PRDA - L:Evidence report

Evidence Report/Technology Assessment
Number 207

Allocation of Scarce
Resources During Mass
Casualty Events

Agency for Healthcare Research and Quality
Advancing Excellence in Health Care • www.ahrq.gov

Evidence-Based
Practice

Evidence Report/Technology Assessment
Number 207

Allocation of Scarce Resources During Mass Casualty
Events
Prepared for:
Agency for Healthcare Research and Quality
U.S. Department of Health and Human Services
540 Gaither Road
Rockville, MD 20850
www.ahrq.gov
Contract No. 290-2007-10062-I

Prepared by:
Southern California Evidence-based Practice Center
Santa Monica, CA
Investigators:
Justin W. Timbie, Ph.D., RAND Corporation
Jeanne S. Ringel, Ph.D., RAND Corporation
D. Steven Fox, M.D., M.S., RAND Corporation
Daniel A. Waxman, M.D., RAND Corporation
Francesca Pillemer, Ph.D., RAND/University of Pittsburgh
Christine Carey, M.A., RAND Corporation
Melinda Moore M.D., M.P.H., RAND Corporation
Veena Karir, PharmD., M.S., RAND/University of Pittsburgh
Tiffani J. Johnson, M.D., RAND/University of Pittsburgh, Children’s Hospital of Pittsburgh
Neema Iyer, M.P.H., RAND Corporation
Jianhui Hu, M.P.P., RAND Corporation
Roberta Shanman, M.L.S., RAND Corporation
Jody Wozar Larkin, M.L.I.S., RAND Corporation
Martha Timmer, M.S., RAND Corporation
Aneesa Motala, B.A., RAND Corporation
Tanja R. Perry, B.H.M., RAND Corporation
Sydne Newberry, Ph.D., RAND Corporation
Arthur L. Kellermann, M.D., M.P.H., RAND Corporation

AHRQ Publication No. 12-E006-EF
June 2012

This report is based on research conducted by the Southern California–RAND Evidence-based
Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality
(AHRQ), Rockville, Md. (Contract No. 290-2007-10062-I). The findings and conclusions in this
document are those of the author(s), who are responsible for its contents; the findings and
conclusions do not necessarily represent the views of AHRQ. No statement in this report should
be construed as an official position of AHRQ or of the U.S. Department of Health and Human
Services.
Funding to support Allocation of Scarce Resources During Mass Casualty Events was provided
by the U.S. Department of Health and Human Services Office of the Assistant Secretary for
Preparedness and Response through an Interagency Agreement with the Agency for Healthcare
Research and Quality (Contract No. 290-2007-10062-I).
The information in this report is intended to help health care decisionmakers—patients and
clinicians, health system leaders, and policymakers, among others—make well-informed
decisions and thereby improve the quality of health care services. This report is not intended to
be a substitute for the application of clinical judgment. Anyone who makes decisions concerning
the provision of clinical care should consider this report in the same way as any medical
reference and in conjunction with all other pertinent information, i.e., in the context of available
resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice
guidelines and other quality enhancement tools or as a basis for reimbursement and coverage
policies. AHRQ or U.S. Department of Health and Human Services endorsement of such
derivative products may not be stated or implied.
This document is in the public domain and may be used and reprinted without permission except
those copyrighted materials that are clearly noted in the document. Further reproduction of those
copyrighted materials is prohibited without the specific permission of copyright holders.
Persons using assistive technology may not be able to fully access information in this report. For
assistance contact [email protected].
None of the investigators have any affiliations or financial involvement that conflicts
with the material presented in this report.
Suggested Citation: Timbie JW, Ringel JS, Fox DS, Waxman DA, Pillemer F, Carey C, Moore
M, Karir V, Johnson TJ, Iyer N, Hu J, Shanman R, Larkin JW, Timmer M, Motala A, Perry TR,
Newberry S, Kellermann AL. Allocation of Scarce Resources During Mass Casualty Events.
Evidence Report No. 207. (Prepared by the Southern California Evidence-based Practice Center
under Contract No. 290-2007-10062-I.) AHRQ Publication No. 12-E006-EF. Rockville, MD:
Agency for Healthcare Research and Quality. June 2012.
www.effectivehealthcare.ahrq.gov/reports/final.cfm.

ii

Preface
The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based
Practice Centers (EPCs), sponsors the development of evidence reports and technology
assessments to assist public- and private-sector organizations in their efforts to improve the
quality of health care in the United States. The reports and assessments provide organizations
with comprehensive, science-based information on common, costly medical conditions and new
health care technologies and strategies.
The EPCs systematically review the relevant scientific literature on topics assigned to them
by AHRQ and conduct additional analyses when appropriate prior to developing their reports
and assessments. To bring the broadest range of experts into the development of evidence reports
and health technology assessments, AHRQ encourages the EPCs to form partnerships and enter
into collaborations with other medical and research organizations. The EPCs work with these
partner organizations to ensure that the evidence reports and technology assessments they
produce will become building blocks for health care quality improvement projects throughout the
nation. The reports undergo peer review and public comment prior to their release as a final
report.
AHRQ expects that EPC evidence reports and technology assessments will inform
individual health plans, providers, and purchasers, as well as the health care system as a whole,
by providing important information to help improve health care quality.
We welcome comments on this evidence report. Comments may be sent by mail to the Task
Order Officer named in this report to: Agency for Healthcare Research and Quality, 540 Gaither
Road, Rockville, MD 20850, or by email to [email protected].
Carolyn M. Clancy, M.D.
Director
Agency for Healthcare Research and Quality

Jean Slutsky, P.A., M.S.P.H.
Director, Center for Outcomes and Evidence
Agency for Healthcare Research and Quality

Stephanie Chang, M.D., M.P.H.
Director
Evidence-based Practice Program
Agency for Healthcare Research and Quality

Richard Ricciardi, Ph.D., N.P., FAANP
Task Order Officer
Center for Primary Care, Prevention
and Clinical Partnerships
Agency for Healthcare Research and Quality

iii

Acknowledgments
The authors would like to thank Aram Dobalian, M.P.H., Director of the Department of
Veterans Affairs Emergency Management Evaluation Center (VEMEC) at the VA Greater Los
Angeles Healthcare System (VAGLAHS), and Kristi Koenig, M.D., professor of emergency
medicine at the University of California, Irvine, for their invaluable input and guidance on the
report. Both are nationally recognized experts in disaster medicine and health system
preparedness.
The authors would also like to thank members of the public who submitted comments on a
draft version of this report.

Technical Expert Panel
Tim Davis, M.D., M.P.H.
National Disaster Medical System
Washington, DC

Deborah Levy, Ph.D., M.P.H.
Centers for Disease Control and Prevention
National Center for Preparedness, Detection,
and Control of Infectious Diseases
Atlanta, GA

Daniel Fagbuyi, M.D.
Children’s National Medical Center
Washington, DC

Meredith Li-Vollmer, Ph.D., M.A.
Seattle & King County
Seattle, WA

DeAnn Friedholm, M.P.A.
Consumers Union
Washington, DC

Jeffrey Lowell, M.D.
Washington University School of Medicine
St. Louis, MO

Cynthia Hansen, Ph.D.
Department of Health and Human Services
Office of the Assistant Secretary for
Preparedness and Response
Office of Preparedness and Emergency
Operations
Washington, DC

Major General Lester Martinez-Lopez,
M.D., M.P.H., FAAFP
Brandon Regional Hospital
Valrico, FL
Mark Williams, M.D., FACP, FHM
Northwestern University Feinberg School of
Medicine
Chicago, IL

James Hodge, J.D., L.L.M.
Arizona State University
Tempe, AZ
Mary Jagim, R.N., B.S.N., CEN, FAEN
Intelligent InSites
Moorhead, MN

Charlotte Yeh, M.D.
AARP Services, Inc.
Tewksbury, MA

Kathy Kinlaw, M.Div.
Emory University
Atlanta, GA

iv

Peer Reviewers
Susan Allan, M.D., J.D., M.P.H.
University of Washington
Seattle, WA

Cheri Hummel
California Hospital Association
Sacramento, CA

Georges Benjamin, M.D., FACP, FNAPA,
FACEP (E), Hon FRSPH
American Public Health Association
Washington, DC

Roberta Kanter, M.D.
Upstate Medical University
Syracuse, NY
Leslee Stein-Spencer, R.N., M.S.
Chicago Fire Department
Chicago, IL

Colonel Connie Boatright, M.S.N., R.N.
Managed Emergency Surge for Healthcare
(MESH)
Consultant Indiana Primary Health Care
Association
Indianapolis, IN

Joseph Waeckerle, M.D., FACEP
University of Missouri–Kansas City School
of Medicine
Leawood, KS

Eric Frykberg, M.D.
University of Florida
Jacksonville, FL

Matthew Wynia, M.D., M.P.H.
University of Chicago
Chicago, IL

v

Allocation of Scarce Resources During Mass
Casualty Events
Structured Abstract
Objectives. This systematic review sought to identify the best available evidence regarding
strategies for allocating scarce resources during mass casualty events (MCEs). Specifically, the
review addresses the following questions: (1) What strategies are available to policymakers to
optimize the allocation of scarce resources during MCEs? (2) What strategies are available to
providers to optimize the allocation of scarce resources during MCEs? (3) What are the public’s
key perceptions and concerns regarding the implementation of strategies to allocate scarce
resources during MCEs? (4) What methods are available to engage providers in discussions
regarding the development and implementation of strategies to allocate scarce resources during
MCEs?
Data Sources. We searched Medline, Scopus, Embase, CINAHL (Cumulative Index to Nursing
and Allied Health Literature), Global Health, Web of Science®, and the Cochrane Database of
Systematic Reviews from 1990 through 2011. To identify relevant non–peer-reviewed reports,
we searched the New York Academy of Medicine’s Grey Literature Report. We also reviewed
relevant State and Federal plans, peer-reviewed reports and papers by nongovernmental
organizations, and consensus statements published by professional societies. We included both
English- and foreign-language studies.
Review Methods. Our review included studies that evaluated tested strategies in real-world
MCEs as well as strategies tested in drills, exercises, or computer simulations, all of which
included a comparison group. We reviewed separately studies that lacked a comparison group
but nonetheless evaluated promising strategies. We also identified consensus recommendations
developed by professional societies or government panels. We reviewed existing State plans to
examine the current state of planning for scarce resource allocation during MCEs. Two
investigators independently reviewed each article, abstracted data, and assessed study quality.
Results. We considered 5,716 reports for this comparative effectiveness review (CER); we
ultimately included 170 in the review. Twenty-seven studies focus on strategies for
policymakers. Among this group were studies that examined various ways to distribute
biological countermeasures more efficiently during a bioterror attack or influenza pandemic.
They provided modest evidence that the way these systems are organized influences the speed of
distribution. The review includes 119 studies that address strategies for providers. A number of
these studies provided evidence suggesting that commonly used triage systems do not perform
consistently in actual MCEs. The number of high-quality studies addressing other specific
strategies was insufficient to support firm conclusions about their effectiveness.
Only 10 studies included strategies that consider the public’s perspective. However, these studies
were consistent in their findings. In particular, the public believes that resource allocation
guidelines should be simple and consistent across health care facilities but should allow facilities
some flexibility to make allocation decisions based on the specific demand and supply situation.
The public also believes that a successful allocation system should balance the goals of ensuring

vi

the functioning of society, saving the greatest number of people, protecting the most vulnerable
people, reducing deaths and hospitalizations, and treating people fairly and equitably. The
remaining 14 studies provided strategies for engaging providers in discussions about allocating
and managing scarce medical resources. These studies did not identify one engagement approach
as clearly superior; however, they consistently noted the importance of a broad, inclusive, and
systematic engagement process.
Conclusions. Scientific research to identify the most effective adaptive strategies to implement
during MCEs is an emerging area. While it remains unclear which of the many options available
to policymakers and providers will be most effective, ongoing efforts to develop a focused, wellorganized program of applied research should help to identify the optimal methods, techniques,
and technologies to strengthen our nation’s capacity to respond to MCEs.

vii

Contents
Executive Summary .................................................................................................................ES-1
Introduction ....................................................................................................................................1
Background ................................................................................................................................1
Context .................................................................................................................................1
Definition of Terms..............................................................................................................2
Scope of the Review ..................................................................................................................5
Key Questions ............................................................................................................................6
Organization of This Report ......................................................................................................6
Methods ...........................................................................................................................................7
Overview ....................................................................................................................................7
Topic Refinement and Review Protocol ....................................................................................7
Technical Expert Panel and Expert Consultants ........................................................................7
Conceptual Framework ..............................................................................................................8
Analytic Framework ..................................................................................................................9
Search Strategy ..........................................................................................................................9
Inclusion and Exclusion Criteria..............................................................................................10
General Criteria ..................................................................................................................11
Key Question 1: What Strategies Are Available to Policymakers To Optimize
Allocation of Scarce Resources During MCEs? ..........................................................11
PICOTS Framework for Key Question 1...........................................................................11
Inclusion and Exclusion Criteria........................................................................................13
Key Question 2: What Strategies Are Available to Providers To Optimize
Allocation of Scarce Resources During MCEs? ..........................................................13
PICOTS Framework for Key Question 2...........................................................................13
Inclusion and Exclusion Criteria........................................................................................15
Key Question 3: What Are the Public’s Concerns Regarding Strategies To Allocate
Scarce Resources? ........................................................................................................15
PICOTS Framework for Key Question 3...........................................................................15
Inclusion and Exclusion Criteria........................................................................................16
Key Question 4: What Methods Are Available To Engage Providers in Developing
Strategies To Allocate Scarce Resources During MCEs? ...........................................16
PICOTS Framework for Key Question 4...........................................................................16
Inclusion and Exclusion Criteria........................................................................................17
Study Selection ........................................................................................................................18
Data Extraction ........................................................................................................................18
Quality (Risk of Bias) Assessment of Individual Studies ........................................................19
Data Synthesis ..........................................................................................................................20
Strength of the Evidence ..........................................................................................................20
Applicability ............................................................................................................................21
Peer Review and Public Commentary .....................................................................................21
Results ...........................................................................................................................................22
Literature Search ......................................................................................................................22
Key Question 1: What Strategies Are Available to Policymakers To Optimize
Allocation of Scarce Resources During MCEs? ................................................................24

viii

Key Points ..........................................................................................................................24
Description of Included Studies—Tested Strategies .........................................................24
Detailed Synthesis of Tested Strategies .............................................................................25
Key Question 2: What Strategies Are Available to Providers To Optimize
Allocation of Scarce Resources During MCEs? ................................................................30
Key Points ..........................................................................................................................30
Description of Included Studies—Tested Strategies .........................................................31
Detailed Synthesis of Tested Strategies .............................................................................33
Key Question 3: What Are the Public’s Concerns Regarding Strategies To Allocate
Scarce Resources? ..............................................................................................................44
Key Points ..........................................................................................................................44
Description of Included Studies .........................................................................................45
Detailed Synthesis ..............................................................................................................45
Allocation Guidelines ........................................................................................................46
Goals of Allocation Systems ..............................................................................................46
Allocation Decisionmakers and the Role of Government .................................................46
Prioritization Criteria .........................................................................................................46
Key Question 4: What Methods Are Available To Engage Providers in Developing
Strategies To Allocate Scarce Resources During MCEs? .................................................49
Key Points ..........................................................................................................................49
Description of Included Studies .........................................................................................50
Detailed Synthesis ..............................................................................................................50
Analysis of State Reports .........................................................................................................53
Reduce Less-Urgent Demand for Medical Resources .......................................................54
Optimize Existing Resources .............................................................................................55
Strategies To Augment Existing Resources .......................................................................56
Adopt Crisis Standards of Care..........................................................................................57
Discussion......................................................................................................................................59
Key Findings ............................................................................................................................59
Limitations of the Review Methods.........................................................................................62
Limitations of the Evidence Base ............................................................................................63
Opportunities for Future Research ............................................................................................65
Key Challenges ........................................................................................................................65
Insufficient Funding ...........................................................................................................65
Inadequate Coordination ....................................................................................................66
Logistical Barriers ..............................................................................................................66
Planning a Prioritized Research Agenda..................................................................................67
Conclusions ..............................................................................................................................69
References .....................................................................................................................................71
Acronyms and Abbreviations .....................................................................................................84

ix

Tables
Table A. Summary of Strategies Addressing Key Question 1, by Category ...........................ES-14
Table B. Summary of Strategies Addressing Key Question 2, by Category ...........................ES-15
Table C. Summary of Strategies Addressing Key Question 4 .................................................ES-18
Table 1. Summary of Strategies Addressing Key Question 1, by Category ..................................25
Table 2. Comparison of Different Point of Dispensing (POD) Strategies .....................................26
Table 3. Strength of Evidence for Key Question 1 ........................................................................30
Table 4. Summary of Strategies Addressing Key Question 2, by Category ..................................32
Table 5. Accuracy of Triage for Individual Triage Tools Reported in 10 Included Studies .........35
Table 6. Strength of Evidence for Key Question 2 ........................................................................38
Table 7. Strength of Evidence for Key Question 3 ........................................................................50
Table 8. Summary of Strategies Addressing Key Question 4, by Category ..................................51
Table 9. Strength of Evidence for Key Question 4 ........................................................................53
Table 10. Key Elements of State Plans ..........................................................................................58
Figures
Figure 1. Achieving National Health Security.................................................................................2
Figure 2. Conceptual Framework for Allocating and Managing Scarce Medical Resources
During a Mass Casualty Event ...................................................................................................8
Figure 3. Literature Flow ...............................................................................................................23

Appendixes
Appendix A. Search Strategy
Appendix B. Data Abstraction Forms
Appendix C. Evidence Tables
Appendix D. Excluded Studies

x

Executive Summary
Background
Most experts define a mass casualty event (MCE) as a natural (e.g., earthquake, pandemic) or
manmade (e.g., detonation of a nuclear device, conventional explosive, bioterror attack) incident
that suddenly or progressively generates large numbers of injured and/or ill people who require
medical and/or mental health care. The magnitude of demand for medical care resources has the
potential to vastly outstrip the ability of a health care facility or a local, regional, or national
public health and health care delivery system to deliver medical care services consistent with
generally established standards of care.
An MCE can occur suddenly, as is typical of an earthquake, tornado, or terrorist bombing;1
or it may evolve over hours to days, as is typical of a hurricane, flood, or disease outbreak;2 or
would likely happen following a bioterror attack.3 Regardless of its rate of onset, the scope and
complexity of an MCE can severely challenge even the most highly experienced and wellequipped health care providers and systems.4
By definition, an MCE generates a level of demand for health care resources that outstrips
available supply. Under those circumstances, local and regional health care providers are unable
to meet victims’ needs at the level normally expected of a modern health care delivery system.
Because such situations are difficult to predict and can occur with little or no warning, health
care systems and providers must be prepared to swiftly implement contingency plans to reduce
less-urgent demand for health care services; optimize the use of existing resources; and secure
additional resources, if possible, from backup sources. If these measures are insufficient to meet
demand, providers may be forced to shift from the traditional treatment approach, which strives
to deliver optimum care to every patient, to one that seeks to do the most good for the most
people with the available resources. This latter concept has come to be known as “crisis
standards of care.”

Objectives
In 2009, the Institute of Medicine (IOM) Committee on Guidance for Establishing Standards
of Care for Use in Disaster Situations published a landmark Letter Report recommending that
health care providers, organizations, government officials, and the public approach the challenge
in a thoughtful and proactive way, anchored in four values: fairness; equitable processes;
community and provider engagement, education, and communication; and the rule of law.5 The
IOM Letter Report also recommended that State plans incorporate, among other things,
evidence-based clinical processes and operations.
To help Federal, State, and local policymakers, providers, and interested members of the
public address the issue with the best available evidence, we were asked to build on the work of
the IOM and previous reviews by conducting a thorough review of the evidence regarding
allocation of scarce medical resources during MCEs.
This report addresses the following Key Questions:
• Key Question 1. What current or proposed strategies are available to policymakers to
optimize the allocation and management of scarce resources during MCEs? What
outcomes are associated with these strategies? What factors act as facilitators or barriers
to their implementation or effectiveness?

ES-1

•

•

•

Key Question 2. What current or proposed strategies are available to providers to
optimize the allocation of scarce resources during MCEs? What outcomes are associated
with these strategies? What factors are identified as facilitators or barriers to their
implementation or effectiveness?
Key Question 3. What are the public’s key perceptions and concerns (e.g., values,
equity, transparency, communication, and public input) regarding the development and
implementation of strategies to allocate and manage scarce resources during actual and
potential MCEs?
Key Question 4. What current or proposed methods are available to engage providers in
discussions regarding the development and implementation of strategies to allocate and
manage scarce resources, both in planning for and during an MCE? What outcomes are
associated with these strategies? What factors are identified as facilitators or barriers to
engaging providers in these discussions?

Analytic Framework
Given the heterogeneity in key aspects of study design across the four Key Questions, we
elected to use the PICOTS framework (populations, interventions, comparators, outcomes,
timings, and settings) as the analytic framework for the review.

Methods
Input From Stakeholders
The Agency for Healthcare Research and Quality (AHRQ) and the Office of the Assistant
Secretary for Preparedness and Response (ASPR) developed the research topic and its four Key
Questions. Investigators at the Southern California Evidence-based Practice Center then refined
the questions in consultation with two nationally recognized experts in disaster medicine and
health system preparedness and an AHRQ-appointed technical expert panel (TEP) of experts
from the fields of public health, disaster preparedness and response, hospital medicine, transplant
surgery, adult and pediatric emergency medicine, nursing, law, health care ethics, military
medicine, risk communication, and public engagement. The TEP provided clinical and
methodological expertise and offered insights on identifying and defining key parameters for the
review, such as criteria for including and excluding studies.

Data Sources and Selection
Our search strategy leveraged existing reviews of the literature, particularly the IOM’s Letter
Report and Summary on Crisis Standards of Care5,6 and the AHRQ and ASPR Mass Medical
Care with Scarce Resources: A Community Planning Guide.7 These reviews helped identify
relevant medical care resource management and allocation strategies that existed when the
documents were published and provided summary information on the relevant outcomes of the
strategies. Our subsequent literature search comprised four parts: (1) a formal search using
multiple research databases, (2) a scan of the “grey” literature, (3) consultation with our TEP to
identify any additional sources, and (4) a review of State plans for allocating scarce resources
during MCEs.
Searched databases included PubMed, Scopus, Embase, CINAHL (Cumulative Index to
Nursing and Allied Health Literature), Global Health, Web of Science®, and the Cochrane
ES-2

Database of Systematic Reviews, from 1990 through 2011. We also searched online library
catalogs, such as the National Library of Medicine’s LocatorPlus, to identify relevant books.
(Appendix A provides details of our search strategy.) We supplemented these searches with a
search of the grey literature using the New York Academy of Medicine’s Grey Literature Report.
This helped identify reports from research and advocacy organizations, including non–peerreviewed reports. As a final check of comprehensiveness, TEP members identified relevant
studies as well as organizations that sponsored research or issued guidance on proposed
strategies for allocating resources during MCEs. We compiled a list of relevant organizations and
used scans of relevant related Web sites to extend our search.
We also reviewed State plans, which were provided to us by ASPR. We identified a small
number of additional plans through reference searches.
For all four Key Questions, we included articles found in the peer-reviewed literature and
grey literature, including but not limited to empirical studies, State and Federal Government
reports, State plans, peer-reviewed reports and papers by nongovernmental organizations, policy
and procedure documents, and clinical care guidelines developed by specialty societies. We
considered both U.S. and international (English and non-English language) sources. For Key
Questions 1, 2, and 4, we included studies that used randomized controlled trials and
observational studies reporting data from real events, drills, exercises, or computer simulations in
which a comparison group or pre- and post- design was used. For Key Question 3, we included
studies reporting the outcomes of systematic data collection efforts (e.g., focus groups, surveys)
that documented patients’ perspectives on resource allocation during MCEs. We excluded
articles published before 1990, publications that presented only conceptual frameworks, nonsystematic reviews, and studies that did not consider strategies in the specific context of an
MCE—for example, a study of emergency medical services or emergency department triage in
the context of routine operations.

Data Extraction and Quality
After the literature search was completed, two researchers screened all titles to eliminate
citations that were clearly unrelated to the topic. Next, two researchers independently reviewed
study abstracts to determine whether the study should be included in the review, based on our
inclusion and exclusion criteria. If no abstract was available, they reviewed the full text.
Two researchers independently reviewed full-text articles and excluded those that (1) failed
to address a Key Question, (2) did not meet our inclusion criteria, or (3) related to training but
did not report changes in actual performance outcomes. When necessary, we resolved
disagreement between reviewers by consensus or third-party reconciliation.
Our data extraction approach was tailored to each Key Question. Because of the volume of
studies describing tested strategies that were relevant to Key Questions 1 and 2, we developed an
electronic data collection form using DistillerSR (see Appendix B) to capture the necessary data
elements. For Key Question 3 and our analysis of State plans, we abstracted data directly into
spreadsheets because of the relatively small number of data elements required for each review.
For Key Question 4, we used a paper-based data collection form (see Appendix B). Although the
number and type of data elements varied by Key Question, they generally included the
following: study design, geographic location, type of MCE, details of the strategy, outcomes
reported, and implementation facilitators and/or barriers.
Few studies included randomized controlled trials; thus we were unable to use the standard,
validated instruments that are typically used to assess the quality of studies in CERs.8 Instead, we

ES-3

determined that a more generic quality rating system would allow for greater comparability
across the diverse research methodologies and outcomes used in the studies. We therefore
conducted an environmental scan of existing rubrics. Finding no single scale that seemed
appropriate for our topic, we developed our own composite scale, drawing heavily on the quality
assessment scale from the Substance Abuse and Mental Health Services Administration’s
National Registry of Evidence-based Programs and Practices and on two other scales commonly
used to appraise the quality of qualitative research.9-11

Data Synthesis and Analysis
Due to the diversity of topics covered in the Key Questions, we structured our findings
around several broad categories, graded by the overall strength of the evidence: (1) strategies
intended to reduce or more effectively manage less-urgent demand for health care services, (2)
strategies intended to optimize the use of existing resources, (3) strategies designed to augment
existing resources, and (4) strategies for ethical decisionmaking regarding allocation (or
reallocation) of scarce medical resources in crisis situations. Within each of these categories, we
considered the weight of evidence regarding the impact of applicable strategies on health
outcomes (e.g., reduced mortality and/or morbidity, adverse events). When no evidence was
found regarding the impact of the strategy on health outcomes, we looked for evidence of its
impact on process measures, such as rates of use of consumable health care resources.
We used the approach for grading the strength of evidence outlined in the Methods Guide for
Effectiveness and Comparative Effectiveness Reviews.12 That approach requires assessment in
four domains: risk of bias, consistency, directness, and precision. After making assessments in
these four domains, we graded the strength of the evidence using the four-point scale (i.e., high,
moderate, low, or insufficient). “High” strength of evidence indicates high confidence that the
evidence reflects the true effect. “Insufficient” strength of evidence indicates that evidence either
is unavailable or does not permit the formulation of conclusions.12

Results
Key Question 1: What Strategies Are Available to Policymakers To
Optimize the Allocation of Scarce Resources During Mass Casualty
Events?
Policymakers—governments at all levels from local to national—play a key role in providing
policy and operational guidance for allocating scarce resources during MCEs. This review
includes 27 studies that provided information on strategies available to policymakers. The
specific strategies are presented in Table A.

ES-4

Table A. Summary of strategies addressing Key Question 1, by category
Strategies

Reduce or manage
less urgent demand
for health care
services

Optimize use of
existing resources

Augment existing
resources

Biological countermeasures (12 studies)
•
POD strategies (e.g., centralized vs. hybrid structure; eliminating conventional
steps; using simulation and decision support to optimize staffing)
•
Optimizing strategies for allocating medication from stockpiles (e.g., level of
preallocation, level of tailoring to population needs, amount for prophylaxis vs.
treatment)
•
Mass vaccination, contact tracing, and school closure
•
Mass distribution of antibiotics using postal carriers
Nonbiological countermeasures (3 studies)
•
Distribution of surgical masks or N95 respirators to the public
•
Restriction of nonurgent demand for hospital care
•
Training for public health officials in their legal authority to implement strategies to
limit the spread of pandemics
Load sharing (2 studies)
•
Central command structure to optimize distribution of patients to hospitals
•
Establishment of site emergency management centers in low vulnerability
locations
•
Robust and interoperable emergency communications systems
•
Coordinated regional trauma systems to facilitate the rapid transfer of hospitalized
and special needs patients
Temporary facilities (3 studies)
•
Alternate-site surge capacity facilities
•
Mobile field hospitals
•
Activating mobile provider units from other Federal agencies to provide hospital
surge capacity
Temporary facilities (3 studies)
•
Mutual aid agreements that allow transshipment of antivirals between counties

Crisis standards of
None
care
POD = point of dispensing

In the category of reducing or managing less-urgent demand for health care services, there is
low to medium strength of evidence to favor a “push” method to deliver medications, such as
via U.S. Postal Service letter carriers, over conventional approaches that “pull” patients to a
fixed point of dispensing (POD). There is also low to medium evidence that better management
of POD operations can speed throughput and therefore more rapidly distribute biological
countermeasures. There is low strength of evidence that public distribution of nonbiological
countermeasures, such as N-95 respirators or surgical masks, will reduce demand for hospital
beds, intensive care unit (ICU) beds, and ventilators. There is insufficient evidence for any
strategies available to policymakers to optimize the use of existing resources. Both studies
reviewed in this area provided highly applicable evidence from real MCEs, but only one of the
studies was high-quality.
The strength of evidence for strategies available to policymakers to augment health care
resources is low. Three studies examined different approaches to augmenting health care
resources following a major hurricane. Each used a vastly different strategy and examined
effectiveness using different end points. Nonetheless, each described an empirically tested
strategy deemed successful by the authors, ranging from opening alternative care sites to a
mobile field hospital to more efficient distribution of patients via a regional medical operations
center.

ES-5

The small number of studies that met the inclusion criteria (n = 27) and the marked
variability in design, focus, and content for this Key Question provide a relatively weak evidence
base for informing policymakers. Over half of the included studies comprised computer
simulations rather than intervention studies, and only a few of these examined similar scenarios
using similar end points.

Key Question 2: What Strategies Are Available to Providers To Optimize
the Allocation of Scarce Resources During Mass Casualty Events?
Numerous studies included in the review provide evidence on a range of strategies intended
to help providers optimize resource allocation during MCEs. A total of 119 studies met our
criteria for inclusion. The specific strategies are presented, by category, in Table B.
A wide range of provider-oriented strategies has been tested in various contexts, including
actual MCEs, exercises, drills, and computer simulations. However, with the exception of
prehospital or “field” triage during MCEs, the body of high-quality evidence addressing any
single strategy is rather small. Typically, not more than one or two studies provided evidence for
any particular strategy. As a result, there is currently insufficient evidence to favor adoption of
one strategy over another.
Three studies described strategies to reduce or manage less-urgent demand for health care
services. Two studies examined techniques to rapidly dispense prophylactic medication. The
third study assessed the effectiveness of a centralized public information system implemented in
Israel. Although each of the studies cleared the threshold for evidence, we rated both simulations
as low quality. Moreover, the incident command system proposed as a solution to address
bottlenecks in the operation of PODs had not been tested in an actual MCE. The applicability of
the public information system to the U.S. context is uncertain. We rated the strength of evidence
provided by these studies as insufficient.
A total of 48 studies included a test of a strategy for optimizing existing resources during an
MCE. Because of the large number of studies reporting the development or implementation of
triage systems, we synthesized evidence on these strategies separately from the remaining
optimization strategies.
Triage systems and explicit triage acuity scales have been used in emergency departments for
many years and have been extensively studied. But triage in the setting of MCEs is quite
different, particularly triage practiced in prehospital settings where first responders may be
required to assess large numbers of victims in a very short time frame. Many of the studies on
this topic raised significant concerns about the performance of current triage systems during
actual MCEs. Studies that tested triage systems during exercises or drills provided evidence with
limited applicability. The strength of evidence for the set of triage studies is low.
Although a clear majority of the other (i.e., nontriage) resource optimization strategies were
found to be effective, the limited level of evidence for each type of strategy does not allow
definitive conclusions to be drawn. Only three studies used randomized designs, and nearly all
studies were limited by small sample sizes. Many studies failed to include a comparison group
and instead typically relied on performance benchmarks from prior events—a potentially
subjective standard. Thus the strength of evidence for the nontriage studies is also low.

