted earlier in this guide, the home will be particularly relevant in the case of a flu 

pandemic. Planners must emphasize the importance of the home as a “safe haven” and consider 

the use of primary care vans to go out into localities to provide services so that people may 

Chapter VIII: Influenza Pandemic Case Study 123
remain in their homes. At the same time, planners need to recognize the vital role of primary 

care providers in deciding which patients may remain at home and which patients need to go to 

the hospital. In the case of a flu pandemic, primary care providers may be the first medical 

personnel contacted. Moreover, the ambulatory care system will be a critical element of a 

system to keep the hospitals from being overwhelmed during a pandemic. 

Finally, in addition to looking at the flu pandemic planning considerations in each health care 

setting, we also detail important palliative care-related issues to be considered. 

Not all the material provided in this chapter will be appropriate to each community planner. 

Indeed, many of the concepts presented here will need to be tailored to the resources available 

and the systems that are in place in the specific community, locality, region, or State. It is hoped 

that planners can use this information to help fill in the gaps in their pandemic preparedness 

plans by answering the questions, “What do I do, and when do I do it?” This chapter aims to 

provide community planners with options to consider in terms of preparing for a potential flu 

pandemic. 

This chapter presents a hypothetical case study, and the material provided, while extensive, is not 

exhaustive. Planners are encouraged to consult the wealth of excellent pandemic influenza 

planning documents for detailed information and recommended actions. 

PANDEMIC PREPAREDNESS RESOURCES

A sample of the many valuable resources for community planners include: 

State and local government pandemic planning and response 

avian and pandemic flu information can be found at

www.pandemicflu.gov. 

HHS Pandemic Influenza Plan: 

www.hhs.gov/pandemicflu/plan. 

CDC Pandemic Influenza information for Health Professionals: 

http://www.cdc.gov/flu/pandemic/healthprofessional.htm. 

World Health Organization materials on influenza preparedness: 

http://www.who.int/csr/disease/avian_influenza. 

State health planning information from The Association of State and Territorial Health Officials: 

www.astho.org. 

The National Governors Association Primer for Governors and Senior State Officials: 

www.nga.org

Chapter VIII: Influenza Pandemic Case Study 124
Pre-Pandemic Period 

This pre-pandemic period represents the period in which we currently find ourselves. 

This period is where most of the advance planning for a pandemic needs to take 

place. An overview of issues and activities that community planners need to consider 

is listed below. 

I. General Coordination and Planning Issues 

Command Structure 

 Determine the trigger for emergency health powers provision (see 

discussion of legal issues in Chapter IV of this guide). Conduct discussions 

with hospital associations and local and State Public Health officials on when 

the trigger would be pulled on emergency health powers provisions and who 

makes that decision.

Develop continuity of government and leadership protocols in the event 

that senior leadership becomes missing, incapacitated, or deceased. 



Conduct regional exercises that are inclusive, use realistic scenarios, 

involve all responders, and embrace participation from agencies that are often 

not included. 



 Include local and State political representatives using education and 

exercises to get them involved, committed, and supportive. 

 Consider the special needs population and children in all planning 

scenarios. 

Communications 

 Begin a public communication campaign. Focus the messaging campaign 

on managing expectations; and providing updates on the community plan for 

pandemic response, including community care sites. This communications 

campaign should be a joint effort by hospitals, hospital partners, and Public 

Health departments. 

 Emphasize prevention. Inform and educate the public about influenza. 

Provide advice and information on prevention and interventions to reduce 

virus transmission so that if and when the virus arrives the public is 

knowledgeable about reducing the spread of the virus. 

Chapter VIII: Influenza Pandemic Case Study 125
II. Prehospital 

 Prepare universal precautions for every patient encounter. 

Pre-plan community staging locations, which would be pre-designated sites 

that could be opened ahead of time for alternative care and EMS staging. 



 Locate transport assets in advance. 

Planners are encouraged to consult the EMS planning checklist available at

www.pandemicflu.gov/plan/pdf/EMS.pdf. 

 Arrange mutual aid agreements for acquisition and use of specialized 

assets. This would be accomplished by meeting with local and regional 

transportation authorities or businesses and agreeing by Memorandum of 

Understanding (MOU) on deployment, available assets, and staging locations 

(e.g., buses, other means of transports, staff augmentation). The MOU could 

be further enhanced by the development of a pre-event contractual agreement 

between the government and these institutions. 

 Evaluate triage models such as JUMPSTART, Israel, and SACO. 

Develop and publicize call centers to minimize load on hospitals and 

clinics.



III. Hospital 

Planners are encouraged to consult the detailed hospital pandemic preparedness checklist available 

at www.hhs.gov/pandemicflu/plan/sup3htmt#app2 as well as overall hospital pandemic planning 

information at www.hhs.gov/pandemicflu/plan/sup3.html#s3-III. 

 The Hospital Planning Committee should complete all components of 

hospital pandemic influenza preparedness and response plans 

(multidisciplinary committee including a range of response partners). 

