Allocation of Scarce Resources During Mass Casualty Events (MCEs): Review Protocol

Allocation of Scarce Resources During MCEs
Full Title: Evidence Review on the Allocation of Scarce Resources During Mass Casualty Events (MCEs)
Evidence-based Practice Center Systematic Review Protocol
May 2011


Contents
Background
The Key Questions
Analytic Framework
Methods
References
Definitions of Terms


Background
This evidence report will help our Nation prepare for large-scale health emergencies—one of 13 "urgent issues" flagged for immediate attention by the Government Accountability Office (GAO) shortly following the 2008 Presidential election.1,2 The GAO's concern is based on ample evidence that our Nation's emergency care system, including emergency medical services (EMS), hospital-based emergency departments, and the inpatient wards and intensive care units (ICUs) of many hospitals, are so overburdened that currently, most are ill prepared to cope with a large-scale public health emergency,3-5 whether the onset is sudden, as is typical of an earthquake or terrorist bombing,6 or protracted, as would be likely in case of a major hurricane, flood, infectious disease outbreak,7 or bioterrorism attack.8

Regardless of the etiology of a major disaster, it can be reasonably foreseen that under current conditions, health care providers and systems will be hard pressed to manage a large-scale surge of victims from a mass casualty event (MCE).9 In such incidents, demand for medical care resources is likely to quickly outstrip the capacity of local or even regional health care providers to meet each patient's needs at the level expected of modern health care delivery systems. When normally available resources are clearly insufficient to meet needs, health care providers must be prepared to implement contingency plans to boost delivery of services, and if this is inadequate, to shift rapidly from strategies designed to deliver optimal care to each patient to a modified approach calculated to do the most good for the most people with the resources at hand. The Institute of Medicine (IOM) terms this strategy "crisis standards of care." IOM's definition follows:

"Crisis standards of care" is defined as a substantial change in usual health care operations and the level of care it is possible to deliver, which is made necessary by pervasive (e.g., pandemic influenza) or catastrophic (e.g., earthquake, hurricane) disaster. This change in the level of care delivered is justified by specific circumstances and is formally declared by a state government, in recognition that crisis operations will be in effect for a sustained period. The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce resources and implementing alternative care facility operations.10

Optimizing resource allocation in an MCE requires a multi-faceted approach that includes strategies to minimize unnecessary demand for health care services, to boost the supply of medical resources for those who need them, and to make difficult resource allocation decisions in crisis care situations. The development and implementation of these strategies requires, in turn, a multi-disciplinary approach that balances multiple considerations, including ethical and legal issues and the special needs of at-risk populations. To be successful, stakeholders from the provider community and the public must be actively engaged in the process of developing and implementing crisis standards of care. One of the first and most critical steps in this process is to systematically review the literature to identify, grade, and summarize relevant evidence regarding how best to approach and manage this process. That is the task we are about to undertake.

Our work will build on previous comprehensive governmental and non-governmental reviews, including important studies performed by the Assistant Secretary for Preparedness and Response (ASPR), a literature review conducted by the Agency for Healthcare Research and Quality (AHRQ) in 2007, a 2008 literature review performed by Koenig and colleagues for the State of California, and a Letter Report on "Crisis Standards of Care" produced by the Institute of Medicine's Forum on Medical and Public Health Preparedness for Catastrophic Events, hereafter referred to as the "IOM Letter Report." These reports provide a strong foundation for our review by creating a conceptual framework for the optimal allocation of scarce resources in MCEs. Our report will build on the framework by identifying existing and proposed allocation strategies, various ways groups have engaged providers and the public, and the key concerns of the public regarding implementation of crisis standards of care. Our report will describe the level of evidence regarding each of these topics. By highlighting the strengths and gaps in the existing evidence base, we hope to inform a research agenda that can quickly improve our Nation's capacity to prepare, respond, and quickly recover from large-scale health emergencies.


full-text (large):
Allocation of Scarce Resources During Mass Casualty Events (MCEs): Review Protocol


Note: The following protocol elements are standard procedures for all protocols.

Review of Key Questions
For all EPC reviews, key questions were reviewed and refined as needed by the EPC with input from the Technical Expert Panel (TEP) to assure that the questions are specific and explicit about what information is being reviewed.

Technical Experts

Technical Experts comprise a multi-disciplinary group of clinical, content, and methodologic experts who provide input in defining populations, interventions, comparisons, or outcomes as well as identifying particular studies or databases to search. They are selected to provide broad expertise and perspectives specific to the topic under development. Divergent and conflicted opinions are common and perceived as healthy scientific discourse that results in a thoughtful, relevant systematic review. Therefore, study questions, design, and/or methodological approaches do not necessarily represent the views of individual technical and content experts. Technical Experts provide information to the EPC to identify literature search strategies and recommend approaches to specific issues as requested by the EPC. Technical Experts do not participate in analysis of any kind nor do they contribute to the writing of the report. They have not reviewed the report except as given the opportunity to do so through the public review mechanism.

Technical Experts must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Individuals are invited to serve as Technical Experts because of their unique clinical or content expertise, and those who present with potential conflicts may be retained. The TOO and the EPC work to balance, manage, or mitigate any potential conflicts of interest identified.

Peer Reviewers

Peer reviewers are invited to provide written comments on the draft report based on their clinical, content, or methodologic expertise. Peer review comments on the preliminary draft of the report are considered by the EPC in preparation of the final draft of the report. Peer reviewers do not participate in writing or editing of the final report or other products. The synthesis of the scientific literature presented in the final report does not necessarily represent the views of individual reviewers. The dispositions of the peer review comments are documented and will, for CERs and Technical briefs, be published three months after the publication of the Evidence report.

Potential Reviewers must disclose any financial conflicts of interest greater than $10,000 and any other relevant business or professional conflicts of interest. Invited Peer Reviewers may not have any financial conflict of interest greater than $10,000. Peer reviewers who disclose potential business or professional conflicts of interest may submit comments on draft reports through the public comment mechanism.



Current as of May 2011


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Internet Citation:

Allocation of Scarce Resources During Mass Casualty Events (MCEs), Review Protocol. May 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/tp/scarcerestp.htm


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