ES-6

Table B. Summary of strategies addressing Key Question 2, by category
Strategies
Biological countermeasures (2 studies)
•
Emergency mass clinic based on CDC guidelines
•
POD strategies (e.g., dynamic staffing)
Public information (1 study)
•
Automated central information distribution system for families
Case managers (1 study)
•
Hospital-based case managers to ensure care coordination
Decontamination (1 study)
•
Strategies to increase decontamination effectiveness (e.g., instructions, providing
washcloths)
Health care worker prophylaxis (1 study)
•
Influenza prophylaxis for health care workers
Health information technology (2 studies)
•
Electronic triage tags to monitor vital signs and transmit information to first
responders
•
Regional telemedicine hub to support delivery of specialty care
Imaging (4 studies)
•
Focused assessment of sonography for trauma (FAST) for triage
•
Sonographic screening for abdominal/pelvic injury or bleeding for triage
•
Accelerated CT protocols
Load sharing (4 studies)
•
Load-sharing protocols
•
Central allocation of patients to hospitals based on available resources
Medical interventions (2 studies)
Optimize use of
•
Medical interventions for the prevention of acute renal failure in crush victims
existing resources
•
Novel drug infusion devices
Space optimization (3 studies)
•
Conversion of lobbies, clinics, and other units to accommodate surge
•
Reverse triage to create surge capacity (e.g., early discharge, increasing use of
community care options)
Training (6 studies)*
•
Hospital staff training (e.g., disaster drills, computer simulations, tabletop
exercises)
•
Triage training (e.g., JumpSTART training program, virtual reality, podcasts,
computer games)
Triage (24 studies)*
•
Triage systems (e.g., START, mSTART, American College of Surgeons
Committee on Trauma criteria, Radiation Injury Severity Classification, CBRNspecific system, Revised Trauma Score, Sacco triage method, SALT, InfluenzaLike Illness Scoring System, TAS Triage Method, Simple Triage Scoring System,
Model of Resource and Time-based Triage)
•
Triage strategies (e.g., combining triage categories, adding categories, one- vs.
two-stage triage)
•
Simplified biodosimetry protocol to triage exposed victims
Resource conversion (1 study)
Augment existing
resources
•
Conversion between formulations of nerve agents to augment supply
General (1 study)
Orthopedics (1 study)
•
External fixation of fractures rather than definitive orthopedic care
Crisis standards
Pediatrics (1 study)
of care
•
Provision of only "essential" interventions
Trauma surgery (2 studies)
•
"Damage control" approach (e.g., for orthopedic surgery or more generally)
CBRN = chemical/ biological/radiological/nuclear; CDC = Centers for Disease Control and Prevention; CT = computed
tomography; POD = point of dispensing; mSTART = modified simple triage and rapid treatment; SALT = sort, assess, lifesaving interventions; START = simple triage and rapid treatment; TAS = triage assessment system
*Includes one meta-analysis.
Reduce or manage
less urgent
demand for health
care services

ES-7

A single study tested a strategy for augmenting scarce resources during an MCE. It examined
a protocol to convert between formulations of nerve agent antidotes to augment the supply. We
rated the strength of evidence in this category as insufficient.
Several studies evaluated outcomes of strategies involving implementation of crisis standards
of care during actual or simulated MCEs. Examples of the identified strategies include the use of
“damage control” surgery to treat the initial influx of complex trauma victims and the use of very
early discharge decisions by a triage committee to allocate ICU care in a field hospital.
Collectively, these studies present encouraging findings. However, we judged most to be of low
quality because they used study designs that did not adequately control for potential confounders.
Moreover, in the studies of actual events, data collection was typically nonsystematic, and the
measures of effectiveness often relied on historical benchmarks that are open to interpretation.
Several studies did not measure health outcomes or even the most relevant process outcomes.
Instead, most of the studies focused on measures of throughput. These challenges may be
unavoidable in the setting of actual MCEs, which often require providers to employ multiple
interventions at once under stressful conditions. We judged the strength of evidence from these
studies to be insufficient to support firm conclusions.

Key Question 3: What Are the Public’s Concerns Regarding Strategies To
Allocate Scarce Resources?
We identified 10 studies that provide information relevant to Key Question 3. The results
regarding public perceptions of how scarce resources should be allocated and managed during
MCEs are generally consistent across studies. While the studies have some limitations, because
they are relatively well-designed we rated the strength of evidence as medium. Findings from
these studies can be summarized as follows:
A successful allocation system should balance the goals of ensuring the functioning of
society, saving the greatest number of people, protecting at-risk populations, reducing deaths and
hospitalizations, and treating people fairly and equitably.
Participants used multiple criteria to prioritize recipients of resources during an MCE. Health
care professionals, health care workers, and first responders were among the highest priority
groups; politicians were among the lowest.
Many participants accorded high priority for receipt of care to children and young adults.
Most participants rejected prioritization criteria based on ability to pay, “first come, first
served,” or random selection (lottery system).
The public showed a high degree of faith and trust in medical professionals to make
appropriate allocation decisions based on their expert opinions.
Resource allocation guidelines should be generally consistent but should allow health care
institutions some degree of flexibility to make allocation decisions based on their specific
demand and supply situation.

Key Question 4: What Methods Are Available To Engage Providers in
Developing Strategies To Allocate Scarce Resources During MCEs?
The 14 studies reviewed for this Key Question employed a wide array of engagement
strategies. They largely focused on planning and exercises, yet they addressed a diverse range of
relevant planning scenarios, resource allocation issues, and stakeholders. The specific strategies
are summarized in Table C.

ES-8

Table C. Summary of strategies addressing Key Question 4
Strategies
•
•
•
Led by Providers

•
•
•
•
•
•

Led or co-Led by
Policymakers

•
•
•
•
•

Enrollment, education, training, and exercise of qualified laboratory staff for preparing
biodosimetry specimens
Organization of de novo regional hospital planning group
Alternative planning models (decentralized regional planning, hospital-directed tiered
regional planning model, third-party directed planning model)
Development of consensus on appropriate pediatric crisis standards of care
Development of evidence-based “reverse triage” classification system
Pilot testing of local-, regional-, and national-level tabletop exercises for the Veterans
Health Administration
Pharmacy-led development of regional pharmaceutical preparedness policies and
procedures
Public health/business partnership for mass dispensing
Development and pilot testing of tabletop exercise template for local-level
governments and providers
Organization of neighboring States into a voluntary disaster surge network
State or local public health department planning model, including development of
mutual aid agreements
Incorporation of community health centers into surge plan, with training for community
health centers and three event-based tests
Developing proposed ethical frameworks and procedures for rationing scarce health
resources within a State (2 studies)
Broadly inclusive regional hospital-level planning process to identify surge beds

Although the evidence provided by these studies did not identify one engagement approach
as clearly superior to the others, several important themes emerged. First, inclusive processes
that engage all major stakeholders are important. This group includes officials from relevant
provider institutions, key professional associations, State and/or local governments, academia,
and the public. Second, systematic and often iterative processes produced more robust and
satisfying products, such as a critical planning framework or a consensus plan. Third, the
involvement of credible subject matter experts enhanced participation, provider satisfaction, and
the quality of the final product. Finally, the initiative taken by nontraditional providers or groups
added innovation and breadth to the range of engagement strategies proposed to enhance medical
surge capacity. Because we judged the likelihood of bias to be low, and the 14 studies were
generally consistent in their findings, we graded the strength of evidence as medium.

State Plans
We reviewed plans from 11 States and one U.S. territory. Collectively, these plans provide an
important window into the current status of State planning for the allocation of scarce medical
resources. The State plans that we reviewed proposed various strategies to reduce or manage less
urgent demand for health care services, optimize use of existing resources, and augment existing
resources when possible. Most tilted heavily toward strategies designed to optimize use of
resources and paid less attention to describing specific methods to reduce demand or augment
existing resources. Few plans proposed legal and operational frameworks for shifting to crisis
standards of care. Fewer still offered providers specific guidance about how to allocate critical
health care resources.

ES-9

Discussion
The September 11, 2001, terrorist attacks and the anthrax attacks that followed transformed
Americans’ views of the danger of terrorism. In the decade that followed, the major causes of
MCEs in the United States involved natural events, including hurricanes Katrina and Rita,
numerous deadly tornados, severe acute respiratory syndrome (SARS), and the 2009 H1N1
influenza. The temblors that struck Haiti, Chile, New Zealand, and Japan remind us that
earthquakes can wreak havoc, even in highly developed nations. As the U.S. population grows
and ages, the odds that a future MCE will outstrip our capacity to respond increase day by day.
This is the context that prompted AHRQ and the Department of Health and Human Services’
Office of the Assistant Secretary for Preparedness and Response to commission this analysis.

Key Findings
There is limited evidence to help policymakers select the most effective strategies to
maximize the use of existing resources or allocate scarce resources using crisis standards during
MCEs. Rapid deployment of effective biological countermeasures could reduce demand for
health care resources in the immediate aftermath of a bioterror attack or a rapidly spreading
pandemic. There is low- to medium-strength evidence that “push” methods that deliver
medications directly to households are more effective than methods that “pull” patients to a fixed
POD. There is low strength of evidence that mass distribution of nonbiological countermeasures,
such as surgical masks, reduces demand for health care resources. There is even less evidence to
support current policies to optimize resource allocation and use. There is limited evidence that
resource use can be optimized by load sharing, transferring patients to more distant hospitals, and
opening temporary facilities.
The evidence base to guide providers on the best strategy or strategies for optimizing
management and allocation of resources during MCEs is equally limited. The only provideroriented strategy that has been subjected to comparative assessment is field triage during MCEs.
A systematic review of field triage systems, comprising 11 papers that evaluated 8 different
triage tools, found limited evidence to confirm the validity of any of these tools.13 For every
other category of provider-based strategies, the evidence base was insufficient to support a
conclusion at more than a low level of evidence.
Although the current evidence base regarding public perceptions of how scarce resources
should be allocated and managed during MCEs is thin, published findings are generally
consistent. All but one of the six studies we reviewed reported data collected from a single
community. Nevertheless, because their findings were generally consistent, we judged the
strength of evidence as medium. They indicate that citizens are interested and motivated to
participate in community forums. Participants expressed the belief that a successful allocation
system should balance the goals of ensuring the functioning of society, saving the greatest
number of people, protecting the most vulnerable, reducing deaths and hospitalizations, and
treating people fairly.
Promising strategies exist for engaging providers in discussions about the development and
implementation of strategies for allocating and managing scarce resources during MCEs, but
none has been sufficiently evaluated. The studies we examined indicated that it is possible to
engage health care providers in productive discussions, but there was insufficient evidence to
recommend one engagement strategy as superior to the others. Nonetheless, several important
themes emerged. First, inclusive processes work better than those that do not. Second, systematic

ES-10

and iterative processes produce more robust and satisfying products. Third, involving credible
subject matter experts enhances participation, satisfaction, and the quality of the final product.
Current consensus guidelines and recommendations from specialty societies and government
advisory groups rest on an insufficient body of evidence. Few offer actionable guidance to
policymakers, health care providers, or the public. Most of the consensus panel
recommendations we reviewed were either dated or presented at a level that is unlikely to be
useful to policymakers or providers. This was particularly true of guidelines produced by
specialty societies. Two societies recommended that ICU resources be allocated on the basis of
“first come, first served.” This guidance contradicts the wishes of the public, based on the limited
number of surveys and public engagement studies published to date (see Key Question 3 above).
Some States have made progress toward adopting plans to manage and, if necessary, allocate
resources under crisis standards of care. Most, but not all, of these plans described strategies that
fit into one or more of four overarching domains: (1) Reduce demand for scarce health care
resources through such measures as mass dispensing of vaccine, prophylactic medications, and
self-quarantine; (2) optimize use of existing resources through triage, load balancing,
repurposing of facilities, more efficient use of providers, and substitution of more plentiful
alternatives; (3) augment existing resources by tapping stockpiles and other reserves and
activating mutual aid agreements; and (4) implement crisis standards of care based on predefined
priorities, with the understanding this means that some patients will receive comfort care rather
than aggressive intervention. No State plan addressed all four domains.

Limitations of the Review Methods
We made a number of tradeoffs to accommodate the vast body of literature on this complex
topic. First, because we sought to identify resource allocation strategies from across the full
spectrum of preparedness and response, we were unable to efficiently search the literature using
a parsimonious set of search terms. Second, because of the challenges in conducting research on
MCEs, we included study designs in this CER that are normally considered to produce lower
levels of evidence, including cohort, before-after, quasi-experimental studies, and consensus
recommendations by specialty societies and national panels. To further broaden our coverage of
the topic, we included in a separate section studies that had some measure of feasibility or
performance but lacked a comparison group. Third, we felt it necessary to develop our own
quality assessment scale for the vast majority of studies covered in this review to accommodate
the broad range of study types. Although the scale appeared to work well, it has not been
validated. There was some degree of subjectivity in assigning scores to each item in our quality
assessment scales; however we required two reviewers to independently rate and reconcile any
discrepant scores to minimize potential bias. Fourth, while the scope of our review was broad, it
may not have addressed key aspects of the management of MCEs, such as the clinical or
logistical aspects of EMS care and transport of patients, other than the technique of field triage in
the setting of MCEs. Finally, despite our use of an extensive literature, publication bias remains a
concern.

Limitations of the Evidence Base
By their nature, MCEs are uncommon and largely unanticipated. MCEs also vary widely
with respect to geography, cause, onset, setting, duration, scale, and many other characteristics.
These aspects, coupled with the rapidly evolving nature of MCEs, make it difficult to draw
generalizable inferences from any single event. Moreover, researchers interested in improving
ES-11

response to MCEs cannot prospectively enroll subjects in a real event, allocate subjects into
treatment groups with precisely controlled study protocols, and systematically collect data.
Some research teams have attempted to model alternative interventions using computer
simulation or have tested them in simulated exercises and drills. While these approaches are
useful, they raise significant internal and external validity concerns. In particular, it is difficult
for even the most realistic models and drills to reproduce the demanding environment of an
actual disaster or MCE and to accurately model human behavior in such incidents.
The scarcity of rigorous methodology, the noncomparability of methods (including
variability in effectiveness measures), and the relative paucity of studies that addressed any
single strategy limited our ability to perform meta-analyses or to draw firm conclusions from
existing studies of this topic. With the exception of prehospital (field) triage, most of the
strategies we identified were assessed by no more than three studies. Many of the articles that we
reviewed assessed the impact of a current or proposed strategy on a clinical process or some
aspect of a process (often using inconsistent metrics); relatively few examined outcomes. When
outcomes were measured, they were often secondary outcomes that served as proxies for the true
outcome of interest (e.g., survival).

Future Research
Our findings have clear implications for future research. Despite the fact that our review
spanned more than 20 years of preparedness research, including the decade following the
September 11, 2001, attacks, it is evident that few strategies, even those widely accepted by the
field, are backed by sufficient evidence to conclusively demonstrate their effectiveness.
Three obstacles are hindering progress in the field. The first and most formidable obstacle is
that current levels of Federal funding for research in this area are not only insufficient, but in
decline. Furthermore, the existing portfolio of extramural research is heavily weighted toward
biological threats. Other threats, including natural disasters, and other challenges, such as health
systems operations in an MCE, are receiving substantially less attention.
The second obstacle is a lack of coordination. Currently, each agency and each researcher
pursues topics of organizational interest. There is little evidence that efforts are coordinated to
minimize overlap or focus on the most urgent gaps. We recommend that the various stakeholder
agencies and nongovernmental organizations come together and jointly develop a coordinated
agenda of applied research. This will not occur without conscious effort.
The third major obstacle is the sheer difficulty of conducting scientifically rigorous research,
especially randomized controlled trials, in an unfolding MCE. This need not block progress in
the field, but it almost certainly calls for research methodologies that are better suited for these
situations. Many successful business innovations have come from “focused empiricism”:
identifying what works and what does not, refining it over time, and embracing a culture of
continuous quality improvement. The same approach may work in the context of MCEs.
With adequate funding, greater coordination, and more flexible approaches to research, rapid
progress can be made. Special attention might be directed to the following priorities:
• Identification of the optimal approach to rapidly distributing various biological and
nonbiological countermeasures to the public. Promising and potential strategies include
engaging a mix of the public sector (e.g., U.S. Postal Service letter carriers) and private
sector (e.g., retail pharmacies, overnight shippers) to disperse products and services to
homes or neighborhood locations that are easily accessible on foot. Studies of this sort
could produce dramatic gains in a short amount of time.

ES-12

•
•
•

•

•

Research directed toward harnessing the capabilities of existing bidirectional
communication devices, technologies, and social media for real-time disease surveillance,
self-triage, community outreach, and coordination of recovery efforts.
Better approaches to prehospital triage during MCEs.
More widespread and substantive work, through public forums and other methods of
engagement, to ascertain the public’s views regarding allocation of scarce resources in
MCEs. A special effort should be made to reach beyond general public forums to elicit
the views of minorities and at-risk communities.
Development of more realistic models and exercises to develop, assess, and refine
optimal approaches to respond to MCEs, including affordable simulations and “nonotice” drills to public health and health system decisionmakers to exercise key elements
of national, State, and community response in challenging situations
Rapid engagement of health care professionals, ethicists, public health officials, and
community members to devise contingent strategies for allocation of scarce resources in a
variety of plausible scenarios—particularly allocation strategies to be implemented under
crisis standards of care.

ES-13

References
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National Center for Injury Prevention and
Control. In a Moment’s Notice. Surge
Capacity for Terrorist Bombings. Atlanta
(GA): Centers for Disease Control and
Prevention. 2007.

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Jadad AR, Moore RA, Carroll D, et al.
Assessing the quality of reports of
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Centers for Disease Control and Prevention.
FluSurge. www.cdc.gov/flu/flusurge.htm.
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Kaji AH, Koenig KL, Lewis RJ. Current
hospital disaster preparedness. JAMAJournal of the American Medical
Association. 2007 Nov;298(18):2188-90.
PMID 18000203.

Mays N, Pope C. Qualitative research in
health care. Assessing quality in qualitative
research. BMJ. 2000 Jan 1;320(7226):50-2.
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Lincoln YS, Guba EG. Naturalistic Inquiry.
Newbury Park, CA: Sage Publications;
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NREPP, SAMHSA's National Registry of
Evidence-based Programs and Practices.
Quality of Research available at:
http://nrepp.samhsa.gov/ReviewQOR.aspx.

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Owens DK, Lohr KN, Atkins D, et al.
AHRQ series paper 5: grading the strength
of a body of evidence when comparing
medical interventions--Agency for
Healthcare Research and Quality. J Clin
Epidemiol. 2010 May;63(5):513-23.
http://effectivehealthcare.ahrq.gov/repFiles/
2009_0805_grading.pdf. PMID 19595577

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Kilner TM, Brace SJ, Cooke MW, et al. In
'big bang' major incidents do triage tools
accurately predict clinical priority?: A
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Salinsky E. Strong as the Weakest Link:
Medical Response to a Catastrophic Event.
National Health Policy Forum Background
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Altevogt BM. Institute of Medicine (U.S.)
Committee on Guidance for Establishing
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Phillips SJ, Knebel A, eds. Mass Medical
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Healthcare Research and Quality; February
2007.

ES-14

Introduction
Background
Context
This evidence report is intended to advance our Nation’s efforts to better prepare for and
respond to large-scale health emergencies—one of 13 “urgent issues” flagged for immediate
attention by the Government Accountability Office in 2008.1,2 The Government Accountability
Office’s concern was based on observations by the Institute of Medicine (IOM) and other groups
that our nation’s emergency care system—encompassing emergency medical services, hospitalbased emergency departments, inpatient wards, and intensive care units—is so overburdened that
it could not readily cope with a large-scale public health emergency.3-5
In 2009, in compliance with provisions of Public Law No. 109-417 (also known as the
Pandemic and All-Hazards Preparedness Act of 2006), the U.S. Department of Health and
Human Services (HHS) released its first-ever National Health Security Strategy for the United
States (hereafter referred to as the NHSS or the Strategy). In its introduction to the NHSS, HHS
noted that considerable progress had been made in the previous decade, but many challenges
remained:
“…Emergency response efforts are sometimes disparate; and effective coordination is
often lacking across governmental jurisdictions, communities, and the health and
emergency response systems.3 Additional steps must be taken to ensure that adequate
medical surge capacity and a sufficiently sized and competent workforce are available
to respond to health incidents, a sustainable medical countermeasure enterprise
sufficient to counter health incidents is fostered, and increased attention is paid to
building more resilient communities and integrating the public, including at-risk
individuals,4 into national health security efforts. Moreover, considerable variation
remains in the degree to which individual States, territories, tribes, and local
jurisdictions are prepared to address large-scale health threats. At the same time, few
evidence-based performance measures and standards exist to gauge the effectiveness of
national health security efforts and progress toward goals5—that is, to assess the extent
to which the Nation is prepared for the types of health incidents that we have
experienced in the past and may have to confront in the future.”6
To achieve national health security, which HHS describes as “…a state when the Nation and
its people are prepared for, protected from, respond effectively to, and able to recover from
incidents with potentially negative health consequences,” the NHSS establishes two overarching
goals: (1) Build community resilience, and (2) strengthen and sustain health and emergency
response systems. To pursue these goals, the NHSS calls for a “systems approach” to health
security. This approach recognizes that many interrelated systems are needed to support and
protect individual and community health. As depicted in Figure 1, the two overarching goals of
the NHSS are supported by 10 strategic objectives. Two of these objectives, integrated, scalable
health care systems and science, evaluation, quality improvement, are the primary focus of this
comparative effectiveness review (CER). However, the issues and strategies addressed in this

1

review are relevant to many of the other objectives (e.g., national health security workforce,
effective countermeasures enterprise).
Figure 1. Achieving national health security

Source: HHS Web site6

The NHSS highlights the importance of improving coordination between Federal, State,
local, and tribal planning, preparedness, and response activities. It further notes that planning
should be guided by the principles articulated in the National Response Framework7 and other
key sources of national homeland security doctrine, such as the National Incident Management
System.8 These principles are particularly relevant for allocating scarce medical resources.

Definition of Terms
For the purposes of this report, we used the following definitions:

“Policymakers”
We defined policymakers as government officials and agencies at the Federal, State,
regional, or local level who have authority to develop and enforce policies and protocols that
drive decisionmaking. For example, policymakers include:
• Federal departments and agencies (e.g., HHS, Department of Homeland Security)
• State and local public health officials
• State governing officials (e.g., governor, State legislature)
• Local governing officials (e.g., mayor, city council, county supervisors)
• State and local emergency management officials

2

•
•

Tribal officials
International health officials (e.g., World Health Organization, Pan American Health
Organization).

“Providers”
We defined providers as individuals who are licensed to provide health care services under
State or tribal law, international standards, or the laws of their country and health care
organizations or institutions that provide patient care. Providers include, for example:
• Licensed individuals, such as physicians, nurses, social workers, pharmacists, and
emergency medical technicians, including paramedics
• Health care organizations, such as health maintenance organizations, private practices,
home care agencies, community health centers, emergency medical services
organizations, and nongovernmental organizations
• Health care facilities or institutions, such as acute care hospitals, skilled nursing facilities,
long-term care institutions, and psychiatric care facilities
• Health responder teams to catastrophic events (e.g. international, nongovernmental
organizations, military).

“Public”
We defined the public as all community members and individuals not addressed as
policymakers or health care providers, regardless of gender, race, ethnicity, sexual orientation,
age, disability, setting, health status, or other defining characteristics.

“Mass Casualty Events”
We defined a mass casualty event (MCE) as a natural (e.g., earthquake, pandemic) or
manmade (e.g., detonation of a nuclear device, conventional explosive, bioterror attack, building
collapse) incident that suddenly or progressively generates large numbers of injured and/or ill
people who require medical and/or mental health care. The magnitude of this increase in demand
for medical care resources has the potential to outstrip the ability of a facility or a local, regional,
or national public health and health care delivery system to deliver medical care services
consistent with established standards of care.
A mass casualty event can occur suddenly, as is typically the case with an earthquake,
tornado, or terrorist bombing,9 or it may evolve over hours to days, as frequently happens in a
hurricane, flood, disease outbreak,10 or bioterror attack.11 Regardless of its rate of onset, the
scope and complexity of an MCE can severely challenge even highly experienced and wellequipped health care providers and systems.12 Typically in an MCE, demand for medical care
resources quickly outstrips the day-to-day capacity of local and regional health care providers,
rendering them unable to meet patients’ needs at the level normally expected in a modern health
care delivery system. When immediately available resources are clearly insufficient to meet
patients’ needs, health care providers and hospitals must be prepared to swiftly implement
contingency plans to accelerate the delivery of services. If this response is inadequate to address
the situation, they may need to shift from the individual approach to health care, which is
intended to deliver optimum care to each and every patient, to one that that seeks to do the most
good for the most people with the resources at hand. This concept has come to be known as
“crisis standards of care.”

3

“Scarce Resources”
For purposes of this review, our technical expert panel defined “scarce resources” as medical
care resources that are likely to be scarce in a crisis care environment. Medical care resources
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,
psychologists, laboratory technicians, other essential workers).

“Crisis Standards of Care”
The foundation for this Evidence-based Practice Center report was laid by the IOM
Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations, which
published a landmark Letter Report in 2009.13 In this report, the committee offered the following
definition of “crisis standards of care”:
“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 health care providers in the necessary tasks of allocating and using
scarce resources and implementing alternative care facility operations.”
To ensure that patients receive the best possible care during a catastrophic event, the IOM
Letter Report recommended that health care providers, organizations, government officials, and
the public approach this challenge in a thoughtful and proactive way.13 The Letter Report
proposed a national approach, anchored in four values:
1. Fairness. The approach should employ standards that are widely recognized as fair by all
concerned, that are evidence-based, and that compassionately respond to the needs of
individuals and the affected population. Proper stewardship of resources is essential to
maintain the trust of patients and the community.
2. Equitable processes. The approach should be transparent in design and decision making
and be consistent across populations and individuals without regard for race, ethnicity,
ability to pay, socioeconomic status, preexisting health conditions, and other
characteristics. When measures are taken, they should reflect the scale of the emergency
and the degree of resource scarcity. Individuals who decide when and how to implement
such standards should be accountable for their decisions. Governments must also be
accountable for assuring appropriate protections and just allocation of resources.
3. Community and provider engagement, education, and communication. Stakeholder input
(from institutions, organizations, providers, and the public) should be sought through a
formalized process of engagement and collaboration.
4. The rule of law. Legal authority is required to properly empower necessary and
appropriate actions during a crisis. Also, an appropriate legal environment is needed to
facilitate implementation of crisis standards in a public health emergency. Otherwise,
health care providers may be reluctant to make the difficult decisions that are needed.
Experts generally agree that optimizing resource allocation in an MCE will require a
multifaceted approach that includes strategies to minimize less-urgent demand for health care
services, effective techniques to boost the supply of medical resources for those who need them,
and evidence-based guidance on how to make difficult resource allocation decisions in crisis care

4

situations. The development and implementation of these strategies will require, in turn, a
multidisciplinary 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 undertook in preparing this report.
Our work builds on previous comprehensive governmental and nongovernmental reviews
and reports.9, 13-18 Collectively, these reports provided our team with a conceptual framework for
approaching and evaluating the extant literature on this topic. In addressing the Key Questions,
this report builds on the existing literature by identifying allocation strategies that are supported
by evidence, describing strategies for engaging providers, and identifying key concerns of the
public regarding the allocation of scarce medical resources.

Scope of the Review
This CER is intended to address four important dimensions regarding allocation of scarce
resources in MCEs. By compiling a thorough, current, and comprehensive evidence review, we
hope to help the Agency for Healthcare Research and Quality and the Office of the Assistant
Secretary for Preparedness and Response provide State governments, as well as planning and
provider communities, with the information they need to clarify processes and/or make difficult
but necessary decisions in the setting of MCEs and other large-scale public health emergencies,
as well as to identify future research and policy needs. While ideally we would have restricted
this CER to incidents that triggered a formal disaster declaration, such as through a Stafford Act
declaration, through the authority of the governor of a State, or within a single community or
institution, such as a hospital, we learned that few studies reported this information consistently.
Requiring such a declaration as an inclusion criterion would ensure comparability but might
exclude important studies.
The scope of this review was intentionally designed to be broad for additional reasons.
Because MCEs are, fortunately, rare, the number of opportunities to conduct rigorous empirical
research is limited. Moreover, the assessment of strategies in the midst of an MCE and potential
"diverting" of resources in the midst of more fundamental needs after the MCE raise important
ethical considerations. Thus, our review comprised a broad range of study designs—several of
which might not be considered sufficiently rigorous for inclusion in a typical systematic review.
An additional challenge is that the consideration of strategies to allocate scarce health care
resources does not happen in an ethical, moral, or legal vacuum. In fact, it is critical to take not
only patient preferences into account, but also the views of health care providers, family
members, entire communities, and at-risk populations. In this issue, as in few others, the social
context in which these decisions are played out is highly relevant to the conduct and relevance of
a particular strategy. Our review specifically sought to assess a broad range of outcomes for the
resource allocation strategies, including both health outcomes and ethical outcomes.
With these considerations in mind, this CER should be relevant to several important groups,
including (1) policymakers charged with responsibility to devise and promulgate strategies to
guide the actions of public health agencies and health care institutions during an MCE; (2) health
care providers who may be faced with the need to allocate scarce resources during an MCE; (3)
patients, family members, and loved ones who may be personally affected by these decisions;

5

and (4) members of the wider community, who also have a stake in how these decisions are
made.

Key Questions
Before conducting the review, the study investigators and our technical expert panel refined
each of the Key Questions. The populations, interventions, comparators, outcomes, timings, and
settings (PICOTS) considered for each Key Question are described in the Methods chapter.
Key Question 1. What current or proposed strategies are available to policymakers to
optimize the allocation and management of scarce resources during MCEs? What outcomes are
associated with these strategies? What factors act as facilitators or barriers to their
implementation or effectiveness?
Key Question 2. What current or proposed strategies are available to providers to optimize
the allocation of scarce resources during MCEs? What outcomes are associated with these
strategies? What factors are identified as facilitators or barriers to their implementation or
effectiveness?
Key Question 3. What are the public’s key perceptions and concerns (e.g., values, equity,
transparency, communication, and public input) regarding the development and implementation
of strategies to allocate and manage scarce resources during both actual and potential MCEs?
Key Question 4. What current and proposed methods are available to engage providers in
discussions regarding the development and implementation of strategies to allocate and manage
scarce resources both in planning for and during an MCE? What outcomes are associated with
these strategies? What factors are identified as facilitators or barriers to engaging providers in
these discussions?

Organization of This Report
In the sections that follow, we describe the methods used to identify, analyze, and classify
published studies that address each of the four Key Questions. We then summarize the key
findings for each of these Key Questions, with supporting tables and appendixes. As noted
above, because we encountered a substantial number of studies that examined a promising
resource allocation technique, technology, or practice but used study designs that lacked
comparison groups, we grouped these “proof of concept” studies differently and summarized
them in a separate section. We then include a summary of strategies that have been proposed by
professional organizations or by the Federal government. Finally, recognizing the IOM Letter
Report’s call for thoughtful State plans, we reviewed a set of State plans for common themes,
features, and gaps. Our objective is to provide readers with a comprehensive view of the current
evidence regarding allocation of scarce resources during MCEs and propose options for
strengthening the evidence base going forward. Moreover, by highlighting strengths and gaps in
the existing evidence base, we hope to inform the development of a research agenda that will
quickly improve our nation’s capacity to prepare, mitigate, respond, and quickly recover from
large-scale health emergencies.

6

Methods
Overview
The methods for this systematic review broadly follow those outlined in the Agency for
Healthcare Research and Quality (AHRQ) Methods Guide for Effectiveness and Comparative
Effectiveness Reviews (available at www.effectivehealthcare.ahrq.gov/methodsguide.cfm). To
the degree feasible, our methods and analyses were determined a priori. However, in the course
of identifying studies we modified the comparative effectiveness review (CER) protocol to better
align with the types of studies we encountered. In particular, we found few studies that compared
strategies in a head-to-head fashion and therefore included all studies that had a valid control
group. In addition, because of the paucity of evidence we were finding in support of existing
resource allocation strategies, we decided to compile a summary of evidence from studies that
might have otherwise been excluded either because they lacked comparison groups or because
they represented consensus guidelines from clinical experts or policymakers.
Because of extreme heterogeneity in the types of resource allocation strategies we
encountered and the small number of studies addressing any particular strategy, we did not
consider meta-analysis or other form of quantitative analysis. Rather, we reviewed individual
strategies within meaningful categories (discussed below), providing synthesis to the extent that
multiple studies addressed a similar topic.
In the remaining sections of this chapter we describe our conceptual framework; the PICOTS
(populations, interventions, comparators, outcomes timings, and settings) framework that guided
our literature search strategy and served as our analytic framework; inclusion and exclusion
criteria; study selection process; data extraction and quality assessment procedures; approach to
data synthesis, and our assessments of the strength and applicability of the evidence. The
contents of this section (and the larger report) are informed by the PRISMA checklist for
reporting systematic reviews.19

Topic Refinement and Review Protocol
AHRQ’s Scientific Resource Center (SRC) and its cosponsoring agency, the Office of the
Assistant Secretary for Preparedness and Response (ASPR), developed the research topic and its
four Key Questions. Investigators at the Southern California Evidence-based Practice Center
then refined the questions in consultation with a technical expert panel (TEP) appointed by
AHRQ. The SRC approved the final version of the review protocol prior to the start of the
review.

Technical Expert Panel and Expert Consultants
The TEP convened for this project included experts from the fields of public health, disaster
preparedness and response, hospital medicine, transplant surgery, adult and pediatric emergency
medicine, nursing, law, health care ethics, military medicine, risk communication, and public
engagement.
We solicited additional input from two subject matter experts, neither of whom served on the
TEP. Both experts were nationally recognized experts in disaster medicine and health system
preparedness and were drawn from the private (academic) and public sector, respectively. Both
experts helped to refine our methodology and identify additional sources of studies for the
review.
7

Conceptual Framework
The conceptual framework for our evidence review is depicted in Figure 2. It illustrates the
broad categories of adaptive strategies developed and used by policymakers and health care
providers to allocate scarce resources during mass casualty events (MCEs) and how the thinking
and actions of both groups are modified by the outcomes of these strategies and by public
opinion. As illustrated in the figure, policymakers and providers develop and implement
strategies using an escalating series of contingent actions, based on the nature, magnitude, scope,
and duration of the MCE.
Figure 2. Conceptual framework for allocating and managing scarce medical resources during a
mass casualty event

KQ = Key Question

During surge conditions, policymakers and providers will initially use strategies that have the
goal of maximizing existing resources by:
• Managing or reducing less-urgent demand for health care services
• Optimizing the use of existing resources
• Augmenting available resources.
Many of these “resource maximization” strategies are aimed at extending use and making
management of resources more efficient to forestall the development of serious shortages. If
these measures prove to be inadequate, health care facilities may seek to augment existing
resources by tapping stockpiles, invoking mutual aid agreements, and exercising other options.