 Develop hospital guidance for flu pandemic control measures 

Chapter VIII: Influenza Pandemic Case Study 126
 Work with other local hospitals, community organizations, State and local 

health departments to coordinate pandemic response actions. 

The hospital pandemic influenza planning committee may include representatives from the 

following departments, among others: 

 Administration  Security 

 Legal counsel  Materials management 

 Infection control/hospital epidemiology  Education/training/Staff development 

 Hospital disaster/emergency coordinator  Occupational health 

 Risk management  Diagnostic imaging 

 Facility engineering/physical plant/institutional safety  Pharmacy 

  Information technology 

 Other members (infectious diseases, mental

 health, social work, critical care medicine, 

 pathology, among others) 

 Nursing administration 

 Medical staff 

 Intensive care 

 Representatives from State and local health 

departments and community partners such as 

EMS, local law enforcement, and community 

service agencies, among others 

 Emergency Department 

 Laboratory services 

 Respiratory therapy 

 Psychiatry 

 Environmental services (housekeeping, laundry) 

 Public relations 

 Assess surge capacity (beds, ventilators, etc.) to meet expected increased 

needs during a pandemic. 

 Develop plan to expand staff capacity. Determine how the hospital will 

meet staffing needs during a pandemic. 

 Draw up preference list of supplemental providers. 

 Consider volunteers, ESAR VHP, CERTs, MRC, clinic staff, out-of-State 

licensed staff, military, retirees, non-health-care staff, among others.

 Ensure policies are in place to test and manage deployment of nonhospital 

personnel at both the community and hospital levels.

 Ensure that a plan for managing volunteers is in place.

 Develop contingency plans for staff absences during a pandemic, 

particularly ER staff. 

 Initiate discussions of allocation of hospital resources during a pandemic; 

hospital administrators to meet with hospital ethics committee early on in 

planning process: 

Source: HHS Pandemic Influenza Plan at www.hhs.gov/pandemicflu/plan/sup3.html#box1.

Chapter VIII: Influenza Pandemic Case Study 127
 Establish hospital process for scarce resource allocation 

 Develop communication process so community understands the 

 rationale behind resource allocation policies. 

 Stockpile supplies and equipment:

 PPE equipment (e.g., gloves, masks)

 Estimate increased need for respiratory care equipment and develop 

 strategy to acquire additional equipment if needed

 Consult with local and State health departments about access to the 

 national stockpile during a pandemic.

 Develop facility access guidelines. 

 Define “essential and “non-essential” visitors and develop policies for 

 restricting visitors during a pandemic (and mechanisms for enforcing the 

 policies) 

 Plan to limit hospital entry to a few key entrances

 Plan for increased security needs during a pandemic.

IV. Alternative Care Sites 

Planners are encouraged to consult the HHS Influenza Plan for Alternative Care Sites at

www.hhs.gov/pandemicflu/plan/sup3.html#altcare. 

A major challenge for planners is that in contrast to hospitals and EMS, ACSs do not 

currently exist as operating medical care systems. In fact, in many communities, 

ACSs have not even been carefully considered as an option for patient care. 

Therefore, it is imperative that the planning process for ACSs begin as early in the 

initial pandemic planning process and include the following activities: 

 Define ownership, command, and control of ACS. 

 Perform site selection based on best estimates of need. 

 Decide on the scope of care to be provided in the ACS. 

 Establish functional requirements based on the level of care to be provided: 

Chapter VIII: Influenza Pandemic Case Study 128
 Acquire supplies, equipment, and pharmaceuticals (including 

 communications equipment). 

 Perform staffing planning, taking into account absentee rates from 

 potential sources of staff members. 

 Develop MOUs for operational support of the ACS. 

 Include housing for health care workers. 

 Develop policies of operation for the ACS, including: 

 Incident command 

 Criteria for admission, discharge, and transfer 

 Clinical roles and responsibilities 

 Infection control 

 Pharmacy and medication control 

 Safety and security 

 Housekeeping 

 Food service 

 Finances and documentation 

 Develop a health care risk communication message, including criteria for 

seeking health care, such as postponement of non-emergency procedures or 

surgeries. 

 Develop criteria for hospital decompression. 

V. Palliative Care 

 Hold planning discussions of limited treatment options due to scarce 

resources. In a situation of scarce resources, decisions will need to be made 

that typically would not be considered under usual circumstances. The 

standards of care and treatment decision options will be appropriate to the 

situation at the time the decision is made. Community planners need to be 

aware that: 

 It may not be possible always to save a life during a pandemic. 

Chapter VIII: Influenza Pandemic Case Study 129
 It is important to have these difficult discussions prior to the occurrence of 

a pandemic. 

 Establish and maintain standards of palliative care. Ensure that standards 

of palliative care are published and available for consideration in pandemic 

planning efforts. 

 Provide education and training for palliative care responders in basic 

preparedness for understanding, recognizing and establishing response 

actions in a pandemic flu situation. 