8

The ultimate goal of these strategies is to preserve generally accepted standards of care.
Specific examples of each type of strategy are included in our PICOTS framework discussed
later in this chapter.
If these contingency measures are inadequate to meet extremely excessive demand, the
institution may be forced to relax standards of care. The allocation or reallocation of resources
under crisis conditions that may reduce the level of care delivered to individual patients is
commonly referred to as “crisis standards of care.” Typically, these strategies are not employed
unless every effort to maximize available resources has been exhausted. Under crisis standards of
care, institutions and providers may shift their approach to allocating resources from one
designed to maximize the outcome of each patient to one that seeks to do the greatest good for
the largest number of people. Aside from strictly utilitarian goals, crisis standards of care may
also have other objectives, such as preserving the long-term functioning of society. During a
prolonged MCE, the health care system may shift into and out of “crisis care” over time, as the
event evolves and stocks of supplies, equipment, and personnel rise and fall. Thus, multiple
strategies may be sequentially employed during an MCE depending on its magnitude and
duration, rate of onset, available resources, and the capacity of the medical care system.
The resource allocation strategies deployed by policymakers and providers influence
individual and population outcomes through both processes of care and health outcomes. Other
outcomes, including the ethical and economic consequences of these strategies, may also be
important to providers, policymakers, and the public.
The outcomes of each strategy shape the refinement or development of new strategies—
indicated in Figure 2 by feedback loops (dashed lines). For example, outcomes of strategies,
particularly adverse outcomes, might provoke strong reaction from the public. Providers or
policymakers may then integrate the expressed preferences of the general public into new or
updated strategies. Provider engagement activities might inform the strategies developed by
policymakers, while, at the same time, the planning efforts of policymakers might also serve as a
catalyst for providers to engage in efforts to develop strategies to respond to MCEs.
While this conceptual framework was developed for the purposes of guiding this review, key
elements draw directly on the Letter Report published by the Institute of Medicine (IOM)
Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations.13

Analytic Framework
Given the heterogeneity in key aspects of study design across the four Key Questions, we
elected to use the PICOTS framework as the analytic framework for the review. We present this
framework separately for each Key Question below.

Search Strategy
Our search strategy leveraged existing reviews of the literature, including but not limited to
those considered in the IOM Letter Report and Summary on Crisis Standards of Care13, 20 and the
Community Planning Guide on Providing Mass Medical Care with Scarce Resources, developed
by AHRQ and ASPR.16 These reviews helped identify relevant medical care resource
management and allocation strategies in existence at the time these documents were published
and summary information on the relevant outcomes of these strategies. Building on this work
helped us focus our search.

9

Our literature search comprised four parts: (1) a formal search using multiple research
databases, (2) a scan of the “grey” literature, a (3) a review of current State plans regarding the
allocation of scarce resources, and (4) consultation with our TEP for any additional sources. In
addition to using an expert, in-house research librarian with special skills in health information,
we benefitted from the services of an expert librarian at the National Institutes of Health (NIH)
who had previously conducted literature searches on this topic on behalf of ASPR.
Because of the cross-disciplinary nature of this topic, our formal literature search used
research databases beyond those covering the biomedical literature. In consultation with our
TEP, we selected seven academic databases: PubMed, Scopus, Embase, Cumulative Index to
Nursing and Allied Health Literature (CINAHL), Global Health, Web of Science®, and the
Cochrane Database of Systematic Reviews. We also searched online library catalogs, such as the
National Library of Medicine’s LocatorPlus, to identify relevant books. Each search spanned the
period from January 1990 through November 2011. We constructed search algorithms for each
database (Appendix A), executed the search, downloaded the results into individual EndNote
libraries, combined libraries from each search, and deleted duplicate references. Using the Web
of Science® database, we also conducted “forward searches” to identify articles that cited key
references.
Our search of the grey literature was confined to the New York Academy of Medicine’s Grey
Literature Report—one of the few existing databases that covers grey literature sources. We did
not pursue additional searches of the grey literature (e.g., LexisNexis) out of concern that these
sources might not provide the high-quality evidence needed to satisfy our inclusion and
exclusion criteria.
Individual members of the TEP provided additional relevant studies, particularly those that
were not published in the peer-reviewed literature. These studies included work that was funded
by the Centers for Disease Control and Prevention and the Veterans’ Health Administration,
professional society guidelines, and research produced by nongovernmental organizations such
as Trust for America’s Health. We compiled a list of these sources and used scans of related Web
sites to broaden our search.
An additional element of this project was a review of State plans for allocating scarce health
care resources during MCEs. Officials at ASPR provided a sample of current State plans for
analysis representing 11 States and the territory of Guam. Because there is no central national
repository for this information, this list is unlikely to be exhaustive and may be regarded as a
snapshot of current State-level efforts to define resource allocation principles and protocols.

Inclusion and Exclusion Criteria
Prior to designing our search strategy, we framed each of the four Key Questions along six
dimensions that are commonly used in CERs: populations, interventions, comparators, outcomes
timings, and settings (PICOTS). This section describes these dimensions and the resulting
inclusion and exclusion criteria for each of the Key Questions, as well as general inclusion and
exclusion criteria.

a

The grey literature comprises evidence that “is produced on all levels of government, academics, business and
industry in print and electronic formats, but which is not controlled by commercial publishers" (Grey Literature
Network Service, 1999).21 Grey literature sources can include abstracts presented at conferences, unpublished data,
government documents, or manufacturer information and can be difficult to locate because these sources are not
systematically identified, stored, or indexed (Relevo and Balshem, 2011).22

10

General Criteria
•

•
•
•

•
•
•
•

Include articles found in the peer-reviewed and grey literatures, including but not limited
to empirical studies, State and Federal government reports, State and Federal plans, peerreviewed reports and papers by nongovernmental organizations, policy and procedure
documents, and clinical care guidelines developed by specialty societies.
Include studies from both U.S. and international sources.
Include English- and non–English-language publications.
Include the following:
o Randomized controlled trials.
o Observational studies reporting data from real events, drills, exercises, or
computer simulations.
o Recommended strategies proposed by national provider groups and/or task forces
or work groups convened by or comprising representatives of the Federal
government.
o Studies reporting the outcomes of systematic data collection efforts (e.g., focus
groups) that document patients’ perspectives on resource allocation during MCEs.
o Systematic reviews of strategies to allocate resources during an MCE.
Exclude studies published prior to 1990.
Exclude publications that present only conceptual frameworks.
Exclude nonsystematic reviews.
Exclude studies that do not consider these strategies in the context of an MCE.

Key Question 1: What Strategies Are Available to Policymakers To
Optimize Allocation of Scarce Resources During MCEs?

PICOTS Framework for Key Question 1
Population
The target population includes policymakers charged with responsibility for developing and
implementing strategies to optimize allocation of resources during MCEs. The affected
population includes people who require medical treatment after an MCE. This group includes
those who are physically injured and/or ill as a direct or indirect result of the MCE and those
with unrelated, but urgent, medical needs (e.g., treatment for heart attacks, stroke, kidney failure,
or cancer). We also address behavioral health needs in the setting of MCEs, including acute
stress, grief, psychosis, and panic reactions.

Interventions
Strategies used by policymakers to maximize scarce resources. These include actions to
manage or reduce less-urgent demand for health care services, optimize existing resources, or
augment the supply of existing resources, and, when these actions are inadequate, to implement
strategies consistent with crisis standards of care. Potential strategies included the following:
• Strategies focused on single or multiple components of the health system, including
emergency medical services and dispatch, public health, hospital-based care, renal
dialysis, home care, primary care, palliative care, mental health, and provider payment
policies.
11

•
•

Actions taken in advance to prepare for large-scale public health events that could trigger
a huge surge in demand for medical and health care resources (e.g., stockpiling).
Adaptive strategies that ensure effective incident command, control, intelligence
gathering, and communication systems, since these are often necessary channels to
implement other strategies that optimally manage and allocate resources.
o Actions taken to maximize resources to avoid the need to shift to crisis standards
of care—for example, actions to substitute, conserve, adapt, and/or reuse critical
resources, including reuse of otherwise disposable equipment and supplies,
expanding scope of practice laws, and altered approaches that maximize delivery
of care.13
o Actions taken to reduce or manage less-urgent demand for health care services in
order to avoid the need to adopt a crisis standard of care—for example, activating
call centers or Web sites that provide information about when and where to seek
treatment and how to adequately care for oneself or family members at home.
o Strategies for making ethical allocation decisions when critical resources will
otherwise be insufficient to meet the population’s needs (i.e., “crisis standards of
care”).

Comparators
Where possible, we considered studies that compared an intervention with one or more
alternative interventions. We also considered studies that compared an intervention with no
intervention (i.e., no change in the approach to resource allocation or management). Studies that
demonstrated the feasibility of a novel technique or technology without a comparison group were
not included in the full CER, but were summarized in a separate section.

Outcomes
Included outcomes depended on the type of intervention and represented one or a
combination of the following:
• Process measures (e.g., number of patients treated, amount of resources obtained, ability
to maintain conventional standards of care, avoidance of crisis standards of care)
• Health outcomes
o Favorable (e.g., decreased mortality, decreased physical and/or psychological
morbidity)
o Unfavorable (e.g., adverse events, such as preventable morbidity and/or mortality)
• Other outcomes (e.g., ethical, legal, financial consequences; public perceptions of the
intervention, public acceptance of or compliance with the intervention)

Timing
We confined our review to studies addressing preparedness and response to MCEs. We also
considered strategies that address the triggers or timing for returning to normal operations. We
only considered strategies specifically addressing long-term recovery from MCEs (e.g.,
community resilience) if these strategies were implemented during the course of an MCE, and
not subsequent to an MCE.

12

Settings
All settings in which patient care might be directed/managed and delivered, including but not
limited to prehospital triage locations (e.g., on-scene, in transport), emergency department triage
and care, inpatient settings (e.g., operating room, intensive care unit, ward, community health
centers, urgent care facilities, long-term care institutions, primary and specialty care practices,
skilled nursing facilities, home care agencies, and alternate care facilities.

Inclusion and Exclusion Criteria
•

•
•
•

•
•
•
•

Include studies that describe the processes and/or outcomes of strategies used by
policymakers or studies that result from the strategic direction provided by policymakers
to maximize and allocate scarce resources during an MCE. (See the Definitions section
for descriptions of policymakers, scarce resources, and MCEs.)
Include if the strategy has been prospectively tested in a real event or tested in the context
of an exercise, drill, or computer simulation.
Include if the strategy arose from a documented after-action report of a real event as long
as the study describes a specific, implementable strategy and systematically reports the
outcomes of the strategy, whether or not a comparison group was used.
Include if the strategy has not been tested but rather proposed by a national provider
organization or a task force convened by the Federal government. Studies must describe
the method by which consensus was achieved by the committee, panel, or work group,
which may include, but is not limited to, the Delphi process.
Exclude if the study does not describe a specific, implementable strategy.
Exclude if the strategy does not relate to scarce resources.
Exclude if the study does not report the outcomes of a strategy, including studies that
report only “lessons learned” from a real event, drill, or exercise.
Exclude if the proposed strategy is not from a national provider organization or a task
force convened by the Federal government or does not describe the consensus
development process.

Key Question 2: What Strategies Are Available to Providers To Optimize
Allocation of Scarce Resources During MCEs?

PICOTS Framework for Key Question 2
Population
The target population includes health care providers who hold responsibility for allocating
scarce resources during MCEs. The affected population includes people who require medical
treatment after an MCE. This group includes those who are physically injured and/or ill as a
direct or indirect result of the MCE and those with unrelated but urgent, medical needs (e.g.,
treatment for heart attacks, stroke, kidney failure, or cancer). We also address behavioral health
needs in the setting of MCEs, including acute stress, grief, psychosis, and panic reactions.

Interventions
Strategies used by providers to maximize scarce resources. These include actions to manage
or reduce less-urgent demand for health care services, optimize existing resources, or augment
13

the supply of existing resources, and, when these actions are inadequate, to implement strategies
consistent with crisis standards of care. Potential strategies included the following:
• Strategies focused on single or multiple components of the health system, including
emergency medical services and dispatch, public health, hospital-based care, renal
dialysis, home care, primary care, palliative care, mental health, and provider
reimbursement.
• Actions taken in advance to prepare for large-scale public health events that could trigger
a huge surge in demand for medical and health care resources (e.g., training staff,
exercising plans, stockpiling critical supplies and equipment).
• Adaptive strategies that ensure effective incident command and communication systems,
since these are often necessary channels to implement other strategies that optimally
manage and allocate resources.
• Actions taken to maximize resources in order to avoid the need to adopt a crisis standard
of care; for example, actions to substitute, conserve, adapt, and/or reuse critical resources,
including reuse of otherwise disposable equipment or supplies, reallocation of staff from
nonclinical to clinical functions (i.e., expanding scope of practice), and altered
approaches to using staff to deliver care.
• Actions taken to reduce or manage less-urgent demand for health care services in order to
avoid the need to adopt a crisis standard of care; for example, activating call centers or
Web sites that provide information about when and where to seek treatment and how to
adequately care for oneself or family members at home.
• Strategies for making allocation decisions when critical resources will otherwise be
insufficient to meet the population’s needs (i.e., “crisis standards of care”).

Comparators
Where possible, we considered studies that compared an intervention with one or more
alternative interventions. We also considered studies that compared an intervention with no
intervention (i.e., no change in the approach to resource allocation or management). Studies that
demonstrated the feasibility of a novel technique or technology without a comparison group were
not included in the full CER, but were summarized in a separate section.

Outcomes
A combination of any of the following:
• Process measures (e.g., number of patients treated, amount of resources obtained, ability
to maintain conventional standards of care, avoidance of crisis standards of care)
• Health outcomes
o Favorable (e.g., decreased mortality, decreased physical and/or psychological
morbidity)
o Unfavorable (e.g., adverse events, such as preventable morbidity and/or mortality)
• Other outcomes (e.g., ethical, legal, financial consequences, public perceptions of the
intervention, public acceptance of or compliance with the intervention)

Timing
We confined the review to studies addressing preparedness and response to MCEs. We
considered strategies that address the triggers or timing for returning to normal operations. We
only considered strategies specifically addressing long-term recovery from MCEs (e.g.,
14

community resilience) if these strategies were implemented during the course of an MCE, and
not subsequent to an MCE.

Settings
All settings in which patient care might be delivered, including but not limited to prehospital
triage locations (e.g., on-scene, in transport), emergency department triage and care, inpatient
settings (e.g., operating room, intensive care unit, ward), community health centers, urgent care
facilities, long-term care institutions, primary and specialty care practices, skilled nursing
facilities, home care agencies, and alternate care facilities.

Inclusion and Exclusion Criteria
•
•
•
•

•
•
•
•
•

Include studies that describe the processes and/or outcomes of strategies used by
providers to maximize or allocate scarce resources during an MCE. (See the definitions
section for detailed descriptions of providers, scarce resources, and MCEs.)
Include if the strategy has been prospectively tested in a real event or tested in the context
of an exercise, drill, or computer simulation.
Include if the strategy arose from a documented after-action report of a real event as long
as the study describes a specific, implementable strategy and systematically reports the
outcomes of the strategy, whether or not a comparison group was used.
Include if the strategy has not been tested but rather proposed by a national provider
organization or a task force convened by the Federal government. Studies must describe
the method by which consensus was achieved by the committee, panel, or work group,
which may include, but is not limited to, the Delphi process.
Exclude if the study does not describe a specific, implementable strategy.
Exclude if the strategy does not relate to scarce resources.
Exclude if the study does not report the outcomes of a strategy, including studies that
report only “lessons learned” from a real event, drill, or exercise.
Exclude if the proposed strategy is not from a national provider organization or a task
force convened by the Federal government or does not describe the consensus
development process.
Exclude strategies that involve training providers to allocate resources if the study reports
only participants’ perceptions of improvement and/or satisfaction with the training
program.

Key Question 3: What Are the Public’s Concerns Regarding Resource
Allocation Strategies?

PICOTS Framework for Key Question 3
Population
The general public, with special attention paid to members of at-risk populations, including,
for example, children and elders, individuals in minority groups, and individuals with special
medical needs.

15

Interventions
Not applicable. This Key Question focuses on public opinions, perceptions, values, and
norms regarding the development and implementation of strategies to allocate and manage scarce
medical resources during an MCE.

Comparators
Studies may compare outcomes from a single setting when conventional standards of care are
in effect, versus outcomes under constrained or crisis care standards. In addition, studies may
compare outcomes of the same resource allocation strategy among individuals or communities
with different characteristics, or they may compare outcomes of distinct resource allocation
strategies in communities with similar characteristics.

Outcomes
Public opinions and/or perceptions of key issues related to the allocation and management of
scarce medical resources during MCEs, including but not limited to values, priorities, and ethics.

Timing
We confined our review to studies addressing preparedness and response to MCEs. We also
considered strategies that addressed the triggers or timing for returning to normal operations. We
only considered strategies specifically addressing long-term recovery from MCEs (e.g.,
community resilience) if these strategies were implemented during the course of an MCE, and
not subsequent to an MCE.

Settings
No exclusions.

Inclusion and Exclusion Criteria
•
•
•

Include studies that use a systematic data collection method (e.g., surveys, focus groups)
to describe public opinion regarding the implementation of strategies for allocating scarce
resources during an MCE.
Studies can consider the general population or subpopulations of interest, such as
minority groups and other at-risk populations.
Exclude studies that do not report public opinion directly, such as those reporting
providers’ or experts’ perceptions of public opinion.

Key Question 4: What Methods Are Available To Engage Providers in
Developing Strategies To Optimize Resource Allocation During MCEs?

PICOTS Framework for Key Question 4
Population
Health care providers, including executive and administrative personnel, chief medical
officers, and other health care providers who lead or staff health care facilities or facilities that
provide auxiliary services (such as laboratories or pharmacy departments) and professional
associations, all regardless of race, gender, ethnicity, religion, sexual orientation, or disability.

16

Intervention
Strategies for engaging providers in discussions regarding the allocation and management of
scarce resources. Strategies for engaging providers include a wide range of activities intended to
accomplish the following:
• Contact and connect with providers (e.g., face-to-face, electronically, through provider
associations).
• Elicit dialogue and discussion with and among providers (e.g., through workshops,
discussion groups, or tabletop exercises to develop a plan or protocol related to decision
making during “crisis care” situations).
• Encourage provider participation in collaborative activities (e.g., voluntary cooperative
planning).

Comparators
Where possible, we considered studies that compared an engagement strategy to one or more
alternative strategies. We also considered studies that used baseline assessments as the
comparator. For example, studies might compare outcomes (including knowledge, attitudes, and
self-reported or observed performance) over time (e.g., before and one or more times after an
intervention). Other studies might not have used a comparator but, rather, assessed the impact of
provider engagement on collaborative efforts at the local/regional, State, and national levels.

Outcomes
We considered any of the following outcomes:
• Process outcomes (e.g., number of providers reached, provider satisfaction with the
process)
• Provider outcomes (e.g., changes in knowledge, attitudes, and self-reported or observed
behavior)
• Local/regional, State, national outcomes (e.g., increased provider participation in MultiAgency Coordination [MAC] groups)

Timing
We confined our review to studies addressing preparedness and response to MCEs. We
considered strategies that addressed the triggers or timing for returning to normal operations. We
only considered strategies specifically addressing long-term recovery from MCEs (e.g.,
community resilience) if these strategies were implemented during the course of an MCE, and
not subsequent to an MCE.

Settings
No exclusions.

Inclusion and Exclusion Criteria
•

Include studies that describe processes and outcomes of strategies used to engage
providers in the development of strategies to allocate scarce resources during MCEs; for
example, planning efforts to develop crisis standards of care protocols and the use of
tabletop exercises to simulate medical decision making during “crisis care” situations.

17

•
•
•
•
•

Include if description of provider engagement is a replicable, systematic planning process
that resulted in a concrete plan, protocol, strategy, or framework.
Include studies that describe engagement strategies for providers exclusively or that
involve multiple stakeholders.
Include studies that describe engagement strategies locally (e.g., within a single medical
center), as well as strategies for regional or nationwide engagement.
Exclude studies not related to provider engagement and surge capacity.
Exclude studies that involve educational interventions only and do not describe
engagement in the development of educational programs.

Study Selection
After conducting the literature search, two researchers screened all titles to eliminate
citations that were clearly unrelated to the topic. Next, abstracts of each study were
independently reviewed by two researchers for inclusion or exclusion according to
predetermined criteria. If no abstract was available, the full text was reviewed. Reasons for study
exclusion at the abstract phase included the following: (1) failure to include a quantitative or
qualitative analysis (e.g., studies reporting “lessons learned” only); (2) failure to address an MCE
context (e.g., studies involving organ transplantation); and (3) failure to address a Key Question.
In cases of disagreement between the reviewers, an independent reviewer was asked to review
the abstract and reconcile the difference.
In the next stage, two researchers independently reviewed full-text articles and excluded
those that: (1) failed to address a Key Question; (2) included consensus recommendations (for
Key Questions 1, 2, and 4) that did not meet our evidence threshold; or (3) related to training
exercises but did not report changes in actual performance outcomes. Disagreement between the
reviewers about whether a study should be included was resolved by consensus. We maintained
a list of studies that were excluded at the full-text review stage with the reason(s) for exclusion
(Appendix D).

Data Extraction
We tailored our data extraction approach to each Key Question. Because of the large volume
of studies describing tested strategies that were relevant to Key Question 1 and especially Key
Question 2, we developed an electronic data collection form using DistillerSR (Appendix B) to
capture the necessary data elements. For Key Question 3 and for our analysis of State plans, data
were abstracted directly into spreadsheets because of the relatively small number of data
elements required for each review. For Key Question 4, we used a paper-based data collection
form (Appendix B). Although the number and type of data elements varied by Key Question,
data elements generally included the following: study design, geographic location, type of MCE,
description of the strategy, outcomes reported, and implementation facilitators and/or barriers.
For Key Question 4, we were also concerned with the types of stakeholders participating in the
engagement strategy.
A total of nine reviewers, all of whom received formal orientation to the review process,
performed data extraction. At least two reviewers abstracted each article that met one or more
inclusion criteria. One reviewer took the lead for reviewing the article, and the second reviewer
fact-checked to assure consistency and accuracy of coding. Differences were resolved by
consultation and, when necessary, adjudication.
18

Abstracted data that were entered into DistillerSR and spreadsheets were then edited and
manipulated to generate evidence tables (Appendix C).

Quality (Risk of Bias) Assessment of Individual Studies
Given the relative rarity and unpredictability of MCEs, we anticipated that few, if any,
relevant studies would use a randomized controlled study design, where validated instruments to
assess methodological quality exist and are widely used.21 Given the diversity in study designs
and outcomes we expected to encounter, we determined that a more generic quality rating system
would be more feasible and allow greater comparability across studies. After conducting an
environmental scan of existing rubrics and finding that no single scale seemed appropriate for
our topic, we developed our own assessment scale. Our instrument combined two items drawn
from the quality assessment scale from the Substance Abuse and Mental Health Services
Administration’s National Registry of Evidence-based Programs and Practices, and items from
two other scales commonly used to appraise the quality of qualitative research.22-24 Appendix B
contains all of our data collection instruments, including quality scales.
We used this composite scale to appraise the quality of studies addressing Key Questions 1,
2, and 4. The five individual items assessed whether or not (1) the level of detail used to describe
the resource allocation strategy was adequate, (2) data collection was systematic (and if so,
whether it was retrospective or prospective), (3) fidelity (defined as the degree to which the
strategy was implemented consistently) was measured or could be inferred from the data
provided, (4) generalizability of the findings was assessed, and (5) potential confounders to the
strategy’s effectiveness were discussed. For Key Question 4, we excluded the item addressing
confounders. For most items, reviewers could allocate up to two points. All quality scores are
presented as the total number of points allocated in reference to the total number of points
possible (e.g., “6 of 8 points”). Scoring each quality item may have entailed some degree of
subjectivity; however, the pair of reviewers for each study reconciled any differences in scores
for each item.
For two types of study designs--computer simulations and systematic reviews--we deviated
from this approach because we believed more tailored quality items were appropriate and
because valid scales were available, respectively. In our environmental scan, we identified one
study25 that offered recommendations for modeling disaster responses in public health. We
identified several key aspects of model quality from this study and adapted our quality
instrument accordingly. Specifically, we eliminated the data collection and fidelity items and
replaced them with two items that assessed the degree to which the authors justified their model
assumptions and/or data inputs and the degree to which the authors performed robust sensitivity
analyses (if at all). For systematic reviews, we used the AMSTAR instrument,26 an 11-item scale
that measures such features as whether a comprehensive literature search was performed,
whether duplicate study selection and data extraction were used, and whether or not the scientific
quality of the included studies was assessed.
For Key Question 3, we elected to develop our own quality scale that reflected key
differences in methodology across the small number of included studies. Using seven binary
items, our scale assessed whether or not studies used a systematic data collection process,
described in detail the subject recruitment methodology, recruited a representative sample,
disclosed funding sources or sponsors, discussed limitations and generalizability, and permitted
the results to be evaluated by an independent third-party.

19

Data Synthesis
We could not quantitatively synthesize data abstracted from the set of included studies
because individual studies rarely addressed similar resource allocation strategies. Moreover,
strategies that were assessed in multiple studies typically differed widely in their context and
outcomes. Accordingly, for Key Questions 1 and 2, we summarized the outcomes of each
strategy qualitatively, using the four broad categories of adaptive strategies described in our
conceptual framework to synthesize our findings. To the extent that clusters of related strategies
emerged within these four broad categories, we reported our findings at the subcategory level.
Wherever possible, we described the degree of consistency in the magnitude and direction of
outcomes for the most relevant outcomes. We also highlighted differences in populations,
context, and methodology that we considered important in interpreting each set of results. Most
of the information we present in our synthesis addresses key dimensions of the subsequent
strength of evidence ratings and assessment of applicability.
Because the included studies for Key Question 3 addressed a narrow range of topics, we
synthesized the evidence from these studies as a single set. For Key Question 4, we described
engagement strategies that were led by providers separately from those that were led or co-led by
policymakers. However, (as described below), we summarized the strength of evidence across
both groups of studies because the nature of strategies did not differ systematically between the
two groups.
For the subset of studies that we included in the review that lacked comparison groups, we
provide a brief summary of the individual strategies described by each. We include these
summaries in a separate section from those studies that underwent our full review. Finally, we
include a qualitative summary of proposed strategies that have been included in consensus
guidelines. We highlight the key recommendations from each provider organization or task force
and emphasize differences in recommendations where they exist.

Strength of the Evidence
We used the approach outlined in the Methods Guide for Effectiveness and Comparative
Effectiveness Reviews to grade the strength of evidence addressing each Key Question.27 This
approach requires assessment in four domains: risk of bias, consistency, directness, and
precision. Risk of bias refers to the internal validity of each study and relies heavily on study
design and the aggregate quality of the included studies; we scored risk of bias as high, medium,
or low. Consistency is a measure of the extent to which effect sizes for the set of studies are
similar in size and direction. We designated evidence in this category as consistent or
inconsistent. Directness refers to the degree to which the strategies have an impact on health
outcomes rather than intermediate outcomes. In this domain we rated evidence as direct or
indirect. Finally, precision refers to the level of certainty surrounding the set of effect estimates.
For this domain, we rated evidence as precise or imprecise. After making assessments in the four
domains, we graded the strength of the evidence using the four-point scale (i.e., high, moderate,
low, or insufficient). As defined by Owens et al., “high” strength of evidence indicates high
confidence that the evidence reflects the true effect. “Insufficient” strength of evidence indicates
that evidence either is unavailable or does not permit the formulation of conclusions.27
For Key Questions 1 and 2 we rated the strength of evidence within categories (or
subcategories) depending on the number of studies available. For both Key Questions 3 and 4,
we rated the strength of evidence across all studies. For Key Question 3, the paucity of studies
20

precluded analysis by methodology (stakeholder forums, interviews or surveys). For Key
Question 4, the vast majority of studies assessed engagement methods that were designed to
develop strategies in multiple categories, and so category-specific ratings were less useful.
A single reviewer graded the strength of evidence for each dimension, which was then
reviewed by a second reviewer. Differences were reconciled through discussion. We determined
overall strength of evidence grades in an analogous manner using a qualitative assessment of the
scores for each dimension. We summarize the strength of evidence grades in the Results section
for each Key Question.

Applicability
In the course of our team’s work, we considered the applicability of the evidence presented
by each article. In seeking to develop MCE resource allocation strategies, providers and
policymakers will want to know the extent to which outcomes realized in the studies we
reviewed are generalizable to the populations, practice settings, and disaster contexts that are
most relevant to them. We conducted qualitative assessments28 of the applicability of evidence
for each Key Question using both the PICOTS framework for each Key Question (see Key
Questions, above) and by abstracting individual items pertaining to various dimensions of
applicability. For example, we noted whether strategies were applicable to specific scales of
events (e.g., local or regional in scope), whether or not the effectiveness of the strategy appeared
to depend on factors unique to the jurisdiction involved (in terms of leadership required,
populations served, stakeholders included, or availability of resources), the degree to which
outcomes were relevant to patients, and the extent to which the strategy was “ready for use.” For
strategies tested outside of the United States, we also assessed the degree to which the strategy
was applicable in the United States. One reviewer assessed the applicability of the evidence,
while a second reviewer verified the appropriateness of the assessments. Areas of disagreement
were resolved through discussion and, if necessary, adjudication.

Peer Review and Public Commentary
Experts from relevant fields and individuals representing stakeholder and user communities
were invited to provide external peer review of this systematic review. The AHRQ Effective
Healthcare Program SRC at Oregon Health Sciences University oversaw the peer review
process. Peer reviewers commented on the content, structure, and format of the evidence report
and were encouraged to suggest any relevant studies that had been missed. AHRQ and SRC staff
also reviewed the report.
The SRC placed the draft report on the AHRQ Web site (http://effectivehealthcare.ahrq.gov/)
for public comment and compiled all comments.
Each member of our TEP was invited to provide written comments on the draft report. We
compiled all comments and addressed each comment individually, making revisions as
appropriate. All changes were documented in a “disposition of comments report” that will be
made available three months after AHRQ posts the final review on its Web site.

21

Results
Literature Search
The peer-reviewed literature searches identified a total of 5,146 potentially relevant citations.
A search of the grey literature yielded 297 citations, and our technical expert panel (TEP)
suggested an additional 56 titles. Reference mining contributed an additional 217 citations. All
5,716 citations were imported into EndNote and then into DistillerSR, a web-based application
designed specifically for the screening and data extraction phases of a systematic review.
Reviewers selected 2,395 relevant and unduplicated titles for abstract review. During the review,
they excluded 995 articles either because the abstract did not appear to answer a Key Question
(664 articles) or because the abstract did not indicate a quantitative or qualitative data analysis
(331 articles). After the abstracts had been reviewed, 1,400 full-text articles were available for
further review.
Screening these articles with the aid of a short form led to the exclusion of 1,000 additional
articles. Articles were excluded for at least one of the following reasons: (1) The article did not
answer a Key Question (692 articles), (2) the article described a training program but did not
report outcomes using performance measures (14 articles), or (3) the article was a proposed
strategy but was not based on adequate consensus (277 articles for Key Questions 1 and 2; 17
articles for Key Question 4).
For Key Question 1, we considered 57 articles for data abstraction. We included nineteen
articles that described tested strategies. We included seven additional articles in a separate group
because they lacked a comparison population. One additional article was included that described
a proposed strategy with a level of consensus that met our criteria. The major reasons for
excluding articles at the data abstraction stage for Key Question 1 were insufficient evidence or
inadequate consensus.
For Key Question 2, we considered 295 articles for data abstraction and ultimately included
55 articles that described tested strategies. We included an additional 47 articles in a separate
group because they lacked a comparison population, and seventeen articles that described a
proposed strategy with adequate consensus in a third group. Reasons for excluding articles
included either insufficient evidence or inadequate consensus.
For Key Question 3, we identified 37 articles, ten of which we included in the review.
Reasons for exclusion included either failure to address a resource allocation context or failure to
assess the public’s opinions directly.
For Key Question 4, we identified 14 articles and included all of them.
In summary, we considered 400 articles for data abstraction. Ultimately, 170 met our
selection criteria, including 27 studies that focused on policymakers (Key Question 1), 119 that
addressed the decisions of providers (Key Question 2), 10 that considered the perspectives of the
public (Key Question 3), and 14 that addressed engagement of providers in developing resource
allocation strategies (Key Question 4). Five articles were written in languages other than English
(4 German and 1 Portuguese). No articles were excluded due to lack of translational resources.
Reviewers used data abstraction tools as shown in Appendix B. We provide the evidence
tables containing key data from the included studies in Appendix C. Citations of articles that we
excluded and the reason for exclusion appear in Appendix D. Figure 3 depicts the literature flow,
indicating the number of studies included and excluded at each screening level and the reasons
for exclusion.
22

Figure 3. Literature flow

KQ = Key Question; TEP = Technical Expert Panel

23

Key Question 1: What Strategies Are Available to Policymakers To
Optimize Allocation of Scarce Resources During MCEs?
What current or proposed strategies are available to policymakers to optimize the allocation
and management of scarce resources during mass casualty events (MCEs)? What outcomes are
associated with these strategies? What factors act as facilitators or barriers to their
implementation or effectiveness?

Key Points
•

•
•

•

•

The small number of studies that met inclusion criteria (n = 19), and the marked
variability in design, focus and content for this Key Question provide a relatively weak
evidence base to inform policymakers. The 19 studies included more computer
simulations (10) than intervention studies (9). Only a few studies examined similar
resource allocation strategies using similar endpoints.
Each computer simulation was distinctly different from the others. Thus, their results
cannot be meaningfully compared across studies. The computer simulations were often of
lower quality than the intervention studies.
Three intervention studies examined the throughput achieved (or simulated) using
different approaches to mass dispensing of medical countermeasures against anthrax. The
standard “centralized” model for point of dispensing was efficient, but a decision-support
software tool tested in Georgia further enhanced its efficiency.29 A “push” strategy using
U.S. mail carriers produced even higher throughput than administration through fixed
sites.30
We could not meaningfully compare results from the three studies that examined
different approaches to augmenting health care resources following a major hurricane.
Each employed a vastly different strategy and examined effectiveness using different end
points. Nonetheless, each describes an empirically tested strategy deemed successful by
the authors, ranging from opening alternate care sites to a mobile field hospital to more
efficient distribution of patients via a regional medical operations center.
None of the included studies examined the implementation of crisis standards of care.

Description of Included Studies—Tested Strategies
The 19 papers included in this review address tested strategies for policymakers to reduce or
manage less urgent demand for health care services (15 studies29-43), optimize use of existing
resources (two studies44, 45), or augment existing resources (four studies 32, 41, 46, 47); two studies
included strategies that were classified in multiple categories.32, 41 No studies examining the
implementation of crisis standards of care met our inclusion criteria. To meaningfully synthesize
the available evidence we further classified strategies into subcategories (Table 1).
The 19 studies comprised three main types of analyses. Nine studies were intervention
studies, including four drills and five analyses involving actual MCEs. Eight of the intervention
studies occurred in the United States, and one study took place in Canada. The remaining ten
studies were computer simulations.
Fifteen studies addressed biological threats, including anthrax (6), pandemic influenza (7),
smallpox (1), and SARS (1). Three addressed natural disasters (hurricanes in each case,
including Hurricane Katrina), and one addressed an explosive event (one of the September 11

24

attacks). All ten computer simulations addressed biological threats, including pandemic
influenza, anthrax, and smallpox.
Among the five studies examining actual MCEs, three used a pre-post design, and two
included only post-test assessments; none used a randomized controlled trial design. Studies
assessing drills included one pre-post design and three post-only designs. Eight of the nine
intervention studies had moderately high quality (50 percent or more of the total possible points
across the quality domains) compared to six of the ten computer simulations.
Table 1. Summary of strategies addressing Key Question 1, by category
Strategies
29-33,35-38,41-43

Reduce or manage
less-urgent demand
for health care
services

Biological countermeasures (12 studies)
• Point of dispensing strategies (e.g., centralized vs. hybrid structure; eliminating
conventional steps; using simulation and decision support to optimize staffing)
• Optimizing strategies for allocating medication from stockpiles (e.g., level of
preallocation, level of tailoring to population needs, amount for prophylaxis vs.
treatment)
• Mass vaccination, contact tracing, and school closure
• Mass distribution of antibiotics using postal carriers
34,39,40
Nonbiological countermeasures (3 studies)
•
Distribution of surgical masks or N95 respirators to the public
•
Restrict nonurgent demand for hospital care
•
Training public health officials in their legal authority to implement strategies to
limit the spread of pandemics
44,45

Optimize use of
existing resources

Load sharing (2 studies)
•
Central command structure to optimize distribution of patients to hospitals
•
Establishment of site emergency management centers in low vulnerability
locations
•
Robust and interoperable emergency communications systems
•
Coordinated regional trauma systems to facilitate the rapid transfer of hospitalized
and special needs patients
41,46,47

Augment existing
resources

Crisis standards
of care

Temporary facilities (3 studies)
•
Alternate-site surge capacity facilities
•
Mobile field hospitals
•
Activating mobile provider units from other Federal agencies to provide hospital
surge capacity
32
Mutual aid agreements (1 study)
•
Mutual aid agreements that allow transshipment of antivirals between counties
None

Detailed Synthesis of Tested Strategies
Strategies To Reduce or Manage Less-Urgent Demand for Health
Care Services
Twelve of the 15 studies reviewed under the broad category of strategies to reduce or manage
less-urgent demand for health care services involved biological countermeasures. The specific
strategies included modeling stockpile allocation, exercising stockpile dispensing, and mass
distribution of antibiotics using mail carriers. The other three studies assessed the effectiveness
of nonbiological countermeasures. These studies included a simulation of the impact of physical

25

barriers to disease transmission, an exercise to raise awareness of legally acceptable intervention
measures to stop the spread of pandemic flu, and implementing restrictions on elective surgery.

Biological Countermeasures
The 12 studies in this group included three intervention studies and nine computer
simulations. The three intervention studies, all judged to be of relatively high quality, addressed
point of dispensing (POD) operations for medical countermeasures against anthrax (presumably
ciprofloxacillin). Two of the three studies provided quantitative end points that suggested they
could be compared across studies (Table 2). One provided evidence that a traditional
“centralized” POD system—where persons come to a fixed site to receive a medical
countermeasure—provided slightly faster and more accurate processing than a hybrid model that
combined both the centralized “pull” approach and a “push” approach in which countermeasures
are delivered to some persons at their work site.31
The second study compared the standard centralized “pull” model to a different “push”
model—one that used U.S. Postal Service mail carriers to deliver the medical countermeasure.
The push approach in that study served more people per hour per provider than the fixed
dispensing sites.30 When we converted the findings of one study into the units measured in the
other, the “push” strategy using mail carriers appeared to produce the highest throughput. If the
figures are indeed comparable, which is not entirely clear, then the centralized POD operations
reported in the first study31 were more efficient than those in the second,30 and the “push”
dispensing via mail carriers was the most efficient method of all.
The third study documented that POD operations supported by a specific decision-support
software tool were demonstrably more efficient on several dimensions than traditional
dispensing systems using no or existing software support. However, the quantitative endpoints
were not comparable, and most comparisons between the one county using the tool and the seven
counties not using it were mostly qualitative.29
Table 2. Comparison of different point of dispensing strategies
Source
Ablah, 2010
Koh, 2008

30

29

Lee, 2006

31

Intervention and Comparison
Groups
Centralized POD model vs.
Hybrid model
(Centralized) POD dispensing
vs. “push” method using mail
carriers

One county using RealOpt
software vs. seven counties not
using the software

Findings
Centralized: 0.75 patients/minute  45 patients/hour
Hybrid: 0.48 patients/minute  to 28.8 patients/hour
Centralized: 1,988 persons/hour, or 33/hour/staff person
Push: 3,833 persons/hour, or 120/hour/staff person
User: Was the only county to exceed 450 targeted households,
and 50% greater throughput than next best county (not using
software); qualitatively—most efficient floor plan, most costeffective dispensing (lowest labor/throughput value), smoothest
operations (shortest average wait time, average queue length,
and equalized utilization rate
Nonusers: No county reached 450 targeted
households; best one achieved 71% of target

POD = point of dispensing

The nine computer simulations were more varied in focus. Five addressed pandemic
influenza, three addressed anthrax, and one addressed smallpox. Most of the influenza
simulations examined different questions and thus were not comparable to one another. One
study examined the use of the same or different drugs for treatment and prophylaxis,36 and one
looked at allocation of the single stockpiled antiviral drug, including its use for treatment or
prophylaxis.32 In the former, the authors found that a two-drug strategy for pandemic influenza
26

(one drug for prophylaxis and a different drug for treatment) is more effective in delaying the
propagation of disease and the emergence of drug resistance (including multi-drug resistance)
than the use of a single drug for both prophylaxis and treatment.36 However, the simulation also
indicated that the two-drug model is more likely to result in multidrug resistance than resistance
to a single drug, which is a significant drawback. The other simulation provided useful, albeit
somewhat less compelling, evidence. It noted that allocation of an antiviral stockpile should not
be determined in advance; instead, it should be based on population attack rates and, potentially,
age. It also indicates that when supplies of effective antiviral drugs are limited, they should be
used for treatment rather than prophylaxis.32
Three studies assessed optimal vaccination-targeting strategies; two focused on the general
population38, 35 and one focused on health care workers specifically.37 The first simulation, which
we rated as high quality, reflects the importance of young children in influenza transmission and
concluded that vaccinating children aged 5 to19 and their parents (ages 30 to 39) is a particularly
effective vaccine targeting strategy, since these children are often vectors of transmission to
others.38 In the second simulation, prioritizing prophylaxis to health care workers was shown to
be an effective use of an antiviral stockpile, and this strategy did not have a deleterious effect on
disease control in the population.37 Another simulation indicated that the most effective targeting
strategy may depend on a policymaker’s objective.35 Specifically, to minimize population
morbidity, the results suggested that children, adolescents, and young adults should be targeted;
in contrast, to minimize mortality, infants, young adults, and older adults should be targeted.
One of the three anthrax simulations examined rapid mass distribution of prophylactic drugs
versus treatment only of symptomatic persons. As expected, the simulation found that the former
strategy prevents significantly more deaths than the latter.41 That study also showed the
significant impact of adequate hospital surge capacity on reducing patient deaths. A second
simulation found that local dispensing capacity was a critical factor in determining the costeffectiveness of other strategies, such as increasing the size of stockpiles and improving
surveillance.33 The other anthrax simulation was of poor quality and thus does not provide
persuasive evidence to support its rather general findings.42
The smallpox simulation provided evidence to suggest that a combination of mass
vaccination and targeted vaccination of contacts is needed to limit disease transmission. It also
noted that school closures would further enhance the impact of such interventions.43
Several of the studies that tested strategies for implementing PODs involved relatively largescale exercises that were conducted in different geographic regions. Evidence from these studies
appears to be generalizable across locations and settings. The applicability of the evidence
generated from computer simulations is exceedingly hard to assess. These studies may not
provide highly applicable evidence if their conclusions rely heavily on assumptions or model
parameters that are contextually inappropriate. Outcomes from tabletop exercises (e.g., increases
in participants’ knowledge and confidence) may not be the most relevant outcomes for
policymakers, who might be more interested in health outcomes or public perceptions of
fairness. But taken together, the studies of biological countermeasures provide reasonably
applicable evidence.

Nonbiological Countermeasures
Three studies assessed nonbiological countermeasures. Two studies involved a pandemic
influenza context, and one study was based on the 2003 SARS epidemic. Among the influenzarelated studies, one was an intervention study and one was a computer simulation; because they
27

addressed entirely different issues, they were not comparable. The intervention study was a
tabletop exercise addressing measures that policymakers could legally take during an infectious
disease event affecting a community. Compared to pre-exercise measurements, post-exercise
measurements reflected significant increases in knowledge and confidence regarding deployment
of such measures.39 The computer simulation indicated that N95 respirators provide better
protection against influenza infection than do surgical masks for both droplet and airborne virus
transmission, but only if compliance with their use is nearly universal.34
The third study in this category assessed the effectiveness of imposing restrictions on
ambulatory and inpatient medical and surgical care for nonurgent cases across all 32 hospitals in
the greater Toronto area during the 2003 SARS epidemic.40 The authors showed that, while
nonurgent admissions decreased significantly, high-acuity emergency department (ED) visits and
interhospital transfers also decreased, suggesting that some patients may not have received
needed care.

Strategies To Optimize Use of Existing Resources
We identified two studies in this category. One was of poor quality despite its providing
highly applicable evidence from an actual MCE45; it is therefore not a robust source of evidence
for this review. It described response strategies following the September 11, 2001, terrorist
attacks in New York City. The study found that the absence of an enforced patient distribution
system led to uneven load in three trauma centers, and attack damage to the Office of Emergency
Management and disruption of cell phone and radio communications exacerbated problems with
coordination and communication.
The second study documented significant reduction in patient transfer times once a
coordinated regional trauma system was introduced for routine, small-scale trauma events.44 A
comparably designed system based on a regional medical operations center was able to
efficiently transfer and manage evacuation patients following Hurricane Katrina and transfer atrisk patients prior to Hurricane Rita.

Strategies To Augment Existing Resources
We reviewed four studies of strategies to augment existing resources. Three of the four were
intervention studies evaluating measures taken after a major hurricane. The fourth was an
influenza computer simulation discussed above under strategies to reduce or manage less-urgent
demand for health care services.
The hurricane-related intervention studies did not report comparable end points; therefore we
cannot make valid comparisons across their different strategies. One study documented the extra
patient load cared for by a mobile field hospital deployed to care for evacuees from Hurricane
Katrina.47 A second reported that an alternate care site in Dallas provided so much medical surge
capacity following Hurricane Katrina that the emergency departments and trauma centers in the
city saw no significant rise in patient visit rates during the two weeks postevent.46 The third
study, which was a computer simulation, concluded that “mobile servers” (augmented hospital
capacity provided by Federal health care providers) reduced predicted patient mortality.41
One study examining the impact of mutual aid agreements allowing transshipment of
antivirals during an influenza epidemic found that the policy mainly favors less densely
populated counties and is only cost-effective when there is geographic variability in the
epidemic.32

28

The strategies we identified for augmenting capacity during MCEs relied on data from two
real events and two computer simulations. All of the strategies were tested at a single site or
within a single region; however, most strategies appear to be broadly applicable across settings.
Several studies within this category reported process outcomes—mainly the number of patients
served—while more relevant outcomes for policymakers might involve health outcomes. While
the mobile field hospital appears to be particularly useful for a broad range of MCEs, the
alternate care site that was established during Hurricane Katrina may only be useful for MCEs in
which victims suffer less severe injuries.
Table 3 outlines the strength of evidence for Key Question 1.
Table 3. Strength of evidence for Key Question 1
Strategies

Risk of Bias

Consistency

Directness

Precision

SOE Grade

High

Consistent

Interventions:
Indirect
Simulations:
Direct

Imprecise

Low/Medium

High

Not
applicable

Two direct,
one indirect

Two precise,
one
imprecise

Low

Reduce or
manage
less-urgent
demand for
health care
services

Biological
countermeasures
(n=12)
Nonbiological
countermeasures
(n=3)

Optimize use
of existing
resources

Load sharing
(n=2)

High

Not
applicable

Indirect

Imprecise

Insufficient

Temporary
facility (n=3)

Low

Consistent

Indirect

Imprecise

Low

Load sharing
(n=1)

Medium

Not
applicable

Indirect

Imprecise

Insufficient

NA

NA

NA

NA

NA

Augment
existing
resources
Crisis
standards of
care

Tested Strategies Lacking Comparison Groups
Seven studies were included in this section of the review. One study presented the results of
an exercise that tested a disaster response protocol for Super Bowl XXXVIII.48 A second study,
conducted as a simulation in Hawaii, demonstrated that prophylactic medication can be
efficiently dispensed with minimal human-to-human contact using a drive-through clinic
model.49 Another simulation study, conducted in the Netherlands, examined laboratory capacity
during MCEs. It found that a national diagnostic laboratory network could handle diagnostic
requests from hospitals during an MCE, but it would have insufficient capacity to manage the
surge of tests that could be generated by the nonhospitalized population.50 A second study related
to laboratory capacity described a customized laboratory information system to support Centers
for Disease Control and Prevention (CDC) activities for rapid sample analysis and data
reporting.51
Two studies assessed resource allocation strategies during hurricanes. Irwin et al. reported
details about the successful use of a multidisciplinary treatment center in Houston to treat large
numbers of evacuees for non-emergent medical concerns in the aftermath of Hurricane Katrina.52
During the time this large facility was in operation, it substantially reduced use of local
emergency departments for non-emergent problems. A related study indicated that deployable

29

military hospitals can effectively supplement surviving local health care capabilities after
disasters.53
One study reported outcomes of an information technology applications deployed during the
height of the 2009 H1N1 pandemic—an interactive, Web-based decision-support tool to help
adults with influenza-like illness self-assess their need for ED care.54 The tool closely adhered to
a diagnostic algorithm the group developed in collaboration with the CDC and subsequently
validated using electronic health information collected from a large HMO in Colorado. The
interactive, Web-based version of this algorithm was offered to the public via Flu.gov and a free
Web site operated by Microsoft (H1N1responsecenter.org). Users accessed it approximately
800,000 times before the end of the pandemic, with no reported adverse events. Although the
report suggests that the concept of a web-based self-triage for influenza-like illnesses is feasible,
it could not quantify the impact of the decision support tool on surge capacity. Similar Web sites
exist, including one developed by a collaboration led by the American Medical Association
(www.AMAfluhelp.org).
Finally, in a study examining resource allocation under crisis standards of care, Etienne et al.
described how a Multidisciplinary Healthcare Ethics Committee determined allocation of
resources during the Haiti earthquake.55 The authors found that this process enabled ethical
decision making in a timely manner.

Proposed Strategies
Our systematic review identified one study that described a proposed strategy for use by
policymakers to allocate resources during MCEs. In 2008, a Federal interagency working group
developed the current national plan for guiding the allocation of influenza vaccines during
pandemics. The guidance is intended for use by Federal, State, local, and tribal governments;
communities; and the private sector.56 Prioritizing the allocation of vaccine was accomplished by
defining four categories in order of importance: (1) homeland and national security; (2) health
care and community support services; (3) critical infrastructures; and (4) the general population.
These target groups are further prioritized into tiers within each category, and, within tiers by the
severity of the pandemic. The rationale behind the prioritization scheme is clearly elaborated in
the report. For example, the highest-tier target group within homeland and national security
comprises deployed and mission-critical personnel, recognizing that “these individuals are
critical to protect national security” and have “a potential greater risk of infection due to
geographic location and crowded living or working conditions.”

Key Question 2: What Strategies Are Available to Providers To Optimize
Allocation of Scarce Resources During MCEs?

Key Points
•

A wide range of provider-oriented strategies has been tested in various contexts,
including actual MCEs, exercises, drills, and computer simulations. However, with the
exception of pre-hospital or “field” triage during MCEs, the body of high-quality
evidence addressing any individual strategy is small, usually with no more than one or
two studies providing evidence in each area. There is insufficient evidence to support the
use of any one strategy over another.

30

•

•

•

•
•
•

Various triage systems and triage acuity scales have been used in emergency department
operations for many years and have been extensively studied. But triage in the setting of
MCEs is quite different, particularly triage practiced in pre-hospital settings where first
responders may be required to assess large numbers of victims in a very short timeframe.
Many of the studies on this topic raised significant concerns about current triage systems
when used during actual MCEs. Other studies tested triage systems during exercises or
drills and provided evidence with limited applicability.
The evidence base available to assess the effectiveness of the remaining strategies
identified under this Key Question is thin. Few studies that met our inclusion criteria
were based on data that were collected during one or more actual MCEs. The quality of
these studies was substantially lower than drill-based studies. Few studies employed a
randomized design. The computer simulations we identified provided low-quality
evidence.
The majority of identified studies reported process measures (e.g., improved throughput
times or triage accuracy) rather than outcomes. Studies that reported outcome data used
less rigorous designs, such as comparing outcomes against historical control groups or a
benchmarked performance rate, rather than a contemporaneous comparison group.
Few of the articles we identified examined specific barriers and facilitators to the
implementation of provider strategies. Those that did reported this information
inconsistently.
Evidence derived from drills and exercises did not report data on outcomes that are
particularly relevant to patients and providers. The applicability of the findings beyond
the immediate exercise setting is questionable.
With few exceptions, strategies proposed by national provider organizations were vague.
Many did not propose actionable steps to help health care providers make difficult
decisions regarding allocation of scarce resources under crisis standards of care.

Description of Included Studies—Tested Strategies
The 55 studies included in this part of the review address tested strategies available to
providers to reduce or manage less-urgent demand for health care services (3 studies57-59),
optimize use of existing resources (48 studies60-107), augment existing resources (1 study108), and
implement crisis standards of care (5 studies77, 79, 109-111). Two studies included strategies that
were classified in multiple categories.77, 79 To meaningfully synthesize the available evidence we
further classified strategies into subcategories (Table 4).
The 55 studies comprised a diverse set of analyses. Thirty-nine studies were intervention
studies, including 19 studies evaluating the outcomes of drills and 20 analyses involving actual
MCEs. Of the remaining 16 studies, 7 were computer simulations, 2 were systematic reviews, 5
were validation analyses, and 2 were laboratory analyses. Seventeen of the 39 intervention
studies took place in the United States, while the remaining 22 represented a range of
international contexts, including Europe (8), Israel (6), Asia (3), Canada (1), Australia (1),
Mexico (1), Rwanda (1), and Haiti (1).
The studies addressed a wide range of MCEs, including explosive events (9), pandemic
influenza (6), natural disasters (6, all of which involved earthquakes), nuclear/radiological events
(3), transportation accidents (3), chemical events (3), multiple hazards (10), other MCEs (5), and
unspecified events (10). The quality ratings were at least moderately high (50 percent or more of
the total possible points across the quality domains) for 41 of the 55 studies.
31

Among the 20 studies examining actual MCEs, 6 used a pre-post design, 13 included only
post-test assessments, and only a single study used a randomized controlled trial design. Studies
assessing drills included 4 randomized designs, 5 pre-post designs, and 10 post-only designs.
Eighteen of the 19 studies involving strategies tested in drills had moderately high quality,
compared with 11 of the 20 analyses of strategies tested during actual MCEs. Both metaanalyses were high quality, but only 3 of the 7 computer simulations were rated as having at least
moderately high quality.
Table 4. Summary of strategies addressing Key Question 2, by category
Strategies
58,59

Reduce or manage
less-urgent
demand for health
care services

Optimize use of
existing resources

Biological countermeasures (2 studies)
•
Emergency mass clinic based on CDC guidelines
•
POD strategies (e.g., dynamic staffing)
57
Public information (1 study)
•
Automated central information distribution system for families
72
Case managers (1 study)
•
Hospital-based case managers to ensure care coordination
63
Decontamination (1 study)
•
Strategies to increase decontamination effectiveness (e.g., instructions, providing
washcloths)
91
Health care worker prophylaxis (1 study)
•
Influenza prophylaxis for health care workers
61,87
Health information technology (2 studies)
•
Electronic triage tags to monitor vital signs and transmit information to first
responders
•
Regional telemedicine hub to support delivery of specialty care
80,86,93,104
Imaging (4 studies)
•
Focused assessment of sonography for trauma (FAST) for triage
•
Sonographic screening for abdominal/pelvic injury or bleeding for triage
•
Accelerated CT protocols
70,75,77,97
Load sharing (4 studies)
•
Load-sharing protocols
•
Central allocation of patients to hospitals based on available resources
82,103
Medical interventions (2 studies)
•
Medical interventions for the prevention of acute renal failure in crush victims
•
Novel drug infusion devices
64,105,107
Space optimization (3 studies)
•
Conversion of lobbies, clinics, and other units to accommodate surge
•
Reverse triage to create surge capacity (e.g., early discharge, increasing use of
community care options)
71,73,81,88,90,99
Training (6 studies*)
•
Hospital staff training (e.g., disaster drills, computer simulations, tabletop
exercises)
•
Triage training (e.g., JumpSTART training program, virtual reality, podcasts,
computer games)
60,62,65-69,74,76,78,79,83-85,89,92,94-96,98,100-102,106
Triage (24 studies)*
•
Triage systems (e.g., START, mSTART, American College of Surgeons Committee
on Trauma criteria, Radiation Injury Severity Classification, CBRN-specific system,
Revised Trauma Score, Sacco triage method, SALT, Influenza-Like Illness Scoring
System, TAS Triage Method, Simple Triage Scoring System, Model of Resource
and Time-based Triage)
•
Triage strategies (e.g., combining triage categories, adding categories, one- vs. twostage triage)
•
Simplified biodosimetry protocol to triage exposed victims

32

Table 4. Summary of strategies addressing Key Question 2, by category (continued)
Strategies
108

Resource conversion (1 study)
•
Conversion between formulations of nerve agent antidote to augment supply
109
General (1 study)
111
Orthopedics (1 study)
•
External fixation of fractures rather than definitive orthopedic care
Crisis standards of
77
Pediatrics (1 study)
care
•
Provision of only "essential" interventions
79,110
Trauma surgery (2 studies)
•
“Damage control” approach (e.g., for orthopedic surgery or more generally)
CBRN = chemical/biological/radiological/nuclear; CDC = Centers for Disease Control and Prevention; CT = computerized
tomography; POD = points of dispensing; SALT = sort, assess,lLife-saving interventions, treatment/support; mSTART =
modified simple triage and rapid treatment; START = simple triage and rapid treatment; TAS = Interdisciplinary Emergency
Service Cooperation Course
*Includes one systematic review.
Augment existing
resources

Detailed Synthesis of Tested Strategies
Strategies To Reduce or Manage Less-Urgent Demand for Health Care
Services
Three studies described strategies to reduce less-urgent demand for health care services. Two
studies examined techniques to rapidly dispense prophylactic medication, while the third study
assessed the impact of a centralized information distribution system to support the information
needs of the public. The strength of evidence provided by these studies was insufficient.
Among the two studies involving delivery of mass prophylaxis, one study demonstrated that
communities can implement existing CDC mass vaccination protocols during a real MCE and
achieve benchmark levels of throughput.58 The second study used a computer simulation to
demonstrate that the design of PODs may require better command and control structures to
address variability in patient flow.59 The third study showed that implementing an automated,
centralized information distribution system in Israel prevented overloading of a hospital’s
communication lines.57
Although each of these studies cleared the threshold for evidence, the two simulations were
of low quality. Moreover, the incident command system proposed as a solution to address
bottlenecks in the operation of PODs has not been tested in an actual MCE. The study of the
mass vaccination clinic used data from an actual event (an outbreak of Hepatitis A) in a
community with apparently average levels of preparedness. The results may be generalizable to
similar communities but may not be generalizable to other types of MCEs. Although the
outcomes of the centralized public information system were assessed at a single hospital, the
findings are likely to be applicable to other Israeli hospitals. However, the requirements for
implementing such a system in the United States are unclear.

Strategies To Optimize Use of Existing Resources
A total of 48 studies included a test of a strategy for optimizing existing resources during an
MCE. Because of the large number of studies reporting the development or implementation of
triage systems, we synthesized the evidence from these studies separately from the remaining
studies in this category. The strength of evidence for both the triage studies and the nontriage
studies is low.
33

Triage Systems
The 24 studies that examined triage systems can be classified in two main groups: (1) those
that examined the validity of new or existing systems, and (2) those that assessed the degree to
which these systems accurately triaged patients during drills or actual MCEs. One recent
systematic review of the validity of triage systems comprising 11 articles (8 triage systems)
concluded that limited evidence supported their validity.62 Among existing systems, the
reviewers considered the Sacco Triage Method the most promising because it was the only
system that combined estimates of patients’ survival probabilities with data on available capacity
at receiving hospitals. A later validation study that was not included in the review showed that
the Field Triage Score predicted patient mortality comparably to the Revised Trauma Score but
was easier to calculate at the scene of an MCE.94 Collectively, these validation studies have low
methodological quality. Most rely on small sample sizes, and few studies assessed the validity
of the tool using prospectively collected health outcomes data from real events. In addition, few
triage tools are applicable to pediatric disaster victims.
Several studies examined the implementation of triage systems during real or simulated
events (Table 5). The vast majority assessed the accuracy of classifying patients into triage
categories using the system’s specific criteria compared to a gold standard (e.g., medical record
review or “true” triage categories determined prior to a drill). Only three studies reported data on
the accuracy of a specific triage system used during an MCE. The reported accuracy of triage
ranged from 62 percent to 100 percent across systems.
A few studies described implementation problems associated with triage systems. For
example, in a commuter rail accident, implementation of Simple Triage and Rapid Treatment
(START) led to poor allocation of patients between trauma centers and community hospitals,
mainly because of confusion about the meaning of each triage category.78 Another study
demonstrated that START triage categories were not sensitive to patients experiencing
myocardial infarction or an asthma attack and may lead to under-triage of individuals with these
conditions.100 Some studies reported triage performance using time-based outcomes, but these
outcomes had limited comparability across studies due to differences in design.
Other studies provided evidence to inform triage approaches beyond the use of specific tools.
For example, one hospital-based triage approach that was found to be superior in a computer
simulation used a two-stage process in which mild cases were first separated from more severely
ill or injured patients, after which the critically ill patients were distinguished from urgent
cases.66 During the Sichuan earthquake of 2008, adding a resuscitation category to the standard
START protocol enabled higher survival rates for a subset of victims who would have otherwise
been categorized as “expectant” and not vigorously resuscitated.67 Other promising triage
protocols included modified dosimetry methods, such as using fewer metaphase spreads for
dicentric chromosome assays.60 One study demonstrated the effectiveness of a quality
improvement program that was initiated in response to triage failures during a 2005 train crash
and reported improvements in performance during a similar crash three years later.95
Although MCE triage has been examined more extensively than any other strategy, many of
the studies we reviewed neither included a contemporaneous comparison group nor reported
patient outcomes associated with the triage protocol. Studies tended to report throughput times or
triage accuracy relative to an existing benchmark. Established standards for what constitutes
acceptable triage performance are lacking, complicating efforts to infer the effectiveness of
specific tools. Few studies tested triage protocols during MCEs. In general, triage accuracy rates
that are measured during drills or exercises may provide evidence with limited applicability,
34

because few drills are likely to capture the unique decision-making context imposed by a real
MCE, and because results may be confounded by training that is part of the exercise.65, 69
Table 5. Accuracy of triage for individual triage tools reported in 10 included studies
Under-triage

Over-Triage

Overall
Accuracy

Real MCE

Drill

Results
Study Type
1%,14%,
ACS Committee on Trauma criteria
33%
x
13%*
74
CBRN triage system
11%
2%
x
89
Influenza-like Illness Scoring system
<1%
x
79
London transit bombings triage method
64%
x
76
Radiation Injury Severity Classification
0.92**
x
68
SALT
10%
6%
83%
x
69
SALT
4%
13%
79%
x
100
START
70%
x
100
START
62%***
x
96
mSTART
3%
5%
x
65
TAS Triage method
0%
0%
100%
x
ACS = American College of Surgeons; SALT = sort, assess,lLife-saving interventions, treatment/support; START = simple
triage and rapid treatment; mSTART = modified simple triage and rapid treatment; TAS = Interdisciplinary Emergency Service
Cooperation Course; CBRN = chemical/biological/radiological/nuclear
*Rates for critical, severe, and moderately injured.
**Kappa statistic.
***Accuracy of triage when clinical status was manipulated for 47 patients.
Note: Data from three systems were not amenable to synthesis.83, 85, 95
84

Nontriage Studies
A total of 24 studies addressed resource optimization strategies other than the use of triage
systems. We describe these results by subcategory and then assess the strength of evidence and
applicability across all studies.
Case Managers
The use of case managers in an Israeli hospital was found to significantly expedite the
delivery of critical tests and procedures and to lower the duration of hospital stays for critically
injured patients.72
Decontamination
A randomized trial of alternative showering strategies suggested that providing washcloths
with instructions to exposed victims of a radiological MCE enhanced the effectiveness of
decontamination compared to the other methods.63
Health Care Worker Prophylaxis
One randomized trial conducted during the 2009 H1N1 influenza epidemic demonstrated that
surgical masks were as effective as more costly and less readily available N95 respirators at
preventing health care workers from contracting influenza.91
Health Information Technology
A computer simulation showed that a regional telemedicine system could potentially reduce
mortality by limiting needless ED bed use and specialty care, thereby increasing surge capacity
following a simulated earthquake.61 A second study demonstrated that triage accuracy can be

35

enhanced through the use of electronic triage tags that monitor vital signs and permit
reclassification of patients as their status evolves.87
Imaging
Four studies evaluated strategies involving the use of imaging to optimize triage or ED
throughput. In two studies, use of imaging improved initial assessment of large numbers of
trauma patients. In the first, Focused Assessment by Sonography in Trauma (FAST) exams were
found to have comparable diagnostic accuracy to CT and other diagnostic techniques.93 A second
study showed that sonography was sufficiently accurate to be used as a primary triage tool
during a major earthquake.86 In two drills, ED throughput was increased through the use of
accelerated multislice CT protocols80, 104
Load-Sharing
Four studies provided evidence that load-sharing strategies can optimize allocation of
patients to trauma centers and avoid the need to adopt crisis standards of care. In one study, the
use of an incident command system successfully allocated victims of a terrorist bombing to avoid
overwhelming the nearest hospital.75 A second study—also describing a terrorist event—
demonstrated that centralized allocation of patients to hospitals, based on available capacity,
achieved balanced allocation of patients to hospitals.97 A third study used a computer simulation
to show that a regional surge distribution strategy reduced mortality among pediatric mass
casualty victims.77 Finally, a load-sharing protocol developed in Germany for disaster situations
involving mass gatherings was found to meet national standards.70
Medical Interventions
Two studies evaluated specific medical interventions for disaster victims and both reported
favorable results. One demonstrated that many disaster victims with rhabdomyolysis from crush
syndrome can avoid renal failure through vigorous fluid resuscitation.103 In a chemical exposure
drill, a novel infusion device proved to be effective at delivering antidote, which enhanced
throughput and increased predicted survival rates.82
Space Optimization
Three studies examined space optimization strategies. Two studies examined “reverse triage”
protocols. One was implemented during a major transportation accident and the other during the
2009 H1N1 influenza epidemic. In the first study, the authors report that the protocol
successfully created additional surge capacity without worsening the prognosis of patients who
were discharged early.64 In the second study, the protocol failed to increase surge capacity—
presumably because hospital management never formally implemented the protocol.107 The third
study demonstrated that re-appropriating hospital lobbies, subspecialty clinics, and short-stay
units (in conjunction with other strategies) increased surge capacity and reduced waiting times
during the 2009 H1N1 epidemic.105
Training
Each of the six studies of preparedness training for MCEs reported that the strategy is
effective. One systematic review on training found that disaster drills were effective in
improving response to MCEs, whereas evidence from computer simulations and tabletop
exercises was inadequate to draw conclusions.81 Among studies that were not included in that
review, one found that a computer game-based triage exercise was more effective in improving
36

triage accuracy than tabletop exercises.88 A virtual reality method of teaching mass casualty
triage skills reportedly improved accuracy,73 whereas a second study indicated that it did not
improve provider performance using the START protocol.90 Another study that used podcasts
and multi-manikin simulations improved triage performance by medical students.71 A typical
“JumpSTART” training session improved triage performance in a subsequent drill.99
Although a clear majority of studies assessing resource optimization strategies indicate that
these methods are effective, the limited level of evidence within each category does not allow us
to draw definitive conclusions. Only three studies used randomized designs, and many studies
failed to include a robust comparison group. Rather, many studies relied on performance
benchmarks from prior events—a potentially subjective standard. For example, it is unclear what
an “acceptable” false negative rate might be for an accelerated imaging protocol. Outcomes of
load-sharing strategies that demonstrated balanced allocation are difficult to interpret: the few
studies published on this topic did not report health outcomes or adverse events associated with
these strategies, three occurred outside the United States, and the remaining study was a
computer simulation. Nearly all studies reported positive results, suggesting that publication bias
may be a threat to the validity of these findings. Although many of these studies drew on data
collected during actual MCEs, they were often limited to a single setting and relied on small
sample sizes, undermining both the validity and applicability of the results.
Despite providing outcomes data with published sources or comparison groups, many of
these strategies can be regarded more accurately as promising pilot tests. For example, strategies
involving electronic triage tags, and technology-enhanced triage training have not been taken to
scale. As a result, important details of these strategies may not yet be fully understood. Loadsharing examples developed in Israel, a compact country where emergency care utilizes a
national incident command system, may not work as well in other settings. Likewise, because the
effectiveness of the telemedicine system was based on simulated data only, an unknown number
of implementation issues may arise when applying the strategy in practice.

Strategies To Augment Existing Resources
A single study assessed different strategies for augmenting scarce resources during an MCE.
Researchers demonstrated the feasibility of augmenting supplies of nerve agent antidote by
converting a more widely available intramuscular formulation of pralidoxime to enable
intravenous administration—a route more suitable for treating critically ill victims of a mass
nerve agent attack.108 The strength of evidence in this category is insufficient.