 Include instruction about self-protection and avoidance of the spread of 

 disease. 

Chapter VIII: Influenza Pandemic Case Study 130
Pandemic Alert Period: Cases Overseas but No 

Confirmed Cases in U.S. 

In this pandemic alert period, there have been confirmed cases of sustained human-to-human 

transmission of the avian H5N1 influenza virus in Asia. Asian nations request aid from the 

United States and take steps to protect their populations and prevent the disease from spreading 

further. By the end of this period in our hypothetical case study there are nearly 500 people 

infected with the virus and nearly 20 deaths from the disease. Planning activities to consider in 

this period, after laboratory-confirmed virus changes that predict sustained human-to-human 

transmission, are listed below. 

I. Prehospital 

Command Structure 

 Establish an Emergency Operations Center (EOC) 

 The EOC should include, but not be limited to, representatives of the 

 following groups: community health centers, home health care 

 organizations, hospitals, Public Health agencies (local, State, and 

 Federal), Metropolitan Medical Response Systems, long-term care 

 organizations, and other health-related groups. 

 The EOC will coordinate all EMS resources by including public, private, 

 and volunteer representatives. 

 The EOC should encourage the use of health area operation centers. This 

 will allow the EOC to communicate directly with a larger medical 

 community, which could provide guidance and direction. 

Communications 

 Establish a comprehensive public information strategy 

 Use mass media to provide the public information on preventive 

 measures, home care management, and the appropriate time to seek 

 health care services. 

 Use community health care call centers to reinforce mass messaging and 

 to provide additional and more tailored information to individuals with 

 questions and concerns. Review these issues for their value as potential 

 mass media messages. 

Chapter VIII: Influenza Pandemic Case Study 131
 Use community call centers to assist with outpatient (home care) 

monitoring and support, thereby helping to extend the reach of public 

health and healthcare systems into households. 

 Use information collected by the call centers for situational awareness and 

disease outbreak management and control. 

II. Hospital 

Command Structure 

 Partially activate the Hospital Incident Command System (HICS) with 

the assignment of an Incident Commander (IC). 

 Hold briefings for administrators and staff members. Review talking 

points and discuss general action plans to be followed in the event that a flu 

pandemic should spread to the United States. 

 Establish the hospital process for allocating scarce resources. 

Activate/test internal hospital committees on standards of care if necessary. 

Review policies and protocols. 

Training 

Conduct Just-in-time-training for staff members, including influenza 

transmission, general information, infection control information, ventilator 

management, and hospital plans. Training is to be conducted via e-mail, 

informational posters, and shift briefings. 



Conduct Personal Protection Equipment (PPE) Training. Perform fit 

testing for the outpatient and inpatient staff, donning/doffing instruction, 

practice, and competencies. This training is to be checked by nursing unit, 

PPE inventory, and parameters for use per infection control. 



Supplies 

Increase hospital supplies from the usual baseline of 3-day supply to 7-day 

supply if possible (based on an estimated 150 percent occupancy rate). 

Specific actions to focus on include: 



 Order, inventory, and increase par levels of IV fluids, medicines, linens, 

 and other consumable medical goods. 

Chapter VIII: Influenza Pandemic Case Study 132
Communications 

Establish lines of communication among Public Health officials, hospitals, 

EMS and emergency medicine to provide daily updates. 



 Identify personnel/procedures to run the Joint Information Center (JIC). 

 Ensure daily communications with Public Health and EMS. 

 Designate a public relations person as the hospital Public Information 

Officer. 

 Reinforce the public information messaging begun in Pre Pandemic 

period. 

Drills, Tests and Reviews 

Test the initiation process with partner facilities (e.g., durable supplies 

stored in a local convention center, disposables from a local Target store and 

partner hospitals via pre-agreement and increased par levels), drill action 

planning cycles, and notifications. 



Test Health Alert Network (HAN) to include off hours and notification of 

HAN alerts from the ED to infection control. 



Review plans for security, behavioral health, and general disaster 

contingencies. 



Review the facilities plan, including HVAC and other 

cohorting plans. 

Monitor Outbreak; Screen Outpatients 

 

 Establish a local Public Health point of contact. Begin Department of 

Health (DOH) monitoring of influenza-like illness (outpatient and inpatient). 

 Screen outpatients per CDC guidance for influenza symptoms based on 

fever and/or respiratory symptoms and travel history. Begin screening at the 

Emergency Department and outpatient clinic check-in points. 

 Verify referral agreements with local hospitals in order to ensure that 

patients will be accepted. Clarify patient movement for infectious cases 

between hospitals (e.g., EMS protocol for transfer patients) and within a 

hospital (e.g., protocol for elevator transport of pandemic patients). 

Reinforce infection control and respiratory etiquette for those with 

respiratory symptoms using posters, staff reminders, educational materials, 

and patient masks and tissues at triage and clinic registration points as well as 

near common points such as elevators and major entrances. 