Strategies for Use Under Crisis Standards of Care
Five studies evaluated outcomes of strategies for use under crisis standards of care during
actual or simulated MCEs. These studies assessed a wide range of non-comparable outcomes that
may have limited relevance to most providers. The strength of evidence from these studies is
insufficient to support firm conclusions.
One article described the use of very early discharge from the intensive care unit (ICU) in a
field hospital during the 2010 Haiti earthquake. The authors reported that this strategy enabled
the hospital to treat a greater number of patients than would have otherwise been possible.109
Two studies assessed outcomes associated with a limited approach to trauma surgery under crisis
standards. The first evaluated impact of “damage control” surgery to treat the initial influx of
complex trauma victims from the London transit bombings. The authors report that this strategy
resulted in lower than expected mortality rates.79 In the second study, hospitals that implemented
37

damage control surgery in the aftermath of a major earthquake improved their operating room
throughput with limited impact on patient outcomes.110 Another study examined the impact of
crisis standards of care for orthopedic surgery under battlefield conditions. It reported faster
throughput, but at the cost of higher complication rates, particularly surgical infections.111
Finally, a computer simulation study found that implementing crisis standards of care for
pediatric disaster victims could reduce mortality, particularly if preceded by strategies to
improve allocation of patients under surge conditions.77 However, this study has limited use
because the specific approach used to implement crisis standards of care was not defined.
Collectively, these studies present encouraging findings but not definitive evidence. Most
studies were of low quality because they used study designs that did not adequately control for
potential confounders. Moreover, in the studies of actual events, data collection was typically
nonsystematic, and measures of effectiveness were often compared to historical benchmarks that
are open to interpretation. Several studies did not measure health outcomes or even the most
relevant process outcomes. Instead, most of the studies focused on measures of throughput.
Reports based on actual MCEs were generally less rigorous but provided more applicable
evidence. Computer simulations and exercises provided low-quality evidence, and their findings
have limited applicability to real MCEs or to other settings. Crisis standards in the studies we
reviewed were implemented in very specific contexts, including an earthquake and a terrorist
bombing, and likely involved different types of injuries and different protocols. Crisis standards
were typically implemented on a small scale and occasionally at a single site, limiting the
generalizability of those studies.
Table 6 outlines the strength of evidence for Key Question 2.
Table 6. Strength of evidence for Key Question 2
Strategies

Risk of Bias

Reduce or
manage lessurgent demand for
health care
services

Consistency

Directness

Precision

SOE Grade

Medium

Consistent

Direct

Imprecise

Insufficient

Triage

High

Inconsistent

Indirect

Imprecise

Low

Other

Medium

Consistent

Direct

Imprecise

Low

Augment existing
resources

Medium

Consistent

Direct

Imprecise

Insufficient

Crisis standards
of care

High

Consistent

Indirect

Imprecise

Insufficient

Optimize use of
existing resources

Tested Strategies Lacking Comparison Groups
We identified 47 additional articles that presented evidence relevant to Key Question 2 but
that did not meet the level of evidence required to be formally included in our review because
they lacked a comparison group (Appendix Table C-5). Although the impact of these strategies
on patient outcomes has not been conclusively demonstrated, many used novel techniques to
optimize use of existing resources, augment existing capacity, and implement crisis standards of
care. None of these articles addressed reducing less-urgent demand for health care services.
38

Some strategies are sufficiently promising to warrant consideration for future research to
advance the field.

Optimizing Resource Use
Seventeen studies sought to optimize resource use through improved approaches to triage or
the use of imaging to support triage decisions. Two reports from actual disaster events112, 113
described the use of ultrasound, particularly the FAST exam, as a screening tool to support triage
decisions. A third study, based on a simulation, assessed the feasibility of implementing
ultrasound screening in the context of an MCE.114 Another simulation study examined the use of
a modified approach to CT scanning as an adjunctive tool for clinicians evaluating large numbers
of patients with complex injuries.115 A retrospective study described the use of three levels of
triage—at disaster sites, primary health care centers, and tertiary referral centers.116 Okumura et
al.117 described an approach that uses colored clothespins to perform color-coded triage for
MCEs that require decontamination. Another drill-based study showed that a care team
comprising both ambulance and hospital staff allowed timely triage for simulated disaster
victims.118
Several exercises and simulations tested the effectiveness of information technology
applications to facilitate MCE triage in the pre-hospital setting. One study employed a portable
data collection tool for first responders. The authors claim that it reduced triage collection time
and improved data collection accuracy in two field simulations.119 Another simulation exercise
demonstrated that it was feasible to use a prototype Radio Frequency Identification (RFID)
technology in the field as part of an online triage system for MCEs.120 A simple navigation
device designed to guide walking wounded to a target destination was successfully tested in a
third study.121 A pilot test of a “Scalable Medical Alert Response Technology,” or SMART, to
monitor unattended patients showed promise in several emergency departments and scenes of
actual MCEs.122 Electronic patient tracking through bar codes123 and web-based triage tools124
have also been shown to be promising techniques for optimizing resources.
Information technology has also been used to improve resource use inside health care
facilities during MCEs. One article described the use of an electronic health information
system—including patient medical records, picture archiving, and communications—that
facilitated patient care in a field hospital established after the 2010 earthquake in Haiti.125 In
another study, Roth and colleagues described a web-based all-hazards electronic disaster
management system designed to optimize resource use by integrating health care data from
multiple sources.126 A test of an automated call-down system demonstrated that roughly a third
of personnel contacted were able to report to the facility in less than 60 minutes.127Another pilot
study tested an educational tool that linked participants’ resource allocation decisions to patient
outcomes.128

Augmenting Existing Resources
Twenty-nine studies in this group focused on augmenting resources by repurposing drugs or
devices; opening ancillary facilities; providing additional training to providers; or modifying
existing equipment, such as ventilators, to serve multiple patients simultaneously. Two studies
involved simulations to test whether a single ventilator could be modified to sustain up to four
individuals.129, 130 One of the studies, conducted with four sheep, concluded that it may be
possible to use this strategy during an MCE, such as a pandemic, when ventilators are in
critically short supply.130 However, the other study, based on a simulation, suggested that such an
39

approach would sustain only four adults for a very limited period of time.129 Another study of
mechanical ventilation devised a prototype that could be quickly manufactured during an
emergency.131 Automatic gas-powered resuscitators have been proposed to augment the supply
of ventilators, but questions about their capacity and usefulness remain.132, 133 Other studies of
respiratory support focused on enhancing capacity to deliver oxygen via an improvised
system,134 testing the feasibility of just-in-time training for medical students to provide bagvalve-mask ventilation,135 and assessing the feasibility of cross-training non-respiratory
therapists to assist in mechanical ventilation.136 Both of the cross-training studies demonstrated
successful competency of trainees.
Several studies examined load-sharing strategies. A descriptive study, based on an actual
MCE, reported successful use of an alternate care site as a temporary burn center coupled with
successful long-distance transfer of some patients.137 Another described the implementation of a
fully equipped mobile surgical hospital (MED-1) during Hurricane Katrina that succeeded in
providing services to approximately 350 patients per day.138 During the 2009 H1N1 pandemic,
an alternate care site effectively expanded ED capacity by 42 percent without any adverse
events.139 Other studies reported the successful conversion of a charter plane to transport a large
number of injured and ill tsunami victims back to their country of origin140 and a successful
trans-provincial mass transfer of patients following a major earthquake in China.141 One study,
conducted in a non-disaster situation, demonstrated that it is possible to implement load-sharing
by transferring pediatric patients, including critically ill children, without adverse outcomes.142
Lessons learned during the mass interstate transfer of pediatric patients during Hurricane Katrina
highlight the need for improved regionalization of pediatric services prior to an MCE.143 Trauma
system structures have been tested as a mechanism for distributing victims of an MCE. For
example, the Medical Alert Center in Los Angeles County has demonstrated its ability to
coordinate distribution of critical casualties among area hospitals and trauma centers.144
Several articles in this group pointed to the role that information technology can play in
augmenting health care resources. One team used a web-based application to assess surge
capacity and other resources in a State disaster exercise.145 Another used a mass-casualty
tracking system to improve coordination and reduce confusion during a simulated MCE.146 A
wireless handheld device for recording and transmitting patient information between first
responders and incident command has also been successfully field tested.147 A system that uses
bar-coded identifiers to represent patients, injuries, facilities, and locations has been shown to
facilitate information transfer and minimize errors during a simulated MCE.148 Two separate
pilot tests demonstrated that electronic medical information tags can increase patient care
capacity in the field and facilitate successful transfer of information to receiving facilities.149
Another study described the use of “pervasive computing technology” for MCEs, using a device
that would capture contextual information from individuals in a non-intrusive manner to
facilitate response. However, a prototype has not been built or tested.150
A few studies examined other approaches to augmenting resources. One study tested a tool
designed to rapidly mobilize anesthesiology staff;151 another used a tool to estimate manpower
reserve and service capacity for radiology staff.152 Two studies focused on lab capacity and
scalability, particularly for chemical and radiological disasters. One of the studies described a
customized laboratory information system developed at the CDC to support emergency response
laboratory activities that would be required for the rapid analysis of samples such as chemical
warfare agents.51 In another study, the Biodosimetry Laboratory in the State of Connecticut
identified 30 willing and qualified labs that could perform initial biodosimetry processing should
40

a radiological disaster occur.153 One study demonstrated the use of a unilateral external fixation
device for stabilizing musculoskeletal injuries prior to major surgery.154 Two studies examined
infectious disease control strategies within health care facilities. The first explored the feasibility
of repurposing existing space to serve highly infectious patients and described the conversion of
existing space within a health care facility into a temporary negative-pressure room through use
of portable, HEPA-filtered forced air.155 The second tested a cost-effective method of
establishing an airborne infection isolation area using a commercially available portable filtration
unit and basic hardware supplies.156

Crisis Standards of Care
A single study focused on crisis standards of care met our criteria for inclusion in the review.
The authors applied a decision support tool previously developed for ventilator allocation during
an influenza pandemic to evaluate ventilator allocation decisions during the Haitian earthquake
of 2010. The study used a case study design and assessed the allocation decisions made for five
pediatric victims of the earthquake.157

Proposed Strategies
We identified 17 additional articles that proposed strategies to help providers allocate scarce
resources during MCEs. These strategies have not been tested in the context of a real event,
exercise, drill, or simulation, but represent the consensus opinion of one or more national
professional organizations or task forces convened by the Federal government. The proposed
strategies reviewed here addressed two major activities: performance of pre-hospital (field)
triage and allocation of scarce resources in the hospital setting.

Prehospital Triage
National Association of EMS Physicians Workgroup
A national workgroup convened by multiple professional societies, provider organizations,
public health organizations, the CDC, and the National Highway Traffic Safety Administration
(NHTSA) reviewed nine existing mass casualty triage systems with the goal of recommending a
single, national standard.158, 159 The work group used elements from existing systems to develop
a new triage method known as SALT (Sort-Assess-Lifesaving Interventions-Treatment and/or
Transport) that could serve as an initial all-hazards triage method. Although this work group
ultimately endorsed the SALT triage system, it viewed it as “a beginning rather than final
product.”
This workgroup subsequently developed the Model Uniform Core Criteria for Mass Casualty
Triage to serve as a national guideline for mass casualty triage while enabling local flexibility in
implementation.160 The Core Criteria consist of four categories: general considerations, global
sorting, lifesaving interventions, and individual assessment of triage categories. Examples of
recommendations include withholding lifesaving interventions if the intervention is not within
the provider’s scope of practice, cannot be performed quickly (i.e., in less than 1 minute), or
requires the provider to stay with the patient. Criteria for individual assessment include using the
“dead” triage category for any patient not breathing after one attempt to open the patient’s
airway and to refrain from counting or timing vital signs during the initial assessment.

41

Scarce Resource Allocation in the Hospital Setting
IOM Committee on Guidance for Establishing Standards of Care for Use in
Disaster Situations
The 2009 IOM Letter Report called on health care providers, organizations, government
officials, and the public to approach the challenge of allocating scarce resources in MCEs in a
proactive and thoughtful way.13 The committee declared that such an effort should be grounded
in the principles of fairness; equitable processes; community and provider engagement,
education, and communication; and the rule of law. The committee called for the development of
“consistent crisis standard of care protocols within each State,” and expressed the hope that their
guidance could produce “a single, national framework for responding to crises in a fair,
equitable, and transparent matter.” The Letter Report outlined a comprehensive framework for
developing appropriate guidelines, based on an inclusive process and the best available medical
evidence. However, it did not offer concrete recommendations to policymakers or providers
about how they should make difficult resource allocation decisions under crisis standards of care.
Our review identified no additional consensus recommendations on crisis standards of care in
response to the Letter Report.
Task Force for Mass Critical Care
The task force developed a series of recommendations during the course of a summit meeting
on definitive care for the critically ill during disasters. We have included three papers containing
detailed recommendations. In the first paper, the Task Force developed recommendations on the
use of equipment and space for creating surge capacity during MCEs.161 It recommended the use
of one mechanical ventilator per patient (rather than the use of a multiple-limb ventilator
circuits)—numerous examples of which were reported in the previous section. It also produced a
list of ideal characteristics for stockpiled surge mechanical ventilators, recommended equipment
for surge PPV, and recommended non-respiratory medical equipment. In the event that ICUs,
post-anesthesia care units, and emergency departments have reached capacity, the Task Force
recommended the following treatment spaces (in order): (1) intermediate care units, step-down
units, and large procedure suites; (2) telemetry units; and (3) hospital wards. The Task Force
strongly discouraged the use of nonmedical facilities to serve as alternate care sites. Finally, the
Task Force endorsed a collaborative team model for staffing during critical care surge.
In the second paper, the Task Force proposed a bundle of seven services that comprise
emergency mass critical care (EMCC).162 Each of these services requires inexpensive equipment
and can be implemented without consuming extensive staff or hospital resources. The Task
Force also developed a framework for optimizing surge capacity that includes various activities
along a continuum from minimal patient need to overwhelming patient need and consists of 5
major types of activities: substitution, adaptation, conservation, reuse, and reallocation. The Task
Force also adopted a multi-tiered critical care surge capacity framework that delineated specific
triggers for escalation to higher tiers.
In the third paper, the Task Force presented a framework for resource allocation during
MCEs that included specific inclusion criteria for the receipt of medical or palliative care.163 The
inclusion criteria recommended by the Task Force are based on those developed by Christian et
al.164 Recommended exclusion criteria take into account both the Sequential Organ Failure
Assessment (SOFA) score and a patient’s chronic illnesses. The Task Force proposed a SOFA
score cutoff corresponding to an 80% risk of mortality, and it also enumerated the specific
chronic illnesses that should be used as exclusion criteria. The Task Force recommended
42

prioritizing patients in the order of their latest SOFA score and daily SOFA trend. Finally, the
Task Force described the recommended responsibilities of the triage officer and the
recommended composition of the triage team—a critical care nurse, respiratory therapist, and/or
clinical pharmacist.
Pediatric Mass Critical Care Task Force
The Task Force proposed minimum resource requirements for pediatric emergency mass
critical care 165 that are largely consistent with those developed by the Adult Task Force on
Emergency Mass Critical Care.161-163 The Task Force also developed specific recommendations
for non-pediatric hospitals, including a recommendation that adult ICUs keep adolescent patients
without consultation (and patients aged 5–8 years after consulting with pediatricians). The Task
Force was unable to recommend a pediatric prognostic scoring system to guide the triage of
pediatric MCE victims due to the poor performance of existing systems. Moreover, the Task
Force declined to endorse exclusion criteria for the use of life support based on pre-existing
conditions despite the fact that other groups have proposed such criteria. The Task Force was
also unable to develop recommendations on criteria for withdrawing life support for pediatric
patients during MCEs. Finally, the Task Force called for the development of a triage protocol
that not only took into account a patient’s likelihood of survival but also the likelihood that a
patient would require a prolonged ICU stay. (This latter point is a notable difference from the
adult recommendations that did not consider prolonged use of ICU resources).
Working Group on Emergency Mass Critical Care
This working group was convened by the Society of Critical Care Medicine and the Center
for Biosecurity at the University of Pittsburgh Medical Center. The work group recommended
that minimal requirements during crisis standards of care include: basic modes of mechanical
ventilation, hemodynamic support, antibiotic or other disease-specific countermeasure therapy,
and a minimum set of prophylactic interventions that can reduce the serious adverse
consequences of critical illness.166 The work group also emphasized that the goal of crisis
standards was to help the greatest number of people survive the crisis, and favored the use of
triage protocols rather than a first come first served model. Additional recommendations
included the personnel that should be involved with emergency mass critical care, the location
where care should be provided, and specific infection control practices.
Society of Critical Care Medicine Ethics Committee
The SCCM Ethics Committee recommended that resource allocation decisions for patients
with otherwise equivalent prognoses should be made on a “first come, first served” basis.167
Although the SCCM listed factors that should be considered when allocating ICU beds, such as
the likelihood of a successful outcome, the patient's remaining life expectancy, and the patient’s
anticipated quality of life, it did not provide specific inclusion/exclusion criteria for these
decisions. Ultimately, the SCCM Committee argued that “institutions should establish an explicit
mechanism for implementing policies to allocate ICU resources.”
American Thoracic Society Bioethics Task Force
The Task Force reached similar conclusions to those of the SCCM Ethics Committee168 It
emphasized that patients who continue to meet criteria for medical need and benefit should
continue to receive ICU care, even if new candidates for ICU admission have an even greater

43

potential for benefit. This task force went further and applied these same principles to all ICU
services, not simply the allocation of ventilators or ICU beds.
Other Recommendations
Other recommendations, such as those by the European Society of Intensive Care Medicine,
offer illustrative inclusion/exclusion ICU admission criteria but stop short of providing
recommendations.169 The Australasian Surge Strategy Working Group enumerated strategies
involving the use of space, staffing, supplies and equipment, and flow to optimize the ED
response to mass casualty events, but it did not specifically address crisis standards of care,
noting that this effort was “beyond the scope of [their] paper.”170 Similarly, other articles
specified objectives for disaster preparedness and response, but not a path to achieving them. For
example, the CDC convened an interdisciplinary panel of experts to develop strategies to assure
surge capacity for sudden MCEs, particularly terrorist bombings.171 The effort culminated in the
development of “surge action templates” tailored to ten distinct disciplines to address known
challenges. The EMS template, for example, calls on local EMS organizations to “describe in a
plan how alternative transport for 200 ambulatory patients will be initiated in the first 10 minutes
after an explosion.” But it does not offer guidance on how to accomplish these objectives.
Another study focused specifically on appropriate use of immunization and postexposure
prophylaxis for tetanus and occupational and non-occupational exposures to bloodborne
pathogens during mass casualty events.172 However, the recommendations did not directly
address altered standards of care when vaccines are in short supply. The European Society of
Intensive Care Medicine’s Task Force for Intensive Care Unit Triage also provided
recommendations and standard operating procedures for patient and staff prophylaxis during a
pandemic.173. Finally, In 2007, the American Medical Association and American Public Health
Association jointly released a set of eight goals for expanding health system surge capacity.174

Key Question 3: What Are the Public’s Concerns Regarding Strategies to
Allocate Scarce Resources?
What are the public’s key perceptions and concerns (e.g., values, equity, transparency,
communication, and public input) regarding the development and implementation of strategies to
allocate and manage scarce resources during both actual and potential MCEs?

Key Points
The evidence across studies is relatively consistent in supporting the following concepts:
• A successful allocation system should balance the goals of ensuring the functioning of
society, saving the greatest number of people, protecting at-risk populations, reducing
deaths and hospitalizations, and treating people fairly and equitably.
• Multiple criteria are used to prioritize recipients of resources during an MCE. Health care
professionals, health care workers, and first responders were among the highest priority
groups; politicians were among the lowest.
• High priority should be given to children and young adults for receipt of care.
• Prioritization criteria should not be based on ability to pay, “first come, first served,” or
random selection (lottery system).
• The public has a high degree of faith and trust in medical professionals to make
appropriate allocation decisions based on their expert opinions.

44

•

Resource allocation guidelines should be generally consistent, but should allow health
care institutions some degree of flexibility to make allocation decisions based on their
specific demand and supply situation.

Description of Included Studies
Our search identified ten studies that addressed this Key Question.175-181, 182-184b Six studies
were conducted in seven different U.S. States (Georgia, Massachusetts, Minnesota,
Nebraska, Oregon, Washington, and Louisiana); two studies were conducted in Australia,175, 176
and one each in Canada181 and Brazil183. Seven studies reported public opinions related to
pandemic influenza, while three177, 183, 184 did not involve a specific MCE context. Two basic
approaches were used to solicit public opinions: (1) public engagement activities in various
forms, such as deliberative meetings, community forums, and small group discussions; and (2)
surveys, including web-based questionnaires, telephone surveys, and solicitation of written
comments.
The number of citizens participating in the studies ranged from fewer than 10 to more than
5,000; public engagement forums (sample size 9–441) involved fewer participants in general but
generated substantially more in-depth discussions among participants. As a result, public
engagement activities provided substantially more detailed information than surveys, although
the latter were more broad-based (sample sizes 1,030–5,220).
177-180182

Detailed Synthesis
A wide range of issues were discussed regarding public opinions on policies and strategies to
allocate and manage scarce medical resources during an MCE. The ten papers all addressed at
least one of two main themes: development of resource allocation policy and criteria for who
should receive treatment under crisis standards of care. Resource allocation policy covered the
public’s perceptions about allocation systems in general such as whether or not resource
allocation guidelines were needed; what goals the allocation system should achieve; who should
make allocation decisions; and what role the Federal and State governments should play in
developing, managing, and implementing such a system. Priority criteria reflected the public’s
views of which groups should be considered high versus low priority for receiving scarce
medical resources during an MCE.
We rated the overall strength of evidence for these studies as medium (Table 7). Because of
the limited number of studies addressing the question, and because four were from outside the
United States, we rated the risk of bias for the set of results as medium. The evidence from the
seven forums and three surveys was remarkably consistent, and, by construction, the evidence
was derived directly from the public (indirect reports of public opinion were excluded). Because
much of the evidence comprised rankings and consensus opinions, we could not meaningfully
evaluate the precision of the results. Key themes arising from public engagement activities are
summarized below.
b

Doctor, 2011175. Docter SP, Street J, Braunack-Mayer AJ, et al. Public perceptions of pandemic influenza
resource allocation: A deliberative forum using Grid/Group analysis. J Public Health Policy. 2011 Jan 13PMID
21228887. and Braunack-Mayer, 2010176. Braunack-Mayer AJ, Street JM, Rogers WA, et al. Including the public
in pandemic planning: a deliberative approach. BMC Public Health. 2010;10:501. PMID 20718996. reported data
from the same public engagement activities. Since they had slightly different focuses of the data reported, we
included them both.

45

Allocation Guidelines
The public agreed that MCEs are highly unusual situations that require decision-making
processes and protocols different from those used in normal clinical circumstances. They
stressed the need to proactively establish allocation standards or guidelines that will be followed
by health care facilities and other providers. Participants generally felt that it will be important to
take into consideration the different capacities that each region or facility might have, as well as
different service demands they might face. Thus, although they widely agreed that guidelines for
crisis standards of care should be generally consistent across health care facilities, they believed
that institutions should have some degree of flexibility to make allocation decisions based on
their specific demand and supply situation. Participants also agreed that guidelines should be
relatively simple so that they could be successfully implemented.180

Goals of Allocation Systems
Participants in these forums listed several goals for a successful resource allocation system:
ensuring the functioning of society, saving the greatest number of people, protecting at-risk
populations, reducing deaths and hospitalizations, and treating people fairly and equitably.
Some participants preferred one goal over another, but one study found that many
participants showed some degree of internal conflict when weighing different goals.181 Other
participants suggested a balance of objectives.179 When forced to choose only one goal,
participants explicitly stated that they would choose ensuring the function of society in the long
run.176 To achieve the goals, most participants agreed that certain compromises might have to be
made. For example, seeking to save the greatest number of people might result in lowered
standards of care.180

Allocation Decisionmakers and the Role of Government
Across most studies, the public showed a high degree of faith and trust in medical
professionals to make appropriate allocation decisions based on their expert opinions. They
believed that health care professionals and experts were essential to ensure a fair and effective
allocation system. Some participants preferred a joint committee consisting of a variety of
experts and policymakers (but not politicians) elected by their peers.175 The public expressed a
lack of trust in elected or appointed representatives and politicians without public health
qualifications to make health resource allocation decisions.
Participants in the Public Engagement Pilot Project on Pandemic Influenza study suggested
that the role of the Federal government should be to provide broad guidance, while
responsibilities for interpreting and implementing the guidance should remain at the State and
local level.178

Prioritization Criteria
Although the underlying rationale of prioritization has always been to ensure the best use of
limited resources without capricious discrimination, participants used mixed criteria to prioritize
recipients of resources during an MCE. Given different situations, participants expressed their
preferences for a range of criteria, including the individual’s role in society (e.g., occupation),
equity, survivability (the number of years a person would live if they are treated and survive),
vulnerability, risk of exposure, and likelihood of recovery. Below, we summarize the key
considerations raised by the public regarding each criterion.
46

“Role in Society” Criterion
A majority of participants across studies seemed to accept the criterion of ranking people
based on their role in maintaining a properly functioning society. Professionals and health
workers were always among the groups given highest priority to ensure an adequate workforce
for providing continuous services to all people. For the same reason, first responders, essential
services (e.g., power, water, electricity, gas), and military personnel were also listed as priority
groups by many participants. This prioritization seemed to reflect the public’s perception that a
successful allocation system should assure the functioning of society. However, one problem
with this criterion, as pointed out by some other participants, was that it was not always easy to
assess an individual’s “value” to society because individuals contribute to society in different
ways.

“Equity” Criterion
Equity was a somewhat expected criterion, given America’s egalitarian nature and the role of
equity concerns in public health in general. All participants in all studies unanimously agreed
that decisions based on race, gender, culture, legal status, nationality, language, or income were
unacceptable; prioritization based on age seemed to favor children and young people over the
elderly. The elderly were not generally perceived as a priority group, although a small proportion
of participants expressed the belief that all age groups should be equally valued and valuable.179
Together with chronically ill and disabled people, the elderly were perceived by some
participants as “not contributors to a future society” and therefore were accorded lower priority
for receipt of scarce health care resources.175 In fact, some participants in one study supported a
policy that would “de-prioritize” persons more than 85 years of age.179
In contrast, many participants listed children and young adults as priority groups. For
example, in a study from Australia, priority was given to children and young people aged 2–30,
because “they are the future.”176 In the United States, children and pregnant women were
prioritized, although to a lesser degree than health care professionals and health workers.180
Findings from a nationwide telephone survey conducted by the American Academy of Pediatrics
highlighted the significant lack of medications for children during disasters.177 A majority of
respondents in the studies we reviewed supported giving higher priority to children who need
life-saving treatment.

“Survivability” Criterion
Many participants expressed the belief that patients’ survivability should be considered and
that health care providers should be the ones to make allocation decisions accordingly. They
argued that allocation of significant resources to an individual with low probability of survival is
a suboptimal use of limited resources, regardless of the importance of that individual’s role in
society.180

Other Findings Related to Prioritization
Political decision makers were generally among the groups accorded the lowest priority,
mainly due to lack of public trust and public suspicion that they would misuse their authority.
Participants raised the issue that improving transparency of decision-making processes and
funding streams and providing more information to the public could be important tools to gain
the public’s trust.

47

A few prioritization methods were rejected by most participants. These methods included
decisions based on ability to pay, “first come, first served,” and random selection via a lottery
system.
Another interesting finding was that some participants changed their priority decisions when
those choices were reassessed in follow-up surveys, implying that their opinions could be
influenced by the process of group deliberation, as well as by exposure to public briefings by
experts. Data from the King County post-forum survey showed that many participants had
shifted their opinions during the time between the forum and the post-forum survey.180 For
example, the percentage of participants who considered children and pregnant women to be a
high-priority group dropped from 71 percent during the forum to 40 percent after the forum.

Special Concerns of At-Risk Participants
Few studies separately reported public opinions on resource allocation regarding at-risk
populations (e.g., minority groups, frail elderly). In most instances, members of these groups
were actively recruited and included in the discussions. The only notable finding was from a
public engagement forum in Seattle and King County, Washington, where Hispanic participants
voiced much stronger opinions about prioritizing children and pregnant women than did nonHispanic participants (70 percent indicating that children and pregnant women should be a
priority vs. 27 percent of non-Hispanics). They also emphasized the needs of minorities and
immigrant populations.

Other Relevant Findings
The public’s perceptions and concerns about medical resource allocation during an MCE did
not always agree with those of policymakers, public health experts, or other stakeholders. Some
doubted how much their concerns and perceptions would be taken into account in establishing a
disaster plan. But in other cases, the public and health policymakers shared the same opinions.
For example, in Australia, the priority groups selected by the public (health care workers and
other functioning groups) based on the criterion of “the need to maintain functioning of critical
infrastructure” corresponded to those outlined in the national pandemic plan.176 In Minnesota, a
majority of the participants agreed on the three resource rationing objectives proposed by expert
panels (reduce deaths, treat people fairly, and protect public health and infrastructure).179
However, other studies showed some nuanced differences in perspectives between the general
public and experts or other stakeholders. For example, the King County study found that while
the goals of prioritization were similar, experts tended to focus on maximizing resources by
assessing survivability and saving the greatest number of people, and the public appeared to
focus more on response capabilities by prioritizing health care workers and first responders.
It was notable that participants generally did not choose prioritization strategies that
specifically favored themselves or their families. For example, the study in Canada found that
participants who had children themselves did not necessarily give priority to children: Only 9.7
percent of participants who had children preferred the child-focused priority plans.181 Similarly,
in the Minnesota public engagement project, which focused on prioritization for socially
vulnerable groups, members of these groups seldom chose to prioritize themselves, but rather
were more likely to prioritize groups associated with critical infrastructures.182 Fear of stigma
following the implementation of such a policy was one of the main reasons cited by these
representatives.

48

Participants acknowledged that an MCE is a difficult situation that would affect everybody.
Some suggested that the number of pharmaceutical manufacturers should be increased to
produce more supplies to meet the needs of an influenza pandemic. Others urged that in an MCE
when medical resources were scarce and difficult allocation decisions must be made, more
communication, information, education, and training would be needed to prepare the public.178
Some participants reported that they would be willing to accept some increase in their income
taxes now as a form of insurance against an inadequate response to a future disaster.176
Table 7. Strength of evidence for Key Question 3
Strategies

Risk of Bias

Consistency

Directness

Precision

SOE Grade

Public engagement
(forums and surveys)

Medium

Consistent

Direct

N/A

Medium

Key Question 4: What Methods Are Available To Engage Providers in
Developing Strategies To Allocate Scarce Resources During MCEs?
What current and proposed methods are available to engage providers in discussions
regarding the development and implementation of strategies to allocate and manage scarce
resources both in planning for and during an MCE? What outcomes are associated with these
strategies? What factors are identified as facilitators or barriers to engaging providers in these
discussions?

Key Points
•

•

•

•
•
•

Nearly all studies described successful engagement strategies that involved multiple
stakeholders and employed an inclusive, systematic, and often iterative process for
reaching decisions or crafting a final plan. The articles we reviewed did not clearly
identify one approach as superior to the others.
Engagement strategies varied by type of policymaker, provider, and range and mix of
participants. Engagement strategies addressed planning for scarce resource allocation at
different jurisdictional levels, ranging from local to regional, State, and even interstate
levels.
Most engagement strategies were not specific to a particular type of disaster or to any
single broad category of adaptive strategy for scarce resource allocation. However, only 5
of 14 studies addressed the development of strategies for implementing crisis standards of
care.
Only 2 of 14 studies described an engagement process that included the public.
Provider engagement was led both by providers and by local or State government
officials. The latter often did so in partnership with other institutions, including academic
institutions.
Technical (e.g., clinical) experts and health leaders both led and participated in provider
engagement strategies, adding credibility to the engagement process and the resulting
plan, protocol, framework, or strategy.

49

Description of Included Studies
The 14 studies included in this part of the review address a wide range of planning activities
and exercises with the goal of developing resource allocation strategies for MCEs. Many
engagement activities involved a combination of adaptive strategies for resource allocation, but
fewer than half of the studies (5) addressed the implementation of crisis standards of care. Six
studies reported the results of engagement activities led by providers, while seven studies
reported on those led or co-led by policymakers. One study reviewed planning models that
included both provider-led and public health department-led engagement models.
All 14 studies took place in the United States but reflected broad geographic diversity: 11
studies described local-, regional-, or State-level planning in urban or rural settings in 16
different, specified States. Two studies were carried out in multiple, unspecified locations. One
study drew experts from across the country.
Nearly half of the studies (6) did not specify the type of MCE to which planning activities or
exercises were oriented. Among the remaining 8 studies, 4 addressed pandemic influenza
preparedness, 2 addressed all-hazards preparedness, 1 addressed biological threats of various
types, and 1 addressed radiological or nuclear threats. Of the 14 included studies, 11 were largely
descriptive, while 3 were intervention studies with at least one post-test measurement.
All engagement strategies involved multiple stakeholders and systematic, often iterative,
consensus building to undertake planning or multi-party exercises. Different studies described
planning at the local, intrastate regional or county, State, or interstate level. Nearly all studies
described engagement of hospitals—often by other hospitals. State and/or local public health
departments were also included in most, though not all, studies. Leaders of engagement
processes, commonly in partnership, included hospitals, State or local public health departments,
academic institutions, intrastate or interstate regional entities, and de novo planning entities. The
range of providers who were targeted by engagement strategies included professional staff in
general or specialty hospitals, clinics, community health centers, pharmacy departments,
laboratories, and front-line health care workers (e.g., emergency medical technicians). Although
most of the studies described well established engagement strategies, some described more novel
strategies. Of note, only 2 of 14 studies included public representation as part of the engagement
process.179, 185 A summary of strategies addressing Key Question 4 is located in Table 8.

Detailed Synthesis
Nearly all studies described a successful engagement process that led to one or more
desirable outcomes, including the development of resource allocation plans, training, or a
commitment of resources. Synthesizing the evidence for Key Question 4 was challenging
because of the nature of this question (related to provider engagement methods, rather than
testing of the resource allocation strategies developed as a result of the engagement process) and
the variability in study focus. However, several facilitators and barriers emerged as general
themes across multiple studies.

50

Table 8. Summary of strategies addressing Key Question 4, by category
Strategies

Strategies led by
providers

Strategies led or
co-led by
policymakers

Enrollment, education, training, and exercise of qualified laboratory staff for preparing
biodosimetry specimens
Organization of de novo regional hospital planning group
Alternative planning models (Decentralized regional planning, Hospital-directed tiered
regional planning model, Third-party directed planning model)
Development of consensus on appropriate pediatric crisis standards of care
Development of evidence-based “reverse triage” classification system
Pilot testing of local-, regional-, and national-level tabletop exercises for the Veterans Health
Administration (VHA)
Pharmacy-led development of regional pharmaceutical preparedness policies and
procedures
Public health/business partnership for mass dispensing
Development and pilot testing of tabletop exercise template for local level governments and
providers
Organization of neighboring States into a voluntary disaster surge network
State or local public health department planning model, including development of mutual aid
agreements
Incorporation of community health centers into surge plan, with training for CHCs and three
event-based tests
Developing proposed ethical frameworks and procedures for rationing scarce health
resources within a State (2 studies)
Broadly inclusive regional hospital level planning process to identify surge beds

Common facilitators of provider engagement strategies included the personal relationships
established, the willing commitment of actors to participate in cooperative planning, the iterative
and broadly inclusive engagement of key stakeholders, and the technical excellence and
credibility of partner institutions or experts. Some papers referred to barriers stemming from the
differences in the organizational cultures of collaborating partners, such as public health and
hospitals186 or public health and business.187 Other barriers related to the long time required to
build critical relationships,188 government regulations,187, 189 the complexity of interstate
agreements,188 and the variability across facilities or other differences that impede a “one size fits
all” approach.179, 190
We rated the overall strength of evidence for Key Question 4 as medium (Table 9). The risk
of bias was medium, given the high likelihood for publication bias (unfavorable engagement
strategies may be significantly less likely to be published). While the evidence on the
effectiveness of the engagement models was consistently positive, it was indirect because the
studies did not report how implementation of the strategies developed from the engagement
process affected population health outcomes. We could not assess precision, given the qualitative
nature of the evidence.
No study appeared to be highly unique to the site where it was carried out; however, the
applicability of the evidence may be somewhat limited to the contexts described in each study.
Most of the studies were at least moderately dependent on the scale of the MCE, such as the
public health–business partnership to dispense medical countermeasures and the different
approaches to optimize or augment resources through the use of existing personnel, health
centers, laboratories, or pharmacy departments to provide surge medical resources. All strategies
related to crisis standards of care were very dependent on scale of the MCE.
Below we summarize the key results according to whether providers or policymakers led or
co-led the engagement process.

51

Engagement Strategies Led by Providers
Individual providers tended to engage other providers to develop highly technical or
clinically oriented resource allocation strategies. For example, one study described how
academic medical leaders engaged clinician and non-clinician experts to develop a 5-category
classification system for “reverse triage” of hospital inpatients, based on their agreement about
varying levels of risk tolerance for major medical consequences.191 In another study, hospital
pediatric leaders engaged other acute care pediatricians from across the country to develop
pediatric crisis standards of care.189
Two studies described more novel engagement approaches. In these instances, the providers
who initiated the engagement represented ancillary clinical services, such as the laboratory and
pharmacy department. In one study, the State biodosimetry laboratory engaged all public and
commercial laboratories in the State to assess and support development of additional capacity to
prepare laboratory specimens for diagnosis of radiation exposure following a major nuclear or
radiological event.153 In the other study, the pharmacy department of a hospital helped lead
development of a regional mass casualty “pharmaceutical preparedness” plan, including
pharmaceutical resource sharing among regional providers.192
Institutional providers such as hospitals engaged other institutional providers in medical
surge planning. In one study, an entirely new planning institute was created: Four unaffiliated
hospitals in Brooklyn engaged the New York City Department of Health to organize the “New
York Institute of All-Hazards Preparedness,” which in turn engaged individual hospitals to work
together to identify enough surge beds to meet national standards across the region as a whole.193
Another study presented extant U.S. models for medical surge planning. Florida and Louisiana
reflect decentralized planning models in which hospitals and the State hospital association
engage other hospitals in surge planning.186 The same study described the decentralized rural
surge planning process in Oregon, in which a regional medical center engaged other hospitals in
surge planning. This study also described hospital-directed tiered regional planning models in
Illinois, Louisiana, and Missouri. In these States, a designated regional hospital engaged other
hospitals in surge planning.
A particularly interesting model is that of the Veterans Health Administration (VHA),
because it is both a very large provider (the largest integrated health care delivery system in the
United States) and a Federal policymaker. One study described a series of pilot tabletop
exercises for the local, regional, and national levels of the VHA system, in which the VHA
engaged other local and regional providers, as well as local and State public health departments
and first responders.194

Engagement Strategies Led or Co-Led by Policymakers
With the exception of the VHA study just noted, government-led engagement strategies were
largely at the State and local government level. In most instances, State or local public health
departments partnered with other institutions, such as academic medical centers, to engage other
providers in planning for scarce resource allocation. Some studies described engagement
strategies involving the traditional and typically large range of partners, while others described
more novel partnerships. For example, the case study compilation of planning models describes
the top-down county planning model with master (State-level) mutual aid agreement exemplified
by California and Illinois, and the third-party-directed planning model of Missouri, where the
State’s health department and a designated hospital engaged other hospitals in surge planning.186

52

Another traditional example is Boston’s public health department and the State primary care
association. Working together, they engaged hospitals, community health centers (CHCs), and
the emergency medical system in planning that added CHCs to the city’s medical surge plan; the
city health department then engaged the Harvard School of Public Health to provide training and
exercises for CHCs. This plan was subsequently tested in three actual events: preparation for the
Democratic National Convention and the public health investigation of two disease outbreaks.190
In another study from Massachusetts, the State’s public health department and a partner
academic institution engaged a wide range of institutional health care providers, other health
agencies, and the general public in developing consensus State-level guidelines and a decisionmaking protocol for crisis standards of care.185 In 2004, RAND Corporation, in conjunction with
local public health departments used tabletop exercise templates that could be locally customized
to assess the strength of relationships between local public health agencies and local delivery
systems when faced with a hypothetical pandemic flu emergency.195
Another study described a similarly inclusive planning process in Utah, in which the State
health department and university medical center engaged multiple hospital and non-hospital
facilities, professional associations, local public health departments, transit, EMS, and church
groups in an iterative process to develop a regional medical surge plan.196 Yet another study
described the initiative of two State health departments and the regional public health
preparedness center in engaging pediatric hospitals, major pediatric clinics, State public health
departments, and emergency responders into a five-State voluntary pediatric surge network; in
doing so, they created a network, an operational handbook, and a formal memorandum of
understanding.188
Examples of less traditional approaches include the partnership of a State government
(Minnesota), a State university, and a health care ethics center to engage local governments,
experts, the general public, and a few hospitals and clinics in developing proposed ethical
frameworks and procedures for rationing scarce medical resources within the State during an
influenza pandemic.179 Another study described a public health–business partnership in Georgia
that engaged providers from the public and business side to refine approaches to, and expand
sites for, mass dispensing of medical countermeasures.187
Table 9. Strength of evidence for Key Question 4
Strategies
All strategies led by
providers or
policymakers

Risk of Bias

Consistency

Directness

Precision

SOE Grade

Medium

Consistent

Indirect

N/A

Medium

Analysis of State Reports
The IOM Letter Report13 called for development of “consistent crisis standards of care
protocols” within each State, with neighboring States, and in collaboration with public and
private sector partners. The Letter Report went on to recommend that each crisis standards of
care protocol address five key elements:
1. A strong ethical grounding

53

2. Integrated and ongoing community and provider engagement, education, and
communication
3. Assurances regarding legal authority and environment
4. Clear indicators, triggers, and lines of responsibility
5. Evidence-based clinical processes and operations.
We reviewed a set of existing State plans to identify and describe the strategies developed by
States to allocate scarce resources during MCEs. The majority of these State plans, plus Guam,
(N=23 States) were compiled as part of the research that contributed to the IOM Letter Report
and were forwarded to us by AHRQ. However, several of the documents we received did not
qualify as a formal State plan or did not directly address the issue of scarce resources. We
identified two additional State plans—New York and Wisconsin—through a search of the
references in the plans we received. When States had multiple plans for different MCE contexts,
we synthesized their content to give the reader a sense of the totality of the State’s strategies.
Ultimately, we reviewed plans from 11 States and one U.S. territory. Collectively, these plans
provide an important window into the current status of State planning and the specific resource
allocation strategies that will be used in response to an MCE.
In general, the strategies outlined in the State plans fit into the same four categories of
adaptive strategies used to guide our CER. These include (1) early actions to reduce or divert
less-urgent demand for health care services; (2) steps to optimize use of existing resources; (3)
efforts to augment existing resources; and finally, if and when these measures prove to be
inadequate to meet demonstrable need, (4) the ability 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. In cases where strategies might be classified in multiple
categories, we explain the rationale for our choice.
In the sections that follow, we qualitatively summarize how these recurring strategies and
themes were addressed across States with plans, plus Guam. Table 10 displays specific elements
of the various plans on a State-by-State basis.

Reduce Less-Urgent Demand for Medical Resources
The State plans we reviewed described several proposed strategies to reduce demand on the
health care system during MCEs. Their strategies followed two basic approaches: keep noncritical patients out of the hospital, and, in the case of an infectious disease outbreak, urge non-ill
members of the public to self-quarantine through social distancing.

Keep Noncritical Patients Out of the Hospital
The State of California, in particular, has devoted considerable attention to strategies to
reduce demand for services that could be provided outside of hospital settings. The State plans
indicate that all elective surgeries should be canceled so medical staff can refocus their energies
and other key resources on patients who require urgent care, and to keep healthy patients away
from those who may be contaminated.197, 198 Although the cancellation of elective surgeries
might alleviate demand to a limited degree, a substantial MCE will likely necessitate further
measures to ensure that sufficient supplies, staff, and facilities are available to treat critically ill
or injured patients. Therefore the plan argues that non-critical care (e.g., first aid, primary care)
could be safely and efficiently provided in off-premises facilities, such as community clinics or
temporary health care facilities to reduce the demand on hospital resources.199-202
54

Encourage the Public to Self-Quarantine (Social Distancing)
For certain infectious disease outbreaks, such as an influenza pandemic, a few States201, 202
discussed measures to impede or delay disease transmission by encouraging the public to selfquarantine. Specific strategies included encouraging employers to allow their employees to
telecommute, closing schools, and educating the public regarding easily implementable nonpharmaceutical interventions, such as wearing a facemask.

Optimize Existing Resources
Nine of the 12 plans we reviewed recommended strategies to leverage the most benefit from
existing health care resources, including staff, stuff (i.e., supplies) and structure.

Repurpose Existing Resources
Several States incorporated a range of approaches to increase bed capacity in their plans,
including repurposing nonpatient care space for patient care, establishing temporary health care
facilities such as tent hospitals, and “freeing up” space through early discharge of stable patients.
Three of 12 States suggested repurposing space by converting overflow space and non-patient
care areas (e.g., waiting rooms) into patient care areas or using outpatient areas for inpatient
care.197, 199 One of the plans recommended enhancing capacity by converting single-occupancy
rooms to accommodate two or three patients.199 Another option described in one of the California
State plans is to triage ventilator-dependent patients directly to step-down units.199 Lastly,
preserving bed capacity might be accomplished by canceling elective surgeries and limiting
those that are done to “life or limb” situations in order to facilitate discharge.203

Optimize Use of Space
Several State plans recommend optimizing the use of space by establishing temporary health
care facilities in non–health care settings.198, 204 Alternatively, California and Guam plan to
expand bed capacity through strategies such as “reverse triage” that either allow for early
discharge of stable patients from the emergency room or the hospital or that persuade outside
facilities, such as long-term care units, to accept lower-acuity patients in transfer.197, 205 Load
balancing by distributing care across a region (e.g., mutual aid) is another common approach to
optimize the use of space within individual facilities. Plans in several States recognized that
morgue capacity could be exceeded and call for the establishment of temporary morgues in
certain scenarios.197, 198, 205

Use Health Care Providers and Nonmedical Staff More Efficiently
During MCEs, medical and nursing staff are likely to quickly become limited resources.
State plans described five strategies involving staffing, including the shifting of duties and
priorities, to accommodate potentially large and rapidly growing patient populations. Several
State plans recommend increasing nursing shift duration (from 8 to 12 hours or from 12 to 16
hours) as well as increasing provider-to-patient ratios to extend the reach of available
personnel.197, 198, 205 Cross-training staff through “just-in-time” training might allow for more
staffing flexibility.205, 206 Examples of potential uses of this strategy during an influenza
pandemic include training health care professionals who are not respiratory therapists to provide
basic respiratory care, including ventilator management (Project XTREME), or teaching
emergency medical services (EMS) personnel to administer vaccines.198 In addition, non-health
care personnel could be deputized to carry out essential non-clinical functions and free up
55

nursing staff.197 During a pandemic, cohorting patients having similar ailments in a single ward
or facility may allow specially trained staff to provide care more efficiently and effectively.197
Finally, relaxing the requirements for medical documentation may enable staff to focus on
patient care or other higher-priority duties.197

Triage
Florida’s prehospital triage strategy indicates that the State’s hospitals are using or
implementing standard triage strategies, including Simple Triage and Rapid Treatment
(START).207 JumpSTART extends the concept of a standardized triage to children. Florida’s
plan also mentions an alternative triage system called the START2Finish® Surge Capacity
Response Model for Healthcare. This model focuses on optimizing allocation of labor, supplies,
and space during an MCE.207 In a similar vein, Utah has devised State-level Pandemic Influenza
Hospital and ICU Triage Guidelines to systematically match patients to appropriate levels of
resources based on their need in order to preserve bed capacity and oxygen capacity, limit or stop
elective surgeries, and maximize available personnel to care for victims of a future flu
pandemic.203

Substitute Effective Alternatives
Plans in two States, Wisconsin and Minnesota, focus on reuse or substitution methods to
optimize available resources. Wisconsin, in its “Oxygen Conservation Strategies in ResourceLimited Situations” plan, recommends several detailed methods for conserving medical oxygen:
(1) Discontinue high-flow applications, such as restricting the use of Simple Mask and partial
rebreather to 10 Ipm; (2) decrease the number of inhalation medication applications or restrict
continuous nebulization therapy; (3) maximize reuse of expendable oxygen appliances, including
disinfecting via high-level procedures (bleach concentrations of 1:10; high-level chemical
disinfection or irradiation if available); and (4) terminally sterilize ventilator circuits, as well as
low- and high-bore tubing.206, 208 Minnesota’s State plan includes similar strategies but also
recommends substituting oral or nasogastric hydration for intravenous hydration or substituting
epinephrine for vasopressor if the need arises.

Strategies To Augment Existing Resources
Increase Reserves and Stockpiles
Several State plans incorporated strategies to draw on equipment, supplies, drugs, and
personnel held in reserve or stockpiled for such contingencies or to secure these resources from
other States or institutions that are not experiencing surge conditions. These strategies included
the use of mutual aid agreements, and coordination with outside agencies, such as the American
Red Cross and the Medical Reserve Corps.
One of California’s plans recommends stockpiling supplies at 20 to 25 percent above
conventional levels to last for at least the first 72 hours (ideally, 96 hours) of an MCE.197 Other
plans recommend inventories or plans to increase critical supplies to assess considerations for
stockpiling, such as ventilators and critical medications.199, 205 Several State plans call for
accessing either drug caches (antibiotics, antivirals) or supplies from the Strategic National
Stockpiles (SNS).197, 206, 209, 210

56

Mutual Aid Agreements
Mutual aid agreements are key elements of several California plans as well as one from
Washington.197, 200, 210-212 Other partnerships that can augment personnel include volunteer
clinical staff, such as the California Medical Assistance Team (CalMAT), federal Disaster
Medical Assistance Teams (DMATs), Emergency System for Advance Registration of Volunteer
Health Professionals (ESAR VHP), Colorado’s Volunteer Mobilizer (CVM) for Medical and
Public Health (CDPHE), the American Red Cross, and the federal Medical Reserve Corps
(MRCs).197, 198, 200, 205

Adopt Crisis Standards of Care
All of the State plans we reviewed addressed general parameters for the shift to crisis
standards of care. Most commented on the following elements:

Define Priority Groups
The first step in defining crisis standards of care is to identify priority groups for certain
types of resources. For example, several States, including Nevada, California, and North Dakota,
discuss the protocol for allocating antiviral agents during a pandemic flu outbreak.204, 209, 210 The
priority groups include those at the highest risk for infection, such as medical personnel, young
children, pregnant women, and the elderly.

Be Prepared To Provide Comfort Care
In the event that lifesaving resources cannot be allocated to patients who need them, either
because they are unavailable or because the patient has a low probability of survival, experts
agree that protocols should be put in place to ensure that these patients are made as comfortable
as possible. Only a single State mentioned comfort care in the plans we reviewed. California has
noted the importance of this issue in their Enhancing Surge Capacity and Partnership Effort
(ESCAPE) Crisis Care Guidelines plan, developed by the University of California, Davis, Health
Systems.204

Allocate Resources Under Crisis Standards of Care
Some State plans offer guidance on how to allocate critical resources under crisis standards
of care. For example, Minnesota and New York have plans to allocate certain medical equipment
and supplies by patient prognosis, using triage methods such as the Sequential Organ Failure
Assessment score (SOFA) and a tool based on the recommendations of the Ontario Health Plan
for an Influenza Pandemic (OHPIP).206, 213 Many of these strategies focus on the distribution of
mechanical ventilators, advocating that assignment (and in some cases reallocation) of
ventilators should be directed toward those patients who are most likely to benefit. New York’s
draft plan for ventilator allocation was cited by several other State plans when they convened a
working group to study this issue.206 Nevertheless, although all of the State plans reference the
need for crisis standards of care, few have articulated guidelines or cited published evidence to
support provider decisions.

57

Table 10. Key elements of State Plans
Keep NonCritical
Encourage
Patients out
the Public to Triage
of the
SelfHospital
Quarantine
Emergency
Departments
Strategies To Reduce
Demand

Use Health
Care
Providers
and NonMedical
Staff More
Efficiently

Balance
Increase
the Load Re-Purpose Substitute
Negotiate
Reserves
Across
Existing
Effective
Mutual Aid
and
Different Resources Alternatives
Agreements
Stockpiles
Facilities

Strategies To Augment Existing
Resources

Optimize Existing Resources

Arizona
California

x

x

x

x

Colorado

x

x

x

x

Florida

x

Guam
Minnesota

x

x

Nevada

x

x

x

x

x

x

x

Crisis Standards of Care

x
x

x

x

x

x

x

x

x

x

x

x
x
x

North Dakota

Washington

x

x

New York

Utah

x

x

x
x

Define
Priority
Groups

Be
Prepared Adopt
to
Crisis
Provide Standard
Comfort of Care
Care

x
x

x

x
x

x

x
x

x

x

Wisconsin

x

58

x

x
x

Discussion
The United States faces a wide range of threats to its health security. The tragic events of
September 11, 2001, and the subsequent anthrax attacks highlight the ongoing danger of
terrorism. In the decade following the September 11, 2001, attacks, the major mass-casualty
events on U.S. soil involved natural disasters, such as hurricanes Katrina and Rita, and naturally
emerging biological threats, such as SARS and 2009 H1N1 influenza. The recent earthquakes
that claimed so many lives around the world remind us that temblors of sufficient magnitude can
cause widespread loss of life, even in highly developed nations, such as Chile, New Zealand, and
Japan.
The predominant belief among authorities is that it is only a matter of time before a major
natural or man-made disaster outstrips the capacity of our health care system to respond.
Whether the incident is local, regional, or national in scope, the common denominator is a stark
imbalance between immediate needs and existing resources, such as personnel, supplies,
medications, and/or equipment at the incident site. When an MCE occurs, first responders,
physicians, nurses, and other health care providers will be forced to make extremely difficult
decisions about the delivery of care in the most demanding of circumstances with significant
clinical, legal, and ethical ramifications. Therefore, strategies to allocate and manage scarce
resources in mass casualty events (MCEs) must be founded in rigorous scientific scrutiny,
grounded in empirical evidence, and thoughtfully considered before they are implemented. This
is the context that led the Office of the Assistant Secretary for Preparedness and Response
(ASPR) to request the Agency for Healthcare Quality and Research (AHRQ) to commission this
comparative effectiveness review.

Key Findings
At the current time, there is limited evidence to help policymakers select the most effective
strategies to allocate scarce resources during MCEs. However, although the evidence is largely
not definitive, there are some specific strategies that appear promising. It is generally accepted
that rapid deployment of biological countermeasures, such as mass vaccinations, mass
dispensing of antivirals, or the rapid distribution of prophylactic antibiotics, could reduce
demand for health care resources in the immediate aftermath of a bioterror attack or pandemic.
There is low- to medium-strength evidence that a “push” method to deliver medications, such as
via U.S. Postal Service letter carriers, is more effective than conventional approaches that seek to
“pull” patients to a fixed point of dispensing (POD) or a neighborhood pharmacy. However,
most of these assessments used speed of distribution rather than accuracy or appropriateness as
their measure of outcome.
There is low to medium strength evidence that better management of POD operations can
speed throughput and therefore accelerate distribution of biological countermeasures. There is
also low strength evidence that public distribution of non-biological countermeasures, such as N95 respirators or surgical masks, can reduce demand for hospital beds, intensive care unit beds,
and ventilators.
There is little evidence to support particular approaches to optimizing resource allocation and
use in conditions of scarcity. There is some evidence that resource use can be optimized by better
load sharing between facilities. There is also limited evidence that pressure on overburdened
59

health care resources may be reduced by transferring patients to more distant hospitals and by
opening temporary facilities, such as a mobile field hospital.
Other than these observations, there is no evidence to guide policymakers in their
deliberations and recommendations regarding how to allocate scarce resources under crisis
standards of care. A focused and prioritized agenda for developing policy guidelines is urgently
needed.
The evidence base to guide providers on the best strategies to optimize the allocation of
scarce resources during MCEs is equally limited. Numerous strategies have been proposed to
help providers and health care systems respond to MCEs. Unfortunately, evidence is insufficient
to favor one of them over the others. Rigorous studies are rare, and much of the evidence that
exists comes from simulations, drills, and exercises, rather than empirical evidence drawn from
actual events. Many of the studies we reviewed did not report outcomes that are relevant to
patients or providers. In most cases, the applicability of the study’s findings beyond the
immediate exercise setting or particular MCE was questionable.
The only provider-oriented strategy subjected to comparative assessment to date is field
triage during MCEs. Even then, the strength of evidence to support use of one approach over
others is low. A systematic review of field triage systems, comprising 11 papers that evaluated
eight different triage tools, found limited evidence for the validity of any existing tool.62
Published derivation and validation studies were of relatively poor quality, in part because most
were based on small sample sizes. Few existing triage tools are specifically designed for use with
pediatric disaster victims.
The accuracy with which providers can apply various triage tools is also unclear. More than
half of the studies of triage accuracy were based on exercises or drills, rather than on actual
events. Exercise-based assessments may not accurately reflect how a triage tool will perform in
an actual MCE. For example, four studies of START, a widely used prehospital triage tool,
reported accuracy rates of 62 percent to 82 percent. But when one group used the tool in an
actual MCE, they found that it poorly allocated patients because providers were confused about
the meaning of the different triage categories. Research is urgently needed to develop a simple,
reliable, and accurate method to triage casualties in an MCE.
For every other category of provider-based strategies, the evidence base was insufficient to
support a conclusion at more than a low level of evidence. With the exception of the previously
mentioned studies of pre-hospital triage, few strategies were evaluated in more than three
studies. As a result, there is very limited evidence to guide providers on the best strategies to use
to reduce demand, optimize use of resources, augment existing resources, or apply crisis
standards of care in the setting of an MCE.
The addition of promising but untested strategies increased the pool of interesting and
potentially promising ideas, but none of the studies in this group is backed by sufficient evidence
to favor one promising idea over another. A few studies, such as those describing the emerging
technique of “damage control surgery,” reported highly encouraging findings. However, most of
the studies we reviewed were prone to at least a medium level of bias. Therefore, we judged the
strength of evidence for most of the provider-based interventions described to date as low or
insufficient.
First responders, physicians, and other health care providers need evidence-based guidance
on how to best manage resource use and, when all else fails, employ crisis standards of care.
Unfortunately, few strategies have been examined with sufficient scientific rigor to guide

60

practice or policy. There is a compelling need to implement a prioritized research agenda and
secure sufficient support to conduct these studies.
Although the evidence base is minimal regarding public perceptions of how scarce resources
should be maximized and crisis standards applied during MCEs, the few published findings are
generally consistent. Firm evidence regarding public perceptions is limited. The majority of the
studies we reviewed reported data collected from a single community, four of which were
outside the United States. Nevertheless, because these studies were well designed and their
findings are generally consistent with each other, we judged the strength of evidence as medium.
Collectively, these studies indicate that citizens are interested and motivated to participate in
community forums. Participants in these forums expressed the belief that a successful allocation
system should balance the goals of ensuring the functioning of society, saving the greatest
number of people, protecting the most vulnerable, reducing deaths and hospitalizations, and
treating people fairly. Although the public wanted appropriate guidelines to be established in
advance with the input of health care professionals, they believed that the guiding parameters
should allow providers a degree of flexibility to make allocation decisions based on their specific
demand and supply situation.
The viewpoints elicited to date should be interpreted with caution. They are drawn from a
relatively small number of participants, including four groups outside the United States. More
substantive public input through community engagement forums will give credence to the
process and ensure the level of public confidence needed to secure citizen cooperation during
future MCEs. Consequently, we recommend that more public engagement studies of the sort
reported to date be conducted in a variety of communities and settings. Determining the most
effective ways to engage the public and to disseminate information to policymakers and
providers is a matter of urgent concern.
Promising strategies exist to engage providers in developing resource allocation strategies,
including crisis standards of care, but none has been sufficiently evaluated. The 14 studies we
examined indicate that it is possible to engage health care providers in productive discussions,
but there was insufficient evidence to recommend one engagement strategy as superior to the
others. Nonetheless, several important themes emerged from our synthesis of this work. First,
inclusive processes that engage all major stakeholders work better than those that do not. Ideally,
such efforts should involve representatives of the relevant provider institutions, professional
associations, State and/or local government, academia, and the public. Second, systematic and
iterative processes produce more robust and satisfying products—such as a critical planning
framework or a consensus plan—than those that do not. Third, involving credible subject matter
experts enhances participation, satisfaction, and the quality of the final product. Finally,
engaging nontraditional providers or groups adds innovation and breadth. Additional research
will be needed to confirm these observations.
In addition to assessing the published research literature, we also analyzed the consensus
guidelines of various specialty societies and task forces and strategies outlined in existing State
plans. These efforts produced two additional summary findings:
Currently, the consensus guidelines and recommendations of specialty societies and
government advisory groups rest on an insufficient body of evidence. Few offer actionable
guidance to policymakers, health care providers, or the public. Most of the consensus panel
recommendations we reviewed are either badly dated or pitched at a level unlikely to be useful to
policymakers or health care providers. This was particularly true of guidelines produced by
specialty societies.
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In many cases, the intent of the consensus task force was to develop principles that providers
at the local level could use to derive their own protocols. This approach contradicts the
recommendations of the committee that produced the IOM Letter Report, which expressed the
hope that their guidance would produce “a single, national framework for responding to crises in
a fair, equitable and transparent matter.”13
It is interesting to note that committees sponsored by the Society for Critical Care Medicine
and the American Thoracic Society’s Bioethics Task Force recommended that intensive care unit
resources be allocated on the basis of “first come, first served.” This position contradicts the
view of the public, based on the limited number of surveys and public engagement studies
published to date. The public, like the authors of the IOM letter report, want to see resource
allocation decisions made in a proactive and thoughtful way that protects the core interests of
society, as defined by the populace.
Some States have made progress toward adopting plans to manage and, if necessary, allocate
resources under crisis standards of care. We reviewed plans from 11 States and one U.S. territory
and abstracted information regarding how policymakers and providers should respond in the
context of an MCE. Some plans seek to reduce less-urgent use of health care resources through
such measures as mass dispensing of vaccine, prophylactic medications, and self-quarantine.
Others seek to optimize use of existing resources through triage, load balancing, repurposing of
facilities, more efficient use of providers, and substitution of more plentiful alternatives. Most
seek to augment existing resources by tapping stockpiling and other reserves and by activating
mutual aid agreements. Finally, some plans recommend that, when all else fails, crisis standards
of care should be implemented based on predefined priorities, with the understanding that this
means certain patients will receive comfort care rather than aggressive intervention. However,
few of the plans defined detailed approaches for making these determinations that could be
readily put into practice. Moreover, few plans proposed legal and operational frameworks for
shifting to crisis standards of care. Although these strategies are appealing in principle, and most
have a high degree of face validity, they are supported by a limited base of evidence.

Limitations of the Review Methods
As with all attempts to systematically review a vast body of literature about a complex topic,
it was necessary to make a number of decisions to clearly define the scope of the review, identify
and assess the key studies, and synthesize the findings. We considered each decision carefully
and believe we have a strong rationale for the choices we made. In making these choices,
however, some trade-offs were made that could be seen as limitations of the study.
First, we chose to keep the scope of the review quite broad. While this was useful in
identifying resource allocation strategies from across the full spectrum of preparedness and
response, it made it difficult to conduct targeted searches of the literature. It is possible that our
more general search did not identify specialized studies that would have been found if the CER
had focused on a small set of specific strategies. The use of reference mining and forward
searches mitigates this possibility to some extent.
Second, because of the challenges in conducting research on MCEs, we included study
designs in this CER that are normally considered to produce lower levels of evidence, including
cohort, before-after, and quasi-experimental studies. In the end, we retained even studies that
referenced historical performance as the comparison standard, but graded the level of evidence
accordingly. To further broaden our coverage of the topic, we included studies that had some
measure of feasibility or performance but lacked a comparison group. Finally, we identified
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consensus recommendations by specialty societies and national panels. None of these provided
new evidence, but they did speak to important dimensions of Key Questions 1 and 2.
Because we included a broader range of study types in the CER, the validated instruments for
assessing quality typically used in CERs were not applicable. We therefore searched for other
relevant rubrics. Finding no single scale that seemed appropriate for our topic, we combined
elements of several and developed our own composite scale. While the scale seemed to work
well, it has not been validated. In addition, as in most rating schemes, there is some degree of
subjectivity in assigning scores to each item in our quality assessment scales. To minimize the
potential bias, two reviewers rated each study independently and any discrepant scores were
reconciled.
We were unable to perform meta-analyses that often accompany CERs due to the wide range
of topics covered, the different measures of effectiveness employed across studies, and the small
number of studies focused on any one particular strategy. As such, the synthesis of the results
and the grading of strength of evidence for each Key Question are primarily qualitative in nature.
While the process was systematic, there is some subjectivity involved.
Although the scope of our review was broad, it did not address every aspect of the
management of MCEs. For example, our review did not address clinical or logistical aspects of
EMS care and transport of patients, other than the technique of field triage in the setting of
MCEs. Finally, although our literature search procedures were extensive, the possibility of
publication bias still exists.

Limitations of the Evidence Base
By their very nature, MCEs are uncommon and largely unanticipated. MCEs also vary
widely from one another with respect to geography, cause, onset, setting, duration, scale, and
many other characteristics. This high degree of unpredictability, coupled with the variability and
rapid evolving nature of MCEs, make it difficult to draw generalizable inferences from any
single event. The technical and ethical dimensions of disaster research are challenging as well.
Unlike directors of clinical trials, researchers interested in improving response to MCEs cannot
prospectively enroll and allocate their subjects into treatment groups with precisely controlled
study protocols. By their nature, MCEs invite and sometimes require improvisation. This makes
such basic processes as systematic data collection difficult at best.
Some research teams have attempted to model alternative interventions using computer
simulation or have tested them in simulated exercises and drills. Although these approaches
provide useful data, they raise significant internal and external validity concerns. It is far from
clear how generalizable the findings of these studies are to actual MCEs. It is difficult for the
most realistic models and drills to reproduce the demanding environment of an actual disaster or
MCE. It is equally difficult to predict human behavior in such incidents, especially if the rescuers
and health care providers lack prior experience.
The current evidence base is characterized by marked variability in methodologies and a
relative paucity of studies that addressed any single strategy. The multiplicity of options assessed
to date means that few strategies have been sufficiently evaluated to confirm their effectiveness.
With the exception of prehospital (field) triage, most of the strategies we identified were
assessed by no more than three studies. This limited the strength of evidence available to
compare one strategy to another. As a result, it was almost impossible to reach firm conclusions
regarding their comparative effectiveness.

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The different measures of effectiveness employed by authors posed another limitation. Most
of the articles that met our generous screening criteria for inclusion assessed the impact of a
current or proposed strategy on a clinical process or some aspect of a process. Relatively few
examined outcomes. When outcomes were measured, they were often secondary outcomes that
served as proxies for the true outcome of interest (e.g., survival). Second, as addressed by
Shekelle and colleagues (in an evidence review on assessing the quality of patient safety
interventions), the outcomes of process interventions are often, if not always, inextricably linked
with the specific context in which they are implemented.214 Thus, no guarantee exists that an
intervention that was successfully implemented in one setting will produce the same results if it
is implemented in a different setting. This challenge is dramatically amplified in the context of
MCEs because the conditions on the ground can vary dramatically from one incident to another.

64

Opportunities for Future Research
This comparative effectiveness review (CER) spans more than two decades of preparedness
research, including the decade following the September 11, 2001, attacks. Despite generous
inclusion criteria, the addition of studies that lacked a control group, and even a supplemental
section examining promising ideas, we determined that few strategies for allocating resources in
a mass casualty event (MCE) have been sufficiently evaluated to confirm their effectiveness.

Key Challenges
Given the challenging nature of the topic and its importance to the health security of the
United States, decisive action is required to quickly build the evidence base required to properly
inform policies and practice. Three hurdles must be cleared to achieve such rapid progress.