Chapter VIII: Influenza Pandemic Case Study 133
Plan for Vaccine Distribution. Arrange internal distribution to staff 

members based on prior planning and in concert with State and regional plan 

criteria for essential personnel. 



III. Alternative Care Sites 

The following measures need to be undertaken to prepare for operation of the ACS: 

 Perform resource assessment for standing up an ACS 

 Include acquisition of additional necessary disposable supplies 

 Finalize policies of operation for the ACS 

 Exercise the ACS if possible 

 As early as possible, explore the legal issues around standing up an ACS 

for full functional exercise with patients 

 Test communications 

 Identify and roster the ACS staff 

 Establish a process of immunization and prophylaxis of potential staff 

members 

 Develop a patient transport plan for movement of ACS patients to and from 

area hospitals 

Chapter VIII: Influenza Pandemic Case Study 134
Pandemic Alert Period: Global Cases and First 

Confirmed Cases in the U.S. 

In this period of our hypothetical pandemic case study scenario, the avian H5N1 flu virus 

begins to spread from Asia to other nations around the world. The number of people infected 

rises significantly as does the number of deaths. The second period ends with the first 

appearance of the avian flu virus in the United States. In this second period planners need to 

consider the following activities. 

I. Prehospital 

 Prepare to open community staging locations 

 Engage mutual aid partners

 Consider home care preparations. During a pandemic, it is likely that the 

home will serve as a major care site. Planners may want to consider the 

following steps:

 Ensure adequate stock of routine, chronic care medications is available to 

the community. 

 Ensure adequate stock of basic first aid supplies, including bandages, 

antipyretic medications (acetaminophen, ibuprofen), oral electrolyte 

solutions), and thermometers. 

 Ensure that backup utility support is in place should the power grid be 

disrupted by decreased staffing for those patients requiring electricity 

support for medical devices.

 Provide advice on the establishment of a “sick room” in the home for 

primary management of ill household members.

 In the event of caring for patients with advanced symptoms “too sick” for 

hospital care, provide symptom palliation with a home care team 

coordinated by local public health authorities.

 Ensure availability of a bedside commode or bedpan.

 Ensure availability of a bedside humidifier if possible. 

Chapter VIII: Influenza Pandemic Case Study 135
II. Hospital 

Command Structure 

 Fully activate the HICS and open a hospital command post. 

Patient Screening 

 Continue to limit hospital entry to a few key entrances. 

Screen patients for symptoms of influenza (fever, respiratory symptoms) 

and relevant travel history (if defined enough) and with rapid diagnostic tests 

if available in the tent adjacent to the triage entrance. 



 Mask patients with suspect symptoms and make sure that providers wear 

appropriate PPE until a potential influenza case is ruled out. 

Anticipate Hospital Surge 

Schedule and, to the extent possible, perform all elective surgeries within the 

next few weeks. 



Ramp up outpatient services by increasing clinic hours and personnel to 

provide nonurgent services (such as annual exams, prenatal checks, and 

rechecks) that would be difficult to obtain during a pandemic. Extra staffing 

will be needed because outpatient services will be a likely place for screening 

of those who are concerned that they may have the flu.



 Communicate with the public about the need to get nonemergency services 

taken care of sooner rather than later. Use mass media to reinforce this 

message: “During a pandemic, you will not be seen in the clinics for 

nonurgent conditions.” 

 Establish a hospital hotline and enable the prerecorded greeting to triage 

calls for information to nonclinical staff and clinical inquiries to appropriate 

staff at the department of health. 

Create temporary anterooms on medical surgical floors, and utilize the 

intensive care unit (ICU) as a cohorting area during the early phase of a 

pandemic. 



Prepare flat space areas in conference rooms, auditoriums, etc., for patient 

care (organize cots, linens, etc.). 



Chapter VIII: Influenza Pandemic Case Study 136
Open a joint information center (JIC) with the hospital association acting 

as liaison with all hospitals in the region. The regional coordinating hospital 

provides updates and solicits baseline availability of ventilators and patient 

beds. 



III. Alternative Care Sites 

 Establish incident command structure for ACS. Planners should ensure 

that ACS is integrated with community, regional and State incident command 

systems. 

 Unpack and inventory supplies at the selected site(s) 

 Enable the security protection systems of the ACS to protect the supplies. 

IV. Palliative Care 

 Discuss goals of care. Each person who is infected with the flu has the 

potential of developing complications, either based on their previous health 

history or as a consequence of the flu itself. These complications may lead to 

a situation where the individual becomes too sick to survive. While the health 

care professional is helping this person through the various stages of their 

disease, it may become necessary to have a discussion regarding the goals of 

care and patient preferences. Establish goals of care, acknowledging that 

individuals may die as a result of influenza. 

 Provide information on treatment options. Patients and families need to 

have updated information so they may understand their condition and 

treatment options. 

 The decisionmaking process about the patient’s care plan must be 

sensitive not only to changes in the patient’s condition but also to the 

availability of community resources. 

 Address pain and symptom control, psychosocial distress, spiritual issues, 

and practical needs with the patient and their family throughout the 

continuum of care. 

V. Home Care Issues 

Chapter VIII: Influenza Pandemic Case Study 137
 Address the myriad challenges of providing health care services in the 

home setting to people with substantial disability and/or an established illness 

or without family or other resources to provide care. Community planners 

should consider the following issues related to providing care in the home 

setting: 

 Develop alternative ways to provide care to people in the community 

such as primary care vans that go into neighborhoods to provide care, 

answer questions, and provide resources. 

 Establish telephone hotlines to answer questions regarding the avian flu 

virus, such as using “Ask-A-Nurse”-type telephone support services and 

make use of existing hotlines. 

 Consider ways to provide incentives for people to work during times of 

crises. Planners should be aware that health care workers may not want to 

leave their families to care for flu patients and should consider incentives 

(e.g., giving them priority status for vaccines). 

Chapter VIII: Influenza Pandemic Case Study 138
Pandemic Period: Increased and Sustained 

Transmission in U.S. Population 

In this the final period of our hypothetical case study planning exercise, the avian flu virus has 

spread to communities across the U.S. Millions of individuals are infected with the virus and the 

death toll is increasing steadily. In this final period of the pandemic, planners need to consider 

the following measures. 

I. Prehospital 

Set Up and Utilize Casualty Treatment Areas 

Use formal triage and treatment protocols and have triage and treatment 

completed in nontraditional triage/treatment areas by bringing prehospital 

personnel to casualty treatment areas. 



Determine who can be treated on site to include those triaged with moderate 

(yellow) and minor (green) status. 



Determine who should be transported to area hospitals and by what means, 

with the sickest casualties with a reasonable chance of survival are treated 

and transported first. 



 Bring in prehospital personnel to staff these areas. 

 Prepare equipment caches containing MCE-specific supplies so they are 

readily deployable. Examples would include staffing and additional fieldrelated treatment modalities for both advanced life support (drugs, airway, 

etc.) and basic life support (splints, oxygen, dressing, etc.) as well as easily 

deployable tents with portable generation. 

Consider suspension of some medical protocols (e.g., base contact for 

certain interventions, expansion of scope of practice, appropriate standard of 

care). 



Consider bringing medical care to the people triaged with moderate 

(yellow) and minor (green) status. 



Consider secondary triage methodologies such as one hospital triaging 

patients to another. 



Chapter VIII: Influenza Pandemic Case Study 139
911 Dispatch Issues 

 Dispatcher screening of response need 

 Provide precaution advice for scene responders 

 Limit the number of responders to the minimal necessary response 

 Provide a nonemergency information and advice line 

Maximize Utilization of Available Personnel 

 Create modified shifts; expand number of providers and vehicle types 

 Maximize Transport Capability 

 Staff ambulances with one EMT and a non-EMT driver (firefighter, police 

officer, teacher, etc.). 

 Expand the use of paramedic-initiated alternative transport mechanisms 

(e.g., buses, taxis, privately owned vehicles). 

 Load ambulances with more than one patient (e.g., two critical, one critical 

plus one or more noncritical). 

 Air transport probably will be of limited use. 

 Maximize Personal Protection Available to Personnel 

Distribute vaccine to personnel with the additional consideration for 

inclusion of family members. 



 Maximize Destination Choices 

 Encourage home care rather than transport, if possible. Transport patients

not only to hospitals but also to clinics and ACS. 

 Consider other potential sites such as nursing homes, public buildings, etc. 

 Consider “batching” noncritical calls in the same geographic area and 

transporting all patients to the closest appropriate facility rather than the 

facility of the patient’s choice. 

Chapter VIII: Influenza Pandemic Case Study 140
II. Hospital 

 Planning and Information 

Institute action planning. The planning section anticipates resource needs 

for the next operational period and gathers situational information from 

within the hospital and from regional/State entities. It also works with 

personnel to determine staffing and availability.



Activate the Joint Information Center opened during the pandemic alert 

period



. The JIC is managed by the hospital association liaison for all 

hospitals in conjunction with Public Health and EMS. The JIC will become 

responsible for providing daily media messages and holding press 

conferences. 

 Establish daily briefing cycle for staff members and media (arranged with 

the JIC). 

Activate Multiagency Coordination System 

 Have key representatives from Public Health, Emergency Medicine, EMS, 

and hospital staff monitoring information on the system status from all 

agencies/hospitals (including liaisons from neighboring States). 

 Conduct action planning at the regional level. 

 Compare the “triage levels” at area facilities to assure consistency. 

 Request resources (when possible) via jurisdictional Emergency Medicine. 

 The Staffing Coordinator manages Public Health, Emergency Medicine, 

EMS, and hospital requests for staffing and allocates them based on the 

sources available, including the Medical Reserve Corps and ESAR VHP. 