Insufficient Funding
Business and health care leaders frequently complain that the “tyranny of the urgent”
distracts them from issues that are more important. This is certainly true in the case of planning
and preparedness for MCEs. Those who are responsible for assuring our nation’s health security
at the national, State, community, and tribal level must be careful to distinguish between what is
urgent and what is important. Because MCEs are rare and largely unforeseeable, efforts to
improve emergency preparedness, mitigation, and response often take a back seat to the day-today demands of managing complex public health and health care systems. But when an MCE
occurs, its urgency and importance eclipse everything else. At that point, it is too late to prepare.
Prior to September 11, 2001, public health in the United States suffered through a long
period of decline. In 1988 and again in 2002, the Institute of Medicine determined that our
nation’s public health system was in “disarray”.215, 216 In the first few years following 9/11 and
the anthrax attacks, large sums of Federal money were directed toward strengthening public
health and hospital emergency preparedness. However, the bulk of these resources were devoted
to biodefense through such Federal programs as BioWatch, BioSense, BioShield, and the
Biodefense Advanced Research and Development Authority (BARDA) and biodefense research
at the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention
(CDC).217 Less money was invested in restoring the core infrastructure and capabilities of public
health and health care systems to respond to the full array of health security threats.
Most of the Federal money that made its way to the States and hospitals during this time was
for capacity building, rather than research to determine the most effective ways to use these
resources. Moreover, most of these resources were restricted to efforts directly related to
biodefense. Little thought was given to creating systems and infrastructures that are capable of
responding to both daily emergencies and MCEs of all types. As the decade progressed, the
global economic crisis and the recession it triggered led to a sharp decline in government
revenues and large cuts in Federal spending for preparedness research, core public health
programs, and staff.
In light of the austere economic environment, future preparedness research activities should
be tightly focused, efficient, and effective. The overarching goal of these studies should be to
provide needed guidance to policymakers and providers. The approach should seek to build a
solid foundation for a health care system that will be robust and responsive in day-to-day
activities, as well as in any health care crisis. With proper guidance and oversight, even a limited
funding stream can produce better research and more valid findings. Health crises are, by their

65

very nature, variable in onset, cause, location, scope, duration, and other characteristics. For this
reason, categorical programs are rarely adequate, because it is impossible to predict the next
MCE or terror attack. Public health and health care systems and providers must be capable of
flexibly responding to a wide range of threats drawing from a toolkit of capabilities and skills.

Inadequate Coordination
Recently, the RAND Corporation, with support provided by the U.S. Department of Health
and Human Services Assistant Secretary for Preparedness and Response, conducted a first-ever
portfolio analysis of nonclassified federally funded extramural research on public health and
health systems preparedness across eight Federal research agencies: the NIH, the CDC, the
Agency for Healthcare Research and Quality, the Department of Homeland Security Office of
Science and Technology, Department of Defense Northern Command, the Department of
Energy, the National Science Foundation, and the Veterans Health Administration.
This analysis determined that 62 percent of identified projects are focused on one or more
aspects of infectious disease, foodborne illness, or pandemic influenza. Only 10 percent of
funded projects addressed natural disasters. Nuclear, radiological, and explosive threats were
each the focus of no more than 4 percent of research projects. More than half of all extramurally
funded projects were laboratory studies; most were funded by the NIH. Only 6 percent of
projects were focused on improving the performance of the health care system in disasters.218
The results of this CER suggest that such an ad hoc, agency-specific approach to
preparedness research may not produce the findings we need to rapidly strengthen the national
health security of the United States. Rather than fragmenting activity and dissipating efforts
across a wide range of objectives, future research activity should be focused on the most urgent
and promising issues. This will only happen if the various Federal agencies and stakeholders
craft a plan to coordinate their activities. Unity of purpose, combined with a sustained stream of
funding, will produce a more rapid and actionable set of advances than a much larger but poorly
coordinated program of research.

Logistical Barriers
We have highlighted the inherent challenges of conducting research during an MCE. Because
these events cannot be readily foreseen, research teams must be assembled and deployed on short
notice. Few institutional review boards are able, much less willing, to provide the requisite
approvals to allow human subjects research in a workable time frame. There are also formidable
ethical and logistical obstacles to collecting data at a time when resources are scarce and large
numbers of people are pleading for help. It is not only difficult to envision conducting
randomized controlled trials in such circumstances; it is nearly unthinkable.
However, it can be argued that the type of research needed to rapidly advance the field does
not employ the sort of study designs typically required for inclusion in a comparative
effectiveness review. Many high-impact business innovations have come from “focused
empiricism”—identifying what works and what does not and subsequently refining promising
strategies. A similar approach undergirds the well-accepted process of continuous quality
improvement. Some experts in health care innovation have argued that beyond basic
determinations of therapeutic efficacy and safety, relying on serially constructed, randomized
controlled trials (RCTs) to establish the comparative effectiveness of various approaches to
health care operations is neither feasible nor desirable.219

66

Hospital leaders should not need the results of RCTs to convince them of the value of rapidly
clearing the emergency department in the short time window between notification that a terrorist
bombing has occurred and the arrival of the first wave of complex casualties.220 Likewise,
Federal and State policymakers should not need RCTs, cohort studies, or quasi-experimental
trials to convince them of the value of stockpiling vital drugs and critical supplies that are likely
to run short in the first few days or weeks following a major MCE. Adoption and consistent
performance of simple performance improvement processes, such as routinely conducting
rigorous but nonjudgmental “after-action reviews” (AARs) following each MCE could produce
rapid advances in technique. This will not happen unless the findings of these AARs are
systematically captured and the resulting observations are widely shared. Such an effort would
go a long way toward promoting systems learning and improved performance.
AARs of large-scale events—the type that trigger a Federal response—could be dramatically
strengthened by predesignating an evaluation team, with contingent approval from a national
institutional review board to rapidly deploy with the lead elements of a Federal disaster response.
A similar concept could be adopted by the United Nations and its member States to prospectively
collect important lessons from global disasters of the scale of the Indonesian tsunami and the
Haiti earthquake.221
At the other end of the spectrum, local planners and hospital officials should view smallscale events, near misses, as opportunities to assess and refine various elements of their
community’s response plan. Federal and State governments should leverage annually recurring
events, such as flu vaccination campaigns, as opportunities to test various elements of their
response plans for bioterrorism and other emerging disease threats.

Planning a Prioritized Research Agenda
With adequate funding, greater levels of collaboration and coordination, and flexible
approaches to various modes of evaluation and research, rapid progress could be made toward
addressing the most urgent and formidable challenges to the health care system in disaster
preparedness and response. Specifically, we recommend the development of a prioritized
research agenda modeled along the following lines:
1. Enhance coordination across Federal research agencies. A Federal interagency working
group on health security research would go a long way toward ensuring that future research
portfolios minimize overlaps and address key gaps. This will only happen if agencies agree
to share information and jointly allocate a portion of their resources.
2. Require federally funded researchers to prospectively categorize the projects and key
findings using a standardized format. If agencies adopt a common taxonomy for categorizing
disaster research, it will be much easier in the future to prospectively identify projects and
index their results. This would allow agency heads, policymakers, and researchers to avoid
needless duplication of effort and better target their activities toward filling critical gaps.
3. Create a centralized information center that banks all available strategic plans and pertinent
discussions of current and past science and ongoing projects.
4. Encourage State officials to engage community members, health care providers, and local
policymakers to ascertain their views about contingent strategies and ethical frameworks for
allocating scarce resources in MCEs. Because public engagement is important, special efforts
should be made to include participants from different regions, ethnic backgrounds, cultures,
ages, and faith traditions.

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5. At the same time, efforts should be made to fully engage provider groups, including primary
care and specialty clinicians and health system administrators, along with experts in health
care law, policy, and ethics, to reach a national consensus on how scarce resources should be
allocated under crisis standards of care. This process should include a systematic effort to
identify the most important legal or regulatory barriers that could impede or undermine
optimal allocation of scarce resources under crisis conditions.
6. Because community forums and face-to-face meetings are costly to conduct, they will never
reach more than a small sample of the public. For this reason, researchers should explore
methods to harness the power and reach of traditional news media (e.g., print, radio, and
television), new media (Internet, short message service [SMS]), and social networks, such as
Facebook and Twitter. The goal of these efforts should be to determine the most effective
ways to engage and inform different segments of the public so that they can take appropriate
action in an unfolding MCE and the recovery phase that follows.
7. Because it will always be extremely difficult to test various strategies under actual
conditions, efforts should be made to develop and refine affordable simulations, computer
models, and drills, including “no-notice” exercises, to more realistically assess and improve
key elements of public health and health system operations and decision making.
8. We urgently need to build on the existing evidence to identify a simple but reliable approach
to field triage in the setting of MCEs. This question could be quickly answered with a
focused program of research. This work might be guided by the Model Uniform Core
Criteria and other consensus-based MCE triage principles and protocols.
9. Additional research devoted to understanding facilitators and barriers to the effective
implementation of incident command systems might provide greater insight into the poor
response to several MCEs that we observed in several studies included in our review, and
might suggest opportunities to strengthen this framework moving forward.
10. Because the consequences of a bioterror attack, a highly lethal flu pandemic, or an emerging
infectious disease are so great, we urgently need to build on the existing evidence to
determine the most effective method or methods to rapidly deploy needed biological and/or
nonbiological countermeasures to the public.
11. Considerable benefit could be achieved by quickly developing and deploying efficient and
affordable IT solutions for a variety of challenges, including (1) systems capable of tracking
victims through various steps in the continuum of care from the scene of an MCE to
definitive care, recovery, and repatriation; (2) software to guide hospital emergency
operations centers through the various phases of responding to an MCE; and (3) passive
public health surveillance systems that track area hospital emergency department, inpatient
bed, and intensive care unit occupancy rates and each institution’s diversion status so local
EMS providers can swiftly determine the best destination for casualties of daily emergencies
as well as MCEs.
12. Similarly quick gains could be achieved by rapidly evaluating a variety of bidirectional
communication technologies, including call centers with automated IVR and nurse advice
lines, Web sites, SMS, and various forms of interactive social media to reach, inform, and
engage the public in bidirectional communication. Automated algorithms, modeled on
existing prototypes, could allow patients to self-triage themselves and get specific advice that
is appropriate to their condition and circumstance. Bidirectional tools of this sort could be
used to better match patients to available resources, reduce needless visits to hospital
emergency rooms, and collect epidemic intelligence in real time.222 Similar approaches could

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be used to enable local nongovernmental organizations and community groups to match
available resources and needs.
13. In addition to interactive communications, other methods and tools are needed to enhance the
capacity of public health agencies, primary care providers, retail clinics, and local/regional
health care systems to safely provide substantial levels of minor illness and injury care. This
will allow resource-constrained hospitals to focus their staff on meeting the needs of more
seriously ill and injured victims.
14. Additional work is needed to improve the methodologies used in disaster research. This
might best be accomplished by an expert panel convened by the Institute of Medicine or a
similar body. This group should pay particular attention to improving existing "measures of
effectiveness," including appropriate measures of outcome. Measurement problems are a
common source of error that weakens the value of many MCE studies. Reviewers and journal
editors generally look at three main areas when considering the merits of a study: internal
validity, external validity, and merit. A study has to answer a question that is meaningful to
have merit. In one former editor’s words, "a difference to be a difference must make a
difference."223
15. As noted in the discussion above, widespread institutionalization of a rigorous and objective
approach to after-action reviews could produce rapid gains in knowledge through focused
empiricism. To maximize the yield of this activity, the standard components of an AAR
should be identified and refined so that they are uniform and helpful. A national
clearinghouse should be created to distill the lessons learned from this process and widely
share them with policymakers, providers, and, when appropriate, the public.
16. The U.S. government should either designate or contract with a small team of evaluators with
prior security clearance and institutional review board approval to be on 24/7 call to
immediately deploy, in the case of a major disaster or terrorist attack, with elements of the
National Disaster Medical System. The only responsibility of this team should be to
prospectively monitor, document, and report back observations of what went well and what
did not over the course of the event. Although these individuals should be empowered to alert
incident commanders to problems they identify, they should not have patient care
responsibilities. This will enable them to focus their attention on rigorous data collection and
analysis. To enable them to perform this important task, the team should granted access to
every aspect of the response, including field hospitals, distribution centers, and the inner
workings of the incident command center. A similar approach should be taken to large-scale
global disasters by the United Nations, the World Health Organization, or another global
relief group. Otherwise, we are doomed to repeat the mistakes of the past.221

Conclusions
Emergency preparedness and response is essential to protect our nation’s health security. Our
nation faces a wide array of man-made and natural threats. The existence of these threats and
others that will undoubtedly emerge in the years to come cannot be ignored or wished away.
Prevention and mitigation can and should remain key elements of our approach. But, from time
to time, terror groups will launch a successful strike, or natural forces will overwhelm the bestbuilt and most thoughtfully designed structures. When that happens, our nation must be prepared
and capable of responding to minimize subsequent harm and loss of life.
In light of these facts, readers of this CER should be concerned by the limited amount of
high-quality, highly applicable evidence to help policymakers, health care providers, and the

69

public determine the best course of action in planning, preparing for, and responding to MCEs.
In the same way that health care providers in a disaster strive to do the most good for the most
people with the resources at hand, so should officials charged with advancing the applied science
of disaster response strive to generate the most useful information in the shortest possible time
within existing and, hopefully, augmented resources.

70

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Acronyms and Abbreviations
AGPRs
AHRQ
ASPR
CalMAT
CDC
CDPHE
CENTRAL
CER
CHC
CINAHL
CME
CT
CVM
DARE
DHS
DHHS
DMAT
DOD
DoE
ED
EMS
EPC
ESAR VHP
ESCAPE
FAST
GAO
HHS
HMO
ICU
IOM
KQ
LIMS
LTC
MAC
MCE
MRC
NHSS
NIH

automatic gas-powered resuscitators
Agency for Healthcare Research and Quality
Office of the Assistant Secretary for Preparedness and Response
California Medical Assistance Team
Centers for Disease Control and Prevention
Colorado Department of Public Health and Environment
Cochrane Central Register of Controlled Trials
comparative effectiveness review
community health centers
Cumulative Index to Nursing and Allied Health Literature
continuing medical education
computerized tomography
Colorado’s Volunteer Mobilizer
Cochrane Database of Abstracts of Reviews of Effects
Department of Homeland Security
Department of Health and Human Services
Disaster Medical Assistance Team
Department of Defense
Department of Energy
emergency department
emergency medical services
Evidence-based Practice Center
Emergency System for Advance Registration of Volunteer Health
Professionals
Enhancing Surge Capacity and Partnership Effort
Focused Assessment by Sonography in Trauma
Government Accountability Office
Health and Human Services
health maintenance organization
intensive care unit
Institute of Medicine
Key Question
Laboratory Information System
long-term care
multi-agency coordination
mass casualty event
Medical Reserve Corps
National Health Security Strategy
National Institutes of Health

84

NORTHCOM
NREPP
NSF
OHPIP
OHSU
OR
PAHO
PICOTS
POD
RCT
SARS
SNF
SNS
SOFA
SRC
TEP
VHA
WHO

Northern Command
National Registry of Evidence Based Programs and Practices
National Science Foundation
Ontario Health Plan for an Influenza Pandemic
Oregon Health Sciences University
operating room
Pan American Health Organization
populations, interventions, comparators, outcomes, timeframes, and
settings
point of dispensing
randomized controlled trial
severe acute respiratory syndrome
skilled nursing facility
Strategic National Stockpile
Sequential Organ Failure Assessment
Scientific Resource Center
technical expert panel
Veterans Health Administration
World Health Organization

85

Appendix A. Literature Search Strategy
INITIAL SEARCHES RAN JANUARY 21, 2011, COVERING 1990-January 2011.
FINAL UPDATE SEARCHES PERFORMED ON NOVEMBER 8, 2011 COVERING
JANUARY 2011-NOVEMBER 2011.
SEARCH #1 (updated 11/8/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
PubMed 2011-2011
SEARCH STRATEGY:
disasters[mesh] OR disaster*[tiab] OR emergencies OR emergency planning OR emergency
preparedness OR mass casualt* OR ((triage[ti] OR triaging[ti]) AND disaster*) OR pandemic[ti]
AND
surge OR scarce OR scarcity OR allocat* OR ration OR mass OR (triage AND (ethic* OR
protocol)) OR "emergency medical care" OR (emergency medical care services[mh] AND
ration) OR remote consultation[mh] OR “crisis standards” OR “altered care” OR “adapted care”
OR “crisis standards of care” OR “altered standards of care”
NOT: Letters, Case Reports, Clinical Trials
NOT: animal*NOT Human*
NOT :("human remains" OR "identifying human bodies" OR autops* OR "end of life planning"
OR pig OR pigs OR porcine OR cow OR cows OR bovine OR horse OR horses OR dog OR
dogs OR cat OR cats OR mice OR mouse OR hamster OR hamsters OR rat OR rats OR
"identification of human bodies" OR epidemiology OR appendectomy OR “dental identification”
OR "water insecurity" OR "mass gatherings" OR "dental identification" OR (food AND ration)
OR clinicaltrials.gov OR "total hip replacement" OR (mass AND cancer) OR ECMO OR
forensic* OR drought OR “abdominal aortic aneurysm” OR (oil AND spill) OR “global
warming” OR “partner violence” OR “violence prevention”)
NUMBER OF ITEMS RETRIEVED: 223
SEARCH #2 (updated 11/8/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
CINAHL – 2011-2011
(Disaster* OR emergencies OR emergency planning OR emergency preparedness OR mass
casualt* OR ((TI triage OR TI triaging) AND disaster*) OR TI pandemic)
AND
(surge OR scarce OR scarcity OR allocat* OR (triage AND (ethic* OR protocol)
OR "emergency medical care" OR ("emergency medical services" AND ration) OR "remote
consultation" OR "crisis standards" OR "altered care" OR "adapted care" OR "crisis standards of
care" OR "altered standards of care")
And Human
Not Letters
Limiters - Date of Publication from: 20110101-20111231; Peer Reviewed; Exclude MEDLINE
records; Human
A-1

NUMBER OF ITEMS RETRIEVED: 7 (1 duplicate) = 6
SEARCH #3 (updated 11/8/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
Cochrane – 2011-2011
“mass casualt*” OR “disaster preparedness” OR (Triag* AND (disaster OR mass))
NUMBER OF ITEMS RETRIEVED: 6
SEARCH #4 (RUN 11/8/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
Embase – 2011-2012
'mass disaster'/exp OR disaster*:ab,ti OR 'emergencies'/exp OR 'emergency'/exp AND
'planning'/exp OR 'emergency'/exp AND preparedness OR 'mass'/exp AND casualt* OR
((triage:ti OR triaging:ti)AND disaster*) OR pandemic:ti AND [embase]/lim
AND
'emergency medical care'/exp OR ('emergency medical services'/exp AND ration) OR 'remote
consultation'/exp OR 'crisis standards' OR 'altered care' OR 'adapted care' OR 'crisis standards of
care' OR 'altered standards of care' OR surge OR scarce OR scarcity OR allocat* OR ration OR
'mass'/exp OR ('triage'/exp AND (ethic* OR protocol)) AND [embase]/lim
AND [humans]/lim AND [1990-2011]/py
NOT
pandemic NEAR/3 vaccin*
NUMBER OF ITEMS RETRIEVED: 21 results (8 duplicates) = 13 results
SEARCH #5 (updated 11/8/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
Web of Science – 2011-2011
TS=disaster* OR TS=emergencies OR TS=emergency planning OR TS=emergency
preparedness OR TS=mass casualt* OR (TI=triage OR TI=triaging) AND TS=disaster*) OR
TI=pandemic
AND
TS=surge OR TS=scarce OR TS=scarcity OR TS=allocat* OR TS=triage AND TS= (ethic* OR
protocol) OR TS="emergency medical care" OR TS= ("emergency medical services" AND
ration) OR TS="remote consultation" OR TS="emergency medical care" OR TS= ("emergency
medical services" AND ration) OR TS="remote consultation" OR TS="crisis standards" OR
TS="altered care" OR TS="adapted care" OR TS="crisis standards of care" OR TS="altered
standards of care"
NOT: Letter
NOT :
(TS="human remains" OR TS="identifying human bodies" OR TS=autops* OR TS="end of life
planning" OR TS=pig OR TS=pigs OR TS=porcine OR TS=cow OR TS=cows OR TS=bovine
OR TS=horse OR TS=horses OR TS=dog OR TS=dogs OR TS=cat OR TS=cats OR TS=mice
OR TS=mouse OR TS=hamster OR TS=hamsters OR TS=rat OR TS=rats OR
TS="identification of human bodies" OR TS=epidemiology OR TS=appendectomy OR TS=
“dental identification” OR TS="water insecurity" OR TS="mass gatherings" OR TS="dental
identification" OR TS= (food AND ration) OR TS=clinicaltrials.gov OR TS="total hip
replacement" OR TS= (mass AND cancer) OR TS=ECMO OR TS=forensic* OR TS=drought
OR TS=“abdominal aortic aneurysm” OR TS= (oil AND spill) OR TS=“global warming” OR
TS= “partner violence” OR TS= “violence prevention” OR TS=geological OR TS="clinical

A-2

trial" OR TS="urban modeling" OR TS="urban simulation" OR )
Refined by: [excluding] Subject Areas=( ENGINEERING, MECHANICAL OR WATER
RESOURCES OR ECOLOGY OR CONSTRUCTION & BUILDING TECHNOLOGY OR
MATHEMATICS, INTERDISCIPLINARY APPLICATIONS OR ENGINEERING,
GEOLOGICAL OR METEOROLOGY & ATMOSPHERIC SCIENCES OR VETERINARY
SCIENCES OR ENGINEERING, OCEAN OR MEDICAL INFORMATICS OR
OCEANOGRAPHY )
NUMBER OF ITEMS RETRIEVED: 273 (before deduping); 227 after de-duping
SEARCH #6 (RUN 11/10/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
Global Health – 1990-2011
1
S DISASTER? OR MASS()CASUALT? OR EMERGENCY(5N)PLAN? OR
EMERGENCY(5N)PREPAR? OR EMERGENCY()MEDICAL()CARE OR
REMOTE()SERVICES OR EMERGENCIES OR PANDEMIC?
S2
S TRIAG?/TI AND DISASTER?
S3 S S1 OR S2
S4 S SURGE OR SCARCE OR SCARCITY OR ALLOCAT? OR RATION OR RATIONED
OR RATIONING OR MASS
S5
S TRIAGE AND (ETHIC? OR PROTOCOL?)
S6
S S3 OR S4
S7
S S3 AND S6
S8
S S3 AND S4
S9
S S8 OR S5
S10
S EMERGENCY()MEDICAL()CARE()SERVICE? AND (RATION OR RATIONED
OR RATIONING)
S11
S EMERGENCY()MEDICAL AND (RATION OR RATIONED OR RATIONING)
S12
S REMOTE?(2N)CONSULT?
S13
S CRISIS(2N)STANDARD? OR ALTERED()CARE OR ADAPTED()CARE
S14
S S9 OR S11 OR S12 OR S13
S15
S S14/ENG
S16
S S15/1990:2011
NUMBER OF ITEMS RETRIEVED: 137 – 51 duplicates – 86
SEARCH #7 (RUN 4/16/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
SCOPUS – 1990-2011
TITLE-ABS-KEY(disaster*) OR emergencies OR {emergency planning} OR emergency
preparedness OR mass casualt* OR TITLE(triage) OR TITLE(pandemic)
AND

surge OR scarce OR scarcity OR allocat* OR ration OR mass OR (triage AND (ethic* OR
protocol))
OR({emergency medical care} OR {remote consultation}) AND ration OR
{crisis standards} OR {altered care} OR {adapted care} OR {crisis standards of care} OR
{altered standards of care} OR {crisis care}

A-3

AND

PUBYEAR AFT 2011
NOT
{human remains} OR {identifying human bodies} OR autops* OR {end of life planning} OR
pig OR pigs OR porcine OR cow OR cows OR bovine OR horse OR horses OR dog OR dogs
OR cat OR cats OR mice OR mouse OR hamster OR hamsters OR rat OR rats OR
{identification of human bodies} OR epidemiology OR appendectomy OR {dental
identification} OR {water insecurity} OR {mass gatherings} OR {dental identification} OR
(food AND ration) OR clinicaltrials.gov OR {total hip replacement} OR (mass AND cancer)
OR ecmo OR forensic* OR drought OR {abdominal aortic aneurysm} OR (oil AND spill) OR
{global warming} OR {partner violence} OR {violence prevention})

NUMBER OF ITEMS RETRIEVED: 218 -114(weeding) – 45 (deduping)= 59
SEARCH #8 (updated 11/8/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
NLMLocatorPlus– 2011-2011
Mass Casualty as a phrase in Title
OR
Disaster in Title
AND
Medicine in Title
NUMBER OF ITEMS RETRIEVED: 15 titles kept 3
(these are in a separate .txt file: NLMupdatedresults.txt)
SEARCH #9 (RUN 11/14/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
NYAM Grey Literature Report– 2011Key word: mass casualty OR disaster OR disasters
NUMBER OF ITEMS RETRIEVED: 12
(these citations are in a separate word document:
NYAM_UpdateDisaster_MassCasualty_11_2011.doc)
SEARCH #1 (RUN 1/21/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
PubMed – 1990-2011
SEARCH STRATEGY:
disasters[mesh] OR disaster*[tiab] OR emergencies OR emergency planning OR emergency
preparedness OR mass casualt* OR ((triage[ti] OR triaging[ti]) AND disaster*) OR pandemic[ti]
AND
surge OR scarce OR scarcity OR allocat* OR ration OR mass OR (triage AND (ethic* OR
protocol)) OR "emergency medical care" OR (emergency medical care services[mh] AND
ration) OR remote consultation[mh] OR “crisis standards” OR “altered care” OR “adapted care”
OR “crisis standards of care” OR “altered standards of care”
NOT: Letters, Case Reports, Clinical Trials
NOT: animal*NOT Human*
NOT :("human remains" OR "identifying human bodies" OR autops* OR "end of life planning"
OR pig OR pigs OR porcine OR cow OR cows OR bovine OR horse OR horses OR dog OR

A-4

dogs OR cat OR cats OR mice OR mouse OR hamster OR hamsters OR rat OR rats OR
"identification of human bodies" OR epidemiology OR appendectomy OR “dental identification”
OR "water insecurity" OR "mass gatherings" OR "dental identification" OR (food AND ration)
OR clinicaltrials.gov OR "total hip replacement" OR (mass AND cancer) OR ECMO OR
forensic* OR drought OR “abdominal aortic aneurysm” OR (oil AND spill) OR “global
warming” OR “partner violence” OR “violence prevention”)
OR:
Levin D[au] AND pandemic[ti]
NUMBER OF ITEMS RETRIEVED: 2472
SEARCH #2 (RUN 1/27/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
CINAHL – 1990-2011
Disaster* OR emergencies OR emergency planning OR emergency preparedness OR mass
casualt* OR ((TI triage OR TI triaging) AND disaster*) OR TI pandemic
AND
surge OR scarce OR scarcity OR allocat* OR (triage AND (ethic* OR protocol)
OR "emergency medical care" OR ("emergency medical services" AND ration) OR "remote
consultation" OR "crisis standards" OR "altered care" OR "adapted care" OR "crisis standards of
care" OR "altered standards of care"
And Human
Not Letters
Date of Publication from: 19900101-20111231; Peer Reviewed; Exclude MEDLINE records
NUMBER OF ITEMS RETRIEVED: 83 (AFTER DEDUPING) 76
SEARCH #3 (RUN 1/27/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
Cochrane – 1990-2011
“mass casualt*” OR “disaster preparedness” OR (Triag* AND (disaster OR mass))
NUMBER OF ITEMS RETRIEVED: 56
SEARCH #4 (RUN 1/27/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
Embase – 1990-2011
'mass disaster'/exp OR disaster*:ab,ti OR 'emergencies'/exp OR 'emergency'/exp AND
'planning'/exp OR 'emergency'/exp AND preparedness OR 'mass'/exp AND casualt* OR
((triage:ti OR triaging:ti)AND disaster*) OR pandemic:ti AND [embase]/lim
AND
'emergency medical care'/exp OR ('emergency medical services'/exp AND ration) OR 'remote
consultation'/exp OR 'crisis standards' OR 'altered care' OR 'adapted care' OR 'crisis standards of
care' OR 'altered standards of care' OR surge OR scarce OR scarcity OR allocat* OR ration OR
'mass'/exp OR ('triage'/exp AND (ethic* OR protocol)) AND [embase]/lim
AND [humans]/lim AND [1990-2011]/py
NOT
pandemic NEAR/3 vaccin*
NUMBER OF ITEMS RETRIEVED: 129 results (before de-duping) 70 (after de-duping & hand
removal)

A-5

SEARCH #5 (RUN 1/27/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
Web of Science – 1990-2011
TS=disaster* OR TS=emergencies OR TS=emergency planning OR TS=emergency
preparedness OR TS=mass casualt* OR (TI=triage OR TI=triaging) AND TS=disaster*) OR
TI=pandemic
AND
TS=surge OR TS=scarce OR TS=scarcity OR TS=allocat* OR TS=triage AND TS= (ethic* OR
protocol) OR TS="emergency medical care" OR TS= ("emergency medical services" AND
ration) OR TS="remote consultation" OR TS="emergency medical care" OR TS= ("emergency
medical services" AND ration) OR TS="remote consultation" OR TS="crisis standards" OR
TS="altered care" OR TS="adapted care" OR TS="crisis standards of care" OR TS="altered
standards of care"
NOT: Letter
NOT :
(TS="human remains" OR TS="identifying human bodies" OR TS=autops* OR TS="end of life
planning" OR TS=pig OR TS=pigs OR TS=porcine OR TS=cow OR TS=cows OR TS=bovine
OR TS=horse OR TS=horses OR TS=dog OR TS=dogs OR TS=cat OR TS=cats OR TS=mice
OR TS=mouse OR TS=hamster OR TS=hamsters OR TS=rat OR TS=rats OR
TS="identification of human bodies" OR TS=epidemiology OR TS=appendectomy OR TS=
“dental identification” OR TS="water insecurity" OR TS="mass gatherings" OR TS="dental
identification" OR TS= (food AND ration) OR TS=clinicaltrials.gov OR TS="total hip
replacement" OR TS= (mass AND cancer) OR TS=ECMO OR TS=forensic* OR TS=drought
OR TS=“abdominal aortic aneurysm” OR TS= (oil AND spill) OR TS=“global warming” OR
TS= “partner violence” OR TS= “violence prevention” OR TS=geological OR TS="clinical
trial" OR TS="urban modeling" OR TS="urban simulation" OR )
Refined by: [excluding] Subject Areas=( ENGINEERING, MECHANICAL OR WATER
RESOURCES OR ECOLOGY OR CONSTRUCTION & BUILDING TECHNOLOGY OR
MATHEMATICS, INTERDISCIPLINARY APPLICATIONS OR ENGINEERING,
GEOLOGICAL OR METEOROLOGY & ATMOSPHERIC SCIENCES OR VETERINARY
SCIENCES OR ENGINEERING, OCEAN OR MEDICAL INFORMATICS OR
OCEANOGRAPHY )
NUMBER OF ITEMS RETRIEVED: 748 (before deduping); 506 after de-duping (and screening)
SEARCH #6 (RUN 2/1/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
Global Health – 1990-2011
1
10670 S DISASTER? OR MASS()CASUALT? OR EMERGENCY(5N)PLAN? OR
EMERGENCY(5N)PREPAR? OR EMERGENCY()MEDICAL()CARE OR REMOTE()SERVICES OR
EMERGENCIES OR PANDEMIC?
S2
16 S TRIAG?/TI AND DISASTER?
S3
10670 S S1 OR S2
S4
93610 S SURGE OR SCARCE OR SCARCITY OR ALLOCAT? OR RATION OR RATIONED OR
RATIONING OR MASS
S5
54 S TRIAGE AND (ETHIC? OR PROTOCOL?)
S6 103284 S S3 OR S4
S7
10670 S S3 AND S6

A-6

S8
996 S S3 AND S4
S9
1026 S S8 OR S5
S10
0 S EMERGENCY()MEDICAL()CARE()SERVICE? AND (RATION OR RATIONED OR
RATIONING)
S11
1 S EMERGENCY()MEDICAL AND (RATION OR RATIONED OR RATIONING)
S12
21 S REMOTE?(2N)CONSULT?
S13
3 S CRISIS(2N)STANDARD? OR ALTERED()CARE OR ADAPTED()CARE
S14
1048 S S9 OR S11 OR S12 OR S13
S15
974 S S14/ENG
S16
930 S S15/1990:2011

NUMBER OF ITEMS RETRIEVED:

930

SEARCH #7 (RUN 4/16/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
SCOPUS – 1990-2011
TITLE-ABS-KEY(disaster*) OR emergencies OR {emergency planning} OR emergency
preparedness OR mass casualt* OR TITLE(triage) OR TITLE(pandemic)
AND

surge OR scarce OR scarcity OR allocat* OR ration OR mass OR (triage AND (ethic* OR
protocol))
OR({emergency medical care} OR {remote consultation}) AND ration OR
{crisis standards} OR {altered care} OR {adapted care} OR {crisis standards of care} OR
{altered standards of care} OR {crisis care}
AND
PUBYEAR AFT 1989
NOT
{human remains} OR {identifying human bodies} OR autops* OR {end of life planning} OR
pig OR pigs OR porcine OR cow OR cows OR bovine OR horse OR horses OR dog OR dogs
OR cat OR cats OR mice OR mouse OR hamster OR hamsters OR rat OR rats OR
{identification of human bodies} OR epidemiology OR appendectomy OR {dental
identification} OR {water insecurity} OR {mass gatherings} OR {dental identification} OR
(food AND ration) OR clinicaltrials.gov OR {total hip replacement} OR (mass AND cancer)
OR ecmo OR forensic* OR drought OR {abdominal aortic aneurysm} OR (oil AND spill) OR
{global warming} OR {partner violence} OR {violence prevention})

NUMBER OF ITEMS RETRIEVED: after deduping 1270 – after weeding 428
SEARCH #8 (RUN 1/28/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
NLMLocatorPlus– 1990-2011
Mass Casualty as a phrase in Title
OR
Disaster in Title
AND
Medicine in Title
NUMBER OF ITEMS RETRIEVED: 141 titles kept 42

A-7

SEARCH #9 (RUN 1/31/2011)
DATABASE SEARCH & TIME PERIOD COVERED:
NYAM Grey Literature Report– 1990-2011
Key word: mass casualty OR disaster OR disasters
NUMBER OF ITEMS RETRIEVED: 290

A-8

Appendix B. Data Abstraction Tools

B-1

B-2

B-3

B-4

B-5

B-6

B-7

B-8

B-9

B-10

B-11

B-12

B-13

B-14

B-15

B-16

B-17

B-18

B-19

B-20

B-21

B-22

B-23

B-24

B-25

B-26

B-27

B-28

B-29

Appendix C. Evidence Tables
Appendix Table C-1a. Tested Strategies to reduce or manage less urgent demand (KQ1)
Appendix Table C-1b. Tested Strategies to optimize use of existing resources (KQ1)
Appendix Table C-1c. Tested Strategies to augment existing resources (KQ1)
Appendix Table C-2. Tested Strategies lacking comparison groups (KQ1)
Appendix Table C-3. Proposed strategies to allocation scarce resources during mass casualty events (KQ1)
Appendix Table C-4a. Tested Strategies to reduce or manage less urgent demand (KQ2)
Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)
Appendix Table C-4c. Tested Strategies to augment existing resources (KQ2)
Appendix Table C-4d. Tested Strategies for crisis standards of care (KQ2)
Appendix Table C-5. Tested Strategies lacking comparison groups (KQ2)
Appendix Table C-6. Proposed strategies to allocate scarce resources during mass casualty events (KQ2)
Appendix Table C-7. Public perceptions and concerns about allocating scarce resources during mass casualty events (KQ3)
Appendix Table C-8. Strategies to engage providers in allocating scarce resources during mass casualty events (KQ4)

C-1

Appendix Table C-1a. Tested Strategies to reduce or manage less urgent demand (KQ1)

Author, Year

Subcategory

Study
Location

Study Type

Study Design

Relevant type of
mass casualty
event

Strategy

Findings

Outcome Modulators

Quality
score

Ablah, 201031 Biological
countermeasures

Nassau Co,
NY

Exercise,
drill, or
training
program

Post only with
comparison
group: Hybrid
POD model

Infectious disease: Use of centralized POD model, Centralized POD model had
This only looked at 1st
Anthrax
as compared with a hybrid
slightly faster processing time responder/receivers and
POD model.
than the hybrid model.
family, not general
population.
Centralized and hybrid
models had similar quality
control outcomes overall.
However, hybrid models were
more likely to follow the
individual steps in the
protocol designed to reduce
medication error. Centralized
PODs were slightly more
accurate in dispensing the
correct medication.
Centralized POD processed
0.75 patients/minute,
compared with 0.48 patients
per minute.