 Communicate with the State EOC or the State DOH about regional resource 

and policy needs. 

 Ensure Public Health coordination with home care agencies and messaging, 

hotline and Internet support for families. 

Review Staffing Plans 

Use families to provide basic patient care. The hospital should engage the 

patients’ families (one person at a time) to provide basic patient care, such as 

feeding. Nurses (including Medical Reserve Corps, ESAR VHP, and retirees 



Chapter VIII: Influenza Pandemic Case Study 141
with appropriate mentorship by current staff nurses) provide medications and 

assessments and review vital signs. 

Respiratory therapy manages ventilators only; other respiratory care 

services are to be provided by nurses. Floor nurses are to receive training 

in basic ventilator monitoring, with floor units supervised by a roving 

ICU nurse to monitor ventilated patients. 



 Physicians see patients on an as-needed basis, providing critical 

 interventions and assessment for interventions, transfer, and discharge. 

Consider expanding staff capacity with changes in staff scheduling (e.g., 

duration of shifts, staffing ratios, changes in staff assignments), though it is 

important to note that longer shift duration during an infectious event



 may be 

detrimental to staff who do not adhere to PPE recommendations when 

fatigued.

 Review Use of Hospital Space and Supplies 

 Set up cohort areas of inpatient and outpatient units for infectious patient 

care. These areas are to be used when volume allows (the entire facility may 

be a cohort during peak periods). 

 Select operating room and procedure room space to be used for additional 

ventilated patient care. 

Use minimal documentation. Use short assessment and plan notes – 

medication and vital signs documentation, for example. 



 Reuse disposable supplies when possible. 

 Clinical Care Committee 

 Institute daily meetings of the clinical care committee to examine new 

guidance, the situation at the hospital, and the regional situation and to 

determine appropriate levels of care to be offered based on staffing and other 

resources. The committee adapts State guidance to the hospital level and 

reviews any updates. 

 The Committee submits recommendations to the Planning Chief and then 

 to the IC. 

 On approval of the IC, any changes to the previous day’s triage, 

 treatment, and diagnosis protocols are communicated to the ED, 

 outpatient, and inpatient areas. These changes may include: 

• Guidance on laboratory and x-ray testing (both influenza case testing 

 and clinical lab/x-ray guidance) 

Chapter VIII: Influenza Pandemic Case Study 142
• Guidance on outpatient/ED denial of service (e.g., deny care to those 

 who will not be seen due to their injury/illness being too minor) 

• Updated information for all patients and family members presenting 

to the facility to be handed out by a triage nurse and reviewed with 

the patient’s nurse or physician 

• Inpatient care guidelines (staff responsibilities) 

• Inpatient triage/resource situation 

• Anticipated events/trends in the next operational period. 

Patient Triage 

Set up a triage team (may consist of one critical care and one infectious 

disease physician, among others) to review conflicting resource needs (e.g., 

two patients needing a single ventilator) on a case-by-case basis. 



 The team recommends assigning the resource to the patient with the 

 better prognosis – using decision tools supplied via the State and the 

 clinical care committee. 

 Physicians are to provide patient care when not performing triage 

 functions. 

Identify a Bed Czar to monitor the bed and “hard” resource statuses (e.g., 

ventilators), make assignments based on availability, and implement triage 

team recommendations. 



 The bed czar receives input from clinical units about patient statuses 

 (improving, deteriorating, etc.) on a scheduled basis. 

Enable Hospital Decompression 

 Establish alternative care sites in conjunction with other area hospitals as 

well as in conjunction with Public Health and Emergency Medicine to enable 

hospital decompression. 

 Notify EMS, Public Health, and others of need to decompress the hospital, as 

needed. 

 Transfer patients to and from facilities as needed based on hospital 

resources; critical care to be concentrated in hospitals. 

Chapter VIII: Influenza Pandemic Case Study 143
Establish a Regional Home Death Management Process 

Set up regional hubs for body retrieval and processing with a review by the 

Medical Examiner, a registration process, and a temporary holding place 

awaiting definite management. 



Deploy refrigerated trucks from the hospital for body management, 

exchanged daily to regional processing sites. 



Arrange for Web-based death certificate processing and secure tracking to 

the Department Of Health. 



Hospitals in Rural Areas 

Some of the issues that planners need to consider that are more likely to apply to 

hospitals located in rural areas, include: 

 The triage physician (and/or nurse) implementing decisions at the 

hospital/ward level. 

 Promoting a regional hospital and multiagency coordination system to 

share staff and resources as possible and help hospitals in the region share 

information. Coordinate the setup of a regional ACS when needed (under the 

host city’s jurisdictional umbrella). 

o Patient referral to regional hospitals (when possible) or supportive care 

provided to the extent possible at the facility. 

o Offsite care (may be a single regional facility). The ACS is the 

screening and care point for noncritical patients (the ACS fulfills the need 

for additional screening/minor treatment in a rural area, whereas in an 

urban area it is opened for referral transfers from hospitals only). In 

smaller communities, hospitals and clinics may not have the space and 

resources for screening that urban areas have, so bottlenecks may occur in 

outpatient assessment as well as inpatient care. 

 Coordination of care with home care/families

 The hospital coordinates with local public health agency to determine the 

scope of care in the community and facilitate home and ;palliative care. 

Transfers from the hospital morgue to a regional processing point or local 

undertakers with the Medical Examiner as needed. 



Chapter VIII: Influenza Pandemic Case Study 144
III. Alternative Care Sites 

 Ensure all ACSs are fully operational. 

 Investigate the need for the establishment of other functional sites for the 

potential purposes of supplying ambulatory care, inpatient care, quarantine, 

and/or palliative care. 

 Establish criteria for terminating operation of the ACSs as the pandemic 

eventually passes. 

IV. Palliative Care 

Patient Triage 

 Establish patient triage criteria by levels of care 

 Classification of patients who are already chronically ill, extremely old, 

or in long-term care facilities (e.g., by physician prognosis). 

Establish Plans for Use of Long-term Care Facilities 

Nursing homes also could provide a preventive care response to an 

influenza pandemic (e.g., immunizations, drug management), thereby 

providing relief to hospitals. Nursing homes have not only the medical 

expertise, but also the capability to maintain supplies that could prove useful 

in a pandemic. 



Chapter VIII: Influenza Pandemic Case Study 145
Chapter VIII: Influenza Pandemic Case Study 146
Appendix A: Participant List 

Expert Meeting on Providing Mass 

Medical Care with Scarce Resources 

L’Enfant Plaza Hotel 

480 L’Enfant Plaza, S.W. 

Washington, DC 

June 1–2, 2006

Appendix B. Bibliography 147
Writing Teams

Ethical Considerations in Community Disaster Planning 

Marc Roberts, Ph.D. 

Professor of Economy 

Department of Health Policy Management 

Harvard University 

Evan G. DeRenzo, Ph.D.

Bioethicist 

Center for Ethics 

Washington Hospital Center 

Alternative Care Sites 

Stephen Cantrill, M.D. 

Associate Director 

Department of Emergency Medicine 

Denver Health Medical Center 

Carl Bonnett, M.D. 

Emergency Medical Services Fellow 

Department of Emergency Medicine 

Denver Health Medical Center 

Dan Hanfling, M.D., FACEP 

Director 

Emergency Management and Disaster Medicine 

Inova Health System 

Peter Pons, M.D. (Also in Prehospital Care) 

Professor of Emergency Medicine 

Department of Surgery 

University of Colorado Health Sciences Center 

Senior Technical Physician, Emergency Department 

Denver Health Medical Center 

Appendix A. Participant List 148 
Assessing the Legal Environment Concerning Mass Casualty Event Planning and 

Response 

James G. Hodge, Jr., J.D., LL.M. 

Associate Professor 

Johns Hopkins Bloomberg School of Public Health 

Executive Director, Center for Law and the Public’s Health 

Georgetown and Johns Hopkins Universities

Hospital/Acute Care 

John L. Hick, M.D. 

Assistant Professor 

Emergency Department 

Hennepin County Medical Center 

Gabor Kelen, M.D. 

Director, Office of Critical Event Preparedness and Response (CEPAR) 

Professor and Chair, Director of Research 

Department of Emergency Medicine 

The Johns Hopkins University 

Daniel O’Laughlin, M.D. 

Assistant Professor of Emergency Medicine 

University of Minnesota/Abbott Northwestern Hospital 

Lewis Rubinson, M.D., Ph.D. 

Health Officer 

Division of Pulmonary and Critical Care Medicine 

Deschutes County Health Department 

Bend Memorial Clinic 

Richard Waldhorn, M.D. 

Distinguished Scholar 

Center for Biosecurity 

University of Pittsburgh Medical Center 

Dennis P. Whalen 

Executive Deputy Commissioner 

New York State Department of Health 

Empire State Plaza 

Palliative Care 

Marianne Matzo, Ph.D., APRN, BC, FAAN 

Professor and Frances E. and Earl Ziegler Chair in Palliative Care 

Palliative Care Nursing 

University of Oklahoma College of Nursing 

University of Oklahoma Health Sciences Center 

Appendix A. Participant List 149 
Anne M. Wilkinson, M.S., Ph.D. 

Senior Social/Behavioral Scientist 

Palliative Care Policy Center 

RAND Corporation 

Maria Gatto, M.A., APRN 

Director of Palliative Care 

Bon Secours Health System 

Joanne Lynn, M.D., M.A., M.S. 

Senior Natural Scientist 

RAND Corporation 

Prehospital Care 

Edward Gabriel, M.P.A., AEMT-P 

Director of Crisis Management 

The Walt Disney Corporation 

George Foltin, M.D. 