6/8

Arora, 201032 Biological
countermeasures
*Also in
Augment
resources

Not
relevant

Computer
simulation

N/A

Infectious disease: 1) Determine what proportion
Influenza
of CDC stockpile to preallocate
in response to pandemic flu
outbreak.

4/7

2) Implement mutual aid
agreements that allow
transshipment of antivirals
between counties.
3) Allocate CDC stockpile
according to age group, gross
attack rate, or population only.
4) Determine what proportion
of CDC stockpile to use for
prophylaxis vs. treatment for
pandemic flu outbreak.

Postponing allocation is
optimal by allowing
allocation according to the
infected population rather
than the susceptible
population.
Transshipment through
mutual aid agreements is an
optimal policy when infection
rates vary across counties and
counties with small
populations are affected.
Allocate CDC antiviral
stockpile according to gross
attack rates rather than
population is the optimal
strategy. Age-based
allocation may also be
optimal.
Limit use of CDC antiviral
stockpile for prophylaxis
when supplies are limited and
focus on treatment instead.

C-2

Vaccine effectiveness is
lower among the elderly

Appendix Table C-1a. Tested Strategies to reduce or manage less urgent demand (KQ1)

Author, Year
Bravata,
200633

Glasser,
201035

Subcategory
Biological
countermeasures

Biological
countermeasures

Study
Location
Not
relevant

Not
relevant

Study Type
Computer
simulation

Computer
simulation

Study Design
N/A

N/A

Relevant type of
mass casualty
event

Strategy

Infectious disease: Comparison of broad
Anthrax
categories of strategies,
including: (1) enhancing
bioterrorism event detection,
(2) increasing local dispensing
capacity, (3) increasing local
inventories of antibiotics, and
(4) increasing the amount of
inventory deployed from the
SNS to the site of an attack.

Findings

Outcome Modulators

Surveillance strategies to
N/A
enhance attack detection do
not result in reduced mortality
when dispensing capacity is
low.

7/9

Increasing local antibiotic
stockpiles and instituting
surveillance systems to
reduce the delay in attack
detection, are cost-effective
only if the community can
achieve a high dispensing
capacity, if the probability of
an attack is greater than
0.0001 per year, and if the
attack is large.

Infectious disease: Target pandemic flu vaccine to A strategy of vaccinating
N/A
Influenza
specific demographic groups
children, adolescents, and
young adults reduced
morbidity the most during a
simulated pandemic, while a
strategy of vaccinating
infants, older adults, and
young adults had the largest
impact on reducing mortality.

C-3

Quality
score

2/7

Appendix Table C-1a. Tested Strategies to reduce or manage less urgent demand (KQ1)

Author, Year
Koh, 200830

Subcategory
Biological
countermeasures

Study
Location

Study Type

Boston, MA Exercise,
drill, or
training
program

Study Design
Post only with
comparison
group: Implicit
benchmark
standard

Relevant type of
mass casualty
event

Strategy

Findings

Outcome Modulators

Infectious disease: 1) A streamlined Point of
Anthrax
Dispensing (POD) strategy for
mass distribution of antibiotics
within 48 hours after an
Anthrax release.

Number of people served per
hour via POD (relative to
benchmark standard)- 1988
person/hour (about
33/hour/staff person)

Heads of household can pick
up meds for all

2) A push method of
dispensing (via U.S. Postal
Service mail carriers) for mass
distribution of antibiotics
within 48 hours after an
Anthrax attack

Number of people served per
hour via mail carrier - 23,000
persons in 6 hours (120
people/hour/carrier)

Preregistered/trained staff
insufficient for probable
demand

No identification requirement
to register

Innovation in training: online
and tailored to background
(clinical/nonclinical) and
commitment
(response/leadership
Neighborhood-centric
strategy for selecting PODs
was seen as important

C-4

Quality
score
6/8

Appendix Table C-1a. Tested Strategies to reduce or manage less urgent demand (KQ1)

Author, Year
Lee, 200629

Subcategory
Biological
countermeasures

Study
Location
Atlanta,
Georgia

Study Type
Exercise,
drill, or
training
program

Study Design
Post only with
comparison
group: 7
counties not
using decision
support
software

Relevant type of
mass casualty
event

Strategy

Infectious disease: Use of integrated simulation
Anthrax
and decision-support software
(RealOpt) to determine
appropriate staffing for point of
dispensing medical
countermeasure following
Anthrax release.

Findings
DeKalb County, the only
county participating in the
point of dispensing exercise
that used RealOpt, achieved
the highest throughput
compared to all other
participating counties.
DeKalb was the only county
to exceed 450 targeted
households; its throughput
was 50% higher than the next
highest county (which
processed only 71% of target
households).

Outcome Modulators

Quality
score

Computation time for a
4/8
simulation required <1
minuted CPU time, compared
to 5-10 hours for existing
commercial software.
Combined computation time
(using RealOpt) for total
860,000 households was 30
minutes.

External evaluators reported
that DeKalb County produced
the most efficient floor plan
(with no path crossing), the
most cost-effective
dispensing (lowest
labor/throughput value), and
the smoothest operations
(shortest average wait time,
average queue length, and
equalized utilization rate). No
quantitative measures were
reported for these parameters.
McCaw,
200836

Biological
countermeasures

Not
relevant

Computer
simulation

N/A

Infectious disease: Optimal strategy for allocation
Influenza
of antivirals from the Strategic
National Stockpile (SNS)
during an influenza pandemic
(if there ARE two effective
drugs)

C-5

The two drug strategy (give a
different drug to Cases versus
their Contacts – i.e. use a
different drug for treatment
versus prophylaxis) is
superior to other strategies
because it produces greater
delays in: a) propagation of
the epidemic and b) the
emergence of drug resistance
(including multi-drug
resistance), but when
resistance does emerge, it is
more likely to be multi-drug
resistance.

The implications of multidrug 7/9
resistance are strongly
dependent on the relative
fitness of mutant strains, with
the potential for either
reduced or extended delays to
an uncontrolled outbreak.
Strategies that allocate
different drugs to treated
cases and their close contacts
are likely to be most effective
at constraining the rate of
resistance emergence

Appendix Table C-1a. Tested Strategies to reduce or manage less urgent demand (KQ1)

Author, Year

Subcategory

Study
Location

Study Type

Study Design

Relevant type of
mass casualty
event

Strategy

Findings

Outcome Modulators

Quality
score

McVernon,
201037

Biological
countermeasures

Not
relevant

Computer
simulation

N/A

Infectious disease: Continuous pre-exposure
Influenza
prophylaxis for health care
workers during a influenza
pandemic

Provision of continuous pre- N/A
exposure prophylaxis to
300,000 HCWs consumed
46% of the stockpile over 18
weeks. While appreciably
depleting resources, such use
had a negligible impact on the
containment effort.
Continuous distribution of
antiviral prophylaxis to
healthcare workers (HCWs)is
considered necessary in the
early phases of the pandemic
response to ensure continuity
of healthcare services, the
finding suggest it does not
compromise population
disease control.

4/7

Medlock,
200938

Biological
countermeasures

Not
relevant

Computer
simulation

N/A

Infectious disease: Model to determine optimal
Influenza
vaccine allocation strategy for
mass prophylaxis to a novel
virus

Mortality (relative to status
quo strategy) and other
outcomes were usually most
reduced by vaccinating
children 5-19 years old
(highest transmission group)
and child-rearing aged adults
(30-39 years), but reduced
mortality by 20-40% relative
to current CDC
recommendations.

5/9

Optimal strategy depends on
which outcome gets priority
(deaths averted, life years
saved, etc.)
Outcome depends on agegroup related transmission
rate
Outcome depends on agespecific mortality
Outcome depends on agespecific vaccine efficacy

C-6

Appendix Table C-1a. Tested Strategies to reduce or manage less urgent demand (KQ1)

Author, Year
Wein, 200341

Subcategory
Biological
countermeasures
(POD)

Study
Location
Not
relevant

Study Type
Computer
simulation

Study Design
N/A

*Also in
Augment
resources

Relevant type of
mass casualty
event

Strategy

Findings

Infectious disease: 1) Aggressive and rapid
Anthrax
antibiotic distribution post
Anthrax mass attack detection

The Number of Deaths
(relative to base case strategy
of no or very delayed
treatment) is a function of the
2) Dramatically expanded POD speed of distribution - Mass
& hospital surge capacity (for antibiotic distribution reduces
example by cross training, and deaths to 123,000 (8.3% of
using non-hospital volunteers
base case) versus 660,000
to extend trained personnel,
deaths (44% of base case) if
and mobile servers from other only symptomatic patients are
federal agencies to provide
treated
hospital surge capacity)
Number of Deaths (relative to
base case strategy) - function
of hospital capacity dramatically decreased with
sufficient personnel - ten-fold
or more, and mobile servers
(e.g., from other federal
agencies)

Outcome Modulators
Antibiotic Efficacy

Quality
score
5/9

Adherence to prophylactic
regimen
Adding mobile servers (to
provide surge hospital care) is
more effective than adding
local servers because the
former are typically less busy
and therefore more available.

Zaric, 200842

Biological
countermeasures

Not
relevant

Computer
simulation

N/A

Infectious disease: Develop a model to optimize
Anthrax
the logistical response to a
bioterrorism event.

The demonstration model
N/A
provides the following
insights: (1) communities
should focus on dispensing
capacity rather than
stockpiling of supplies. (2)
improved surveillance can
reduce mortality if adequate
dispensing capacity exists.
(3) the mortality from an
attack is significantly affected
by the number of unexposed
individuals who seek
prophylaxis and treatment.

3/9

Zenihana,
201043

Biological
countermeasures

Not
relevant

Computer
simulation

N/A

Infectious disease: A combination of mass
Smallpox
vaccination, contact tracing
and vaccination, and school
closure as countermeasures to a
smallpox bioterrorism attack

A combination of mass
vaccination and contact
tracing and vaccination can
lead to lower mortality,
quicker eradication, and less
vaccine use than either
strategy separately. School
closure potentiates the effect
of all strategies.

3/7

C-7

Time required to trace
contacts
Number of days between
index patient and start of
countermeasures
1-day vs. 2-day mass
vaccination periods

Appendix Table C-1a. Tested Strategies to reduce or manage less urgent demand (KQ1)

Author, Year

Subcategory

Cahill, 200834 Nonbiological
countermeasures

Study
Location
Not
relevant

Study Type
Computer
simulation

Study Design
N/A

Relevant type of
mass casualty
event

Strategy

Infectious disease: Distribute surgical masks or
Influenza
N95 respirators to the public to
limit the spread of pandemic
influenza (both droplet and
airborne transmission).

Findings
Use of N95 respirators lowers
the probability of infection
and the percentage of the
population infected compared
to surgical masks. Estimated
outpatient visits for the N95
mask (100% compliance)
were 14,330, as compared to
the surgical mask (100%
compliance) with 56,200
outpatient visits. However, at
60% compliance, this range
narrows to 126,640-128,070.
Use of N95 respirators
reduces use of hospital beds,
ICU beds, and ventilators
compared to surgical masks.
Estimated hospitalizations for
the N95 mask (100%
compliance) were 300, as
compared to the surgical
mask (100% compliance)
with 1,190 hospitalizations.
However, at 60% compliance,
this range narrows to 580590.
N95 respirators and surgical
masks had comparable
impacts on workdays lost and
total economic losses at
compliance levels of 60%, but
respirators were superior
when compliance levels were
100%.

C-8

Outcome Modulators
Optimal strategy depends on
attack rate and level of
compliance wearing masks.
Protective efficiency of mask
types is based on theoretical
calculations involving droplet
size, not empiric evidence

Quality
score
2/9

Appendix Table C-1a. Tested Strategies to reduce or manage less urgent demand (KQ1)

Author, Year
Savoia,
200939

Subcategory
Nonbiological
countermeasures

Schull, 200740 Nonbiological
countermeasures

Study
Location
US

Canada/
Australia/
New
Zealand

Study Type
Exercise,
drill, or
training
program

Analysis of
single real
event

Study Design
Pre-post

Pre-post with
comparison
group: Ottawa
and London,
similar but
unaffected
regions in
Canada

Relevant type of
mass casualty
event

Strategy

Findings

Outcome Modulators

Infectious disease: Tabletop Exercise (and
Influenza
didactic session) to train Public
Health officials in what steps
they can legally take to limit
spread in response to a
pandemic

After participating in the
course there was a
statistically significant
increase in most participants'
knowledge of and level of
confidence in their legal
authority to take specific
response actions (such as
imposing quarantine) to limit
pandemic spread.

Infectious disease: Restrict ambulatory and
SARS
inpatient medical and surgical
activity to urgent cases.
Respiratory isolation rooms
were expanded. Visitor access
was severely restricted. A
centralized system was created
to screen all requests for interhospital patient transfers

The rate of overall and
N/A
medical admissions decreased
by 10%–12%; there was no
change in the comparison
regions.
The rate of elective surgery in
Toronto fell by 22% and 15%
during the early and late
restriction periods
respectively and by 8% in the
comparison regions.
Decrease in high acuity ED
visits and inter-hospital
transfers in Toronto relative
to comparison regions
suggests potential unintended
consequences.

C-9

Quality
score

Legal authority may be
4/7
present, but procedures to
implement that authority may
still be lacking...
Legal professionals gained
somewhat more knowledge

4/8

Appendix Table C-1b. Tested Strategies to optimize use of existing resources (KQ1)

Author, Year

Subcategory

Epley, 200644 Load sharing

Study
Location
Southwest
Texas

Study Type
Analysis of
multiple real
events

Study Design

Relevant type of
mass casualty
event

Pre-post with
All-hazards,
comparison
Natural Disaster:
group: Routine Hurricane
trauma system
(pre-/post-) and
disaster trauma
system

Strategy

Findings

Outcome Modulators

Use of comparable
coordinated regional trauma
systems for routine (Medcom)
and disaster (Regional
Medical Operations Center)
operations to facilitate the
rapid transfer of hospitalized
and special needs patients
following small-scale trauma
events and disasters.

Pre-post- analysis of
Medcom: • Pre-Medcom (10
mos.): Transfer decision time
115 +/-3 min; transfer accept
time 30.5min; total transfer
time 145+/-12min. • PostMedcom (10 yrs): Transfer
decision time 80+/-1min,
transfer accept time 10 +/-2
min, total transfer time 91 +/1 min

Medcom (routine) and
RMOC (disaster) regional
trauma systems are
comparable, inter-related and
symbiotic.

Regional Medical Operations
Center (RMOC) : • PostHurricane Katrina- transferred
6 patients/hour & 170
patients/hour from 2
incoming transports • PreHurricane Rita: transferred 20
patients/hour
Simon, 200145 Load sharing

NYC

Analysis of
single real
event

Post only with
comparison
group:
Qualitatively
compared
against
counterfactual

Explosive,
Terrorism

1) Control the distribution of
urgent patients through scene
or central command to limit
overwhelming the nearest
hospital.
2) Site emergency
management centers in a low
vulnerability location.
3) Use robust and
interoperable emergency
communications systems.

No enforced patient
distribution system led to
moderate and critical patients
swamping the two nearest
trauma centers, while a 3rd
trauma center 3 miles from
scene sat idle
Attack damage to Office of
Emergency Management
(OEM) dramatically
exacerbated communication
and coordination efforts
including patient distribution
Cell phone and radio
disruptions (from attack
damage and post-attack
overload) prevented response
coordination - most patient
distribution was blind to
hospital resource availability

C-10

Quality
score
4/8

Medcom is practical smallscale rehearsal for major
disasters.
Authors unaware of
comparative data between
trauma system; benchmarks
would be useful.

N/A

2/8

Appendix Table C-1c. Tested Strategies to augment existing resources (KQ1)

Author, Year

Subcategory

Arora, 201032 Mutual aid
agreements
*Also in
Reduce
demand

Study
Location
Not
relevant

Study Type
Computer
simulation

Study Design
N/A

Relevant type of
mass casualty
event
Infectious disease:
Influenza

Strategy
1) Determine what proportion
of CDC stockpile to
preallocate in response to
pandemic flu outbreak.
2) Implement mutual aid
agreements that allow
transshipment of antivirals
between counties.
3) Allocate CDC stockpile
according to age group, gross
attack rate, or population
only.
4) Determine what proportion
of CDC stockpile to use for
prophylaxis vs. treatment for
pandemic flu outbreak.

Findings
Postponing allocation is
optimal by allowing
allocation according to the
infected population rather
than the susceptible
population.

Outcome Modulators
Vaccine effectiveness is
lower among the elderly

Quality
score
4/7

Transshipment through
mutual aid agreements is an
optimal policy when infection
rates vary across counties and
counties with small
populations are affected.
Allocate CDC antiviral
stockpile according to gross
attack rates rather than
population is the optimal
strategy. Age-based
allocation may also be
optimal.
Limit use of CDC antiviral
stockpile for prophylaxis
when supplies are limited and
focus on treatment instead.

Blackwell,
200747

Temporary
facilities

US

Analysis of
single real
event

Post only with
comparison
group:
Qualitatively
compared to
implied
standard of
limited or no
care available.

Natural Disaster:
Hurricane

Deploy a mobile field
hospital

C-11

7,400 patients were evaluated N/A
and treated over a 6-week
period.

3/5

Appendix Table C-1c. Tested Strategies to augment existing resources (KQ1)

Author, Year
Eastman,
200746

Subcategory

Study
Location

Temporary
facilities

Dallas, TX

Study Type
Analysis of
single real
event

Study Design
Pre-post

Relevant type of
mass casualty
event
Natural Disaster:
Hurricane

Outcome Modulators

Quality
score

Strategy

Findings

Implement alternate-site
surge capacity facility during
a mass casualty event

All other trauma centers/EDs
in Dallas had no statistically
significant increases in visit
rates during the two-week
period in which the alternate
care site was operational
compared to visit rates in the
prior year.

Leadership team for the
4/7
alternate care site also served
as medical direction team for
the City of Dallas Emergency
Medical Services and
enhanced effectiveness
through greater coordination
with other agencies.

There were no incidents of
safety or contamination
breaches during operation of
the alternate care site.

Availability of space and
physical structure (especially
climate-controlled)
Level I centers were required
to provide staff and resources,
and took nearly 7 days to
obtain necessary equipment.
Limited capabilities for
surgical intervention.

Wein, 200341

Temporary
facilities
*Also in
Reduce
demand

Not
relevant

Computer
simulation

N/A

Infectious disease:
Anthrax

1) Aggressive and rapid
The Number of Deaths
antibiotic distribution post
(relative to base case strategy
Anthrax mass attack detection of no or very delayed
treatment) is a function of the
2) Dramatically expanded
speed of distribution - Mass
POD & hospital surge
antibiotic distribution reduces
capacity (for example by
deaths to 123,000 (8.3% of
cross training, and using non- base case) versus 660,000
hospital volunteers to extend deaths (44% of base case) if
trained personnel, and mobile only symptomatic patients are
servers from other federal
treated
agencies to provide hospital
surge capacity)
Number of Deaths (relative to
base case strategy) - function
of hospital capacity dramatically decreased with
sufficient personnel - ten-fold
or more, and mobile servers
(e.g., from other federal
agencies)

C-12

Antibiotic Efficacy
Adherence to prophylactic
regimen
Adding mobile servers (to
provide surge hospital care) is
more effective than adding
local servers because the
former are typically less busy
and therefore more available.

5/9

Appendix Table C-2. Tested Strategies lacking comparison groups (KQ1)

Strategy
Augment resources

Mass
Casualty
Context
All-hazards

Augment resources

van Asten,
2009 50

Author,
Year
Balch, 2004

Innovation
Community
readiness

Description
Conducted an exercise to demonstrate community readiness
and medical response to a MCE

Hurricane

Surge, alternate
care site-real event

Description of a multidisciplinary Hurricane Katrina
Evacuation Center

Augment resources

Infectious
Disease

Load sharing

Strengthening national lab surge capacity with regard to
diagnostic demand

Weddle,
2000 53

Augment resources

Hurricane

Readiness

Improve the efficiency of deployable military hospitals to
supplement surviving local health care capabilities after
disasters

Etienne,
2010 55

Crisis standards of
care

Earthquake

Ethics committee

Multidisciplinary Healthcare Ethics Committee to determine
allocation of resources

Kellermann,
2010 54

Reduce demand

Infectious
Disease

Web-based self
triage

Deployment of clinical algorithm during 2009 H1N1 enabled
adults with influenza-like illness to self assess need for ED
versus clinic or self care

Zerwekh,
2007 49

Reduce demand

All-hazards

Biological
countermeasure

Drive-thru clinic model for dispensing SNS medication

48

Irvin, 2007
52

C-13

Results
Shadow Bowl earthquake scenario
demonstrated significant strain on the
healthcare system.
Successful non-ED alternative to address
non-emergent medical concerns
National network of laboratories has
capacity to handle diagnostic requests from
hospitals, but probably insufficient for a
surge generated in the non-hospitalized
population (Netherlands)
Improve communications while requesting
resources, broaden the range of available
health assets, position resources regionally
or in the civilian sector, and create clear
indications for full-scale deployable
hospitals when they are required.
Describe guiding ethics principles for
allocation of resources
Two websites deployed and used during
2009 H1N1 pandemic; one via flu.gov.
Approximately 800,000 visits nationwide,
no reports of adverse outcomes. Unable to
measure impact due to no follow up
Timely dispensing of prophylactic
medications with high accuracy and
minimal human to human contact

Appendix Table C-3. Proposed strategies to allocation scarce resources during mass casualty events (KQ1)
Author,
Year
No
Author,
56

Organization, Task
Force, or Panel
U.S. Department of
Health and Human
Services; U.S.
Department of
Homeland Security

Title of Report or
Article
Guidance on
Allocating
and Targeting
Pandemic
Influenza Vaccine

Proposed Strategy
Guidance on the allocation and targeting of influenza vaccines during influenza pandemics for Federal, State, local
and tribal governments, communities, and the private sector. According to the recommendation, pandemic
vaccination target groups are prioritized into four categories by order of importance: homeland and national security,
health care and community support services, critical infrastructures, and the general population. These target groups
are further prioritized into tiers within each category, and prioritization by tier depends on the severity of the
pandemic. For example, in the general population, highest risk groups include pregnant women then infant and
toddlers whereas the lowest risk groups include healthy adults 19-64 years old. A detailed rationale for prioritization
is provided.

C-14

Appendix Table C-4a. Tested Strategies to reduce or manage less urgent demand (KQ2)
Author, Year

Subcategory

Erwin, 200958 Biological
countermeasures

Study
Location
US

Study Type
Analysis of
single real
event

Study Design
Post only with
comparison
group:
Benchmark

Relevant type of
mass casualty
event
Infectious disease:
Smallpox

Strategy

Findings

Use CDC smallpox postexposure clinic guidelines to
establish an emergency mass
clinic. (The guidelines were
implemented during a
Hepatitis A outbreak.)

Time per patient - mean: 10
minutes for individuals and
mean: 3.5 minutes for groups

Outcome Modulators
N/A

4/8

Ability to accurately forecast
future arrivals based upon
current demand might be
limited

2/7

Immunizations (actual
demand) per staff-hour - 1.45
immunizations per staff-hour
(versus CDC benchmark of
1.58 immunizations per staffhour)

Hupert,
200959

Biological
countermeasures

Not
relevant

Computer
simulation

N/A

Infectious disease:
Anthrax

Account for temporal
variability in patient arrivals
by dynamically adjusting
staffing to meet demand in
point-of-dispensing stations
for mass prophylaxis using
Dynamic POD Simulator

For a given number of staff
hours, dynamic changes in
staffing in response to
demand can increase the
capacity (number of patients
treated) of a POD station.

Adini, 201057

Public
information

Israel

Analysis of
multiple real
events

Pre-post

All-hazards

Use a standardized,
automated central information
distribution system for
hospitals to help family
members locate and identify
MCE victims

Overload of hospital
N/A
communication lines occurred
frequently during MCEs,
prior to deploying the central
information system, but has
never happened since
implementing the system

C-15

Quality
score

4/8

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year

Subcategory

Einav, 200972 Case
managers

Study
Location
Israel

Study Type
Analysis of
multiple real
events

Study Design
Pre-post

Relevant type of
mass casualty
event
Explosive

Strategy
Use of case managers in
supervising patient care and
transfer of care throughout an
MCE.

Findings

Outcome Modulators

Using case managers
N/A
improved patient
management and flow with
similar staff and no additional
resources. Reductions were
observed in: the number of xrays/patient/1st 24-hour (P <
0.001), time to performance
of first chest x-ray (P =
0.015), time from first chest
x-ray to arrival at the next
diagnostic/treatment location
(P = 0.016), time from ED
arrival to surgery (P = 0.022)
and hospital lengths of stay
for critically injured
casualties (37.1 +/- 24.7
versus 12 +/- 4.4 days, P =
0.016 for ISS > or = 25).

Quality
score
3/8

Using case managers had no
adverse impact on the health
outcomes of critically injured
patients. Mortality rates were
similar for critically injured
patients.
Amlot, 201063 Decontamina- Western
tion
Europe

Exercise,
drill, or
training
program

Randomized
controlled trial

Chemical,
Biological,
Radiological,
Nuclear

Use of instructions, washcloth
and/or shower duration to
increase decontamination
effectiveness

C-16

Any form of showering is
more effective than not
showering; however, the use
of a washcloth significantly
improved results over
showering alone, showering
with instructions or
showering for longer.
Washcloth use led to 20%
less contamination, compared
to other interventions.

Showering instructions were 3/6
provided before the shower,
and were not available during
the shower, which may have
reduced effectiveness.

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year

Subcategory

Study
Location

Study Type

Study Design

Relevant type of
mass casualty
event

Strategy

Findings

Loeb, 200991

Health care
worker
prophylaxis

Canada

Analysis of
single real
event

Randomized
controlled trial

Infectious disease:
Influenza

The use of surgical masks in
place of N95 respirators to
protect healthcare workers
against influenza.

Surgical masks were deemed
noninferior to N95
respirators. The lower end of
the 95% confidence interval
for the reduction in incidence
of influenza (N95-surgical)
was greater than the
established noninferiority
limit of -9%.

Gao, 200787

Health info
technology

US

Exercise,
drill, or
training
program

Post only with
comparison
group: Paper
triage tags

Unspecified

Use electronic triage tags
(Advanced Health and
Disaster Aid Network, AIDN) to monitor vital signs and
transmit information to first
responders.

Time required for triage was
similar in both electronic and
paper triage groups.

Outcome Modulators
N/A

5/6

Triage status indicator used
5/8
LEDs that were difficult to
see from a distance under
bright sunlight and when the
Electronic triage tags allowed triage tag was flipped over on
first responders to re-triage
the patient.
patients three times more
often as first responders who Patients might wander out of
used paper triage tags.
range or vehicles (e.g., fire
trucks) might block data
transmissions.
Pulse oximeter readings have
limited accuracy in the
presence of methemoglobin,
carboxyhemoglobin, nail
polish, nail fungus,
fluorescent light, and motion.
Tags used at least eight times
less energy than existing,
similar devices

C-17

Quality
score

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year

Subcategory

Xiong, 201061 Health info
technology

Study
Location
Not
relevant

Study Type
Computer
simulation

Study Design
N/A

Relevant type of
mass casualty
event
Natural Disaster:
Earthquake

Strategy
Implement regional
telemedicine hub to support
delivery of specialty care
during MCE

Findings
Use of the telemedicine hub
reduced the number of deaths
by 5.4%, 36.5% and 27.3%
for the major, medium and
minor scale earthquake
scenarios respectively.
Use of the telemedicine hub
reduced local ED bed usage
and local trauma specialist
usage for medium and minor
earthquakes.

Outcome Modulators
Rapid availability of
specialists external to the
event are required

Quality
score
2/7

Local ED resources may
serve as a bottleneck and
require higher rates of transfer
even when the telemedicine
hub is operational

Use of the telemedicine hub
lowered average wait times
for ED beds and specialists.
Beck-Razi,
200793

Imaging

Israel

Analysis of
single real
event

Medical record
review

Explosive, Trauma: Use of focused assessment of
War
sonography for trauma
(FAST) in for MCE triage.

Validation
study

FAST results were generally
consistent with the results of
CT scans, laparotomy and
clinical observation. Overall
accuracy of FAST (compared
to other methods) was 93.1%
(sensitivity: 75.0%,
specificity: 97.6%).

Sonography in this study was
performed and interpreted by
radiologists, not emergency
medicine
physicians/providers

6/8

Type of injury varied between
soldiers (open wounds and
fractures) versus civilians
(blast/shrapnel injuries)
FAST only can detect
fluid/air so can diagnose
bleeding, but cannot exclude
all clinically important types
of abdominal injury

Korner,
2011104

Imaging

Western
Europe

Exercise,
drill, or
training
program

Post only with
comparison
group: 4-slice
MDCT

MCEs involving
major trauma

Use 64-slice multi-detector
computerized tomography
scan (vs. 4-slice MDCT) with
high volume image reading
capabilities to facilitate triage
during MCEs

The 64-MDCT protocol
reduced image processing
time from an average of 9.0
minutes to 4.1 minutes.

Large volume of data led to
an overload of the 3D
workstation; backups
workstations would be
required
Image quality might be a
modulator but it was not
assessed as part of the study

C-18

7/8

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year
Korner,
200680

Subcategory
Imaging

Study
Location
Western
Europe

Study Type
Exercise,
drill, or
training
program

Study Design

Relevant type of
mass casualty
event

Pre-post with
Unspecified
comparison
group:
Individually
admitted
patients after
multiple trauma
(historical)

Strategy

Findings

Outcome Modulators

Implement accelerated whole
body multislice computed
tomography protocol (Triage
MSCT)

Use of the triage MSCT
protocol allowed a throughput
of 6.7 patients per hour
compared to 2.4 patients per
hour for the standard
protocol.

Triage MSCT patients were
assumed to undergo
preparation at the site of the
MCE or during transport, did
not undergo focused
abdominal ultrasound, and
were transferred directly to
the CT exam room. This
accounted for most of the
throughput gain.

Triage MSCT protocol
produced an average of 201
images per patient compared
with 1031 images per patient
for the standard protocol.

Quality
score
5/7

To decrease image number
and image calculation time,
no high-resolution
reformations and multiplanar
reformations were calculated
in the Triage MSCT group.
Tube cooling problem were
encountered when using the
Triage MSCT protocol that
required a reduction in dose
for each scan and
consequently the potential for
lower image quality. This
issue may be avoided by
using newer scanners.
Staff participating in the
study were instructed before
the simulation on how to
operate the CT console with
the new MSCT protocol.

Sarkisian,
199186

Imaging

Eastern
Europe

Analysis of
single real
event

Retrospective
case review

Natural Disaster:
Earthquake

Sonographic screening for
abdominal/pelvic injury or
bleeding to triage earthquake
MCE casualties and screen
for occult injuries

False positive rate of 0/345
(0%) among patients without
true abdominal trauma.
(Reviewers' calculation)
False negative rate of 4/55
(7.2%) among patients with
true abdominal trauma.
(Reviewers' calculation)
Mean exam time of 4 minutes
(Range: 1-10 minutes)

C-19

N/A

4/8

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year
Kanter,
200777

Subcategory
Load sharing

Study
Location
Not
relevant

Study Type
Computer
simulation

Study Design
N/A

Relevant type of
mass casualty
event
Unspecified

*Also in
Altered
standards

Strategy
1) Control distribution of