Associate Professor of Pediatrics and Emergency Medicine 

Center for Pediatric Emergency Medicine 

Bellevue Hospital 

Paul Maniscalco, M.P.A., EMT-P 

Assistant Professor/Chief Researcher 

Homeland Security Policy Institute 

The George Washington University 

Richard Serino, EMT-P 

Chief 

Boston Emergency Medical Service

Appendix A. Participant List 150 
Meeting Participants

Michael B. Anderson, M.H.A. 

Senior Advisor for Public Health and Emergency Preparedness 

Preparedness Directorate 

Office of Grants and Training 

U.S. Department of Homeland Security 

Knox Andress, R.N. 

Weapons of Mass Destruction Response Coordinator 

CHRISTUS Schumpert Health System 

Emergency Preparedness Committee 

Emergency Nurse Association 

Lynne Bergero, M.H.S.A. 

Project Director 

Division of Standards and Survey Methods 

Joint Commission on Accreditation of Healthcare Organizations 

Sumner L. Bossler, R.N., CEN 

Senior Public Health Analyst 

Health Care Emergency Preparedness 

Bioterrorism Hospital Preparedness Program 

Health Resources and Services Administration 

U.S. Department of Health and Human Services 

James Geiling, M.D. 

Chief of Medicine 

Veteran Affairs Medical and Regional Office Center 

White River Junction, VT 

Robert M. Gougelet, M.D. 

Assistant Professor of Emergency Medicine 

Dartmouth Hitchcock Medical Center 

Medical Director, Disaster Response 

Dartmouth Medical School 

James G. Hodge, Jr., J.D., LL.M. 

Associate Professor 

Johns Hopkins Bloomberg School of Public Health 

and Executive Director 

Center for Law and the Public’s Health at 

Georgetown and John Hopkins Universities 

Richard C. Hunt, M.D., FACEP 

Director 

National Center for Injury Prevention and Control 

Division of Injury and Disability Outcomes and Programs 

Centers for Disease Control and Prevention 

U.S. Department of Health and Human Services 

Appendix A. Participant List 151 
Brian Kamoie, J.D., M.P.H. 

Special Assistant 

Department of Health Policy and Department of Health Services Management and Leadership 

Office of the Assistant Secretary for Preparedness and Response 

U.S. Department of Health and Human Services 

Ann Knebel, R.N., D.N.Sc., FAAN 

Deputy Director for Preparedness Planning 

Office of Preparedness and Emergency Operations 

Office of the Assistant Secretary for Preparedness and Response 

U.S. Department of Health and Human Services 

William J. Kormos, USAF, M.Sc., CHE 

CONUS Medical Planner 

Force Health Protection and Readiness 

Office of the Assistant Secretary of Defense 

U.S. Department of Defense 

Julie Krueger 

Public Health Fellow 

Office of Emergency Medical Services 

National Highway Traffic Safety Administration 

U.S. Department of Transportation 

Deborah A. Levy, Ph.D., M.P.H. 

Senior Advisor for Healthcare Preparedness 

Division of Healthcare Quality and Promotion 

National Center for Infectious Diseases 

Centers for Disease Control and Prevention 

U.S. Department of Health and Human Services 

David Marcozzi, M.D., FACEP 

Senior Medical Advisor 

Office of Preparedness & Emergency Operations 

U.S. Department of Health and Human Services 

F. Christy Music, M.S., M.T., ASCP, SBB 

Senior Advisor, Health Affairs and Medical Homeland Security Policy 

Office of the Assistant Secretary of Defense for Homeland Defense 

U.S. Department of Defense 

La Forice Nealy 

Director of Response and Emergency Communication 

The American Red Cross of Greater Chicago 

Ann E. Norwood, M.D. 

Senior Analyst 

Office of the Assistant Secretary for Preparedness and Response 

U.S. Department of Health and Human Services 

Appendix A. Participant List 152 
Nicki T. Pesik, M.D. 

Deputy Science Team Medical Officer 

Bioterrorism and Preparedness and Response Program 

Centers for Disease Control and Prevention 

U.S. Department of Health and Human Services 

Sally J. Phillips, R.N., Ph.D. 

Director, Public Health Emergency Preparedness Research Program 

Center for Primary Care, Prevention, and Clinical Partnerships 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

Melissa Sanders, R.D. 

Branch Chief 

Health Care Emergency Preparedness 

Bioterrorism Hospital Preparedness Program 

Health Resources and Services Administration 

U.S. Department of Health and Human Services 

Scott Sasser, M.D. 

National Center for Injury Prevention and Control 

Department of Emergency Medicine 

Centers for Disease Control and Prevention 

U.S. Department of Health and Human Services 

Kevin Yeskey, M.D. 

Director, Office of the Secretary 

Office of the Assistant Secretary for Preparedness and Response 

U.S. Department of Health and Human Services 

Appendix A. Participant List 153 
Appendix B. Bibliography 154
Appendix B. Bibliography

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Appendix B. Bibliography 166 
Appendix B. Bibliography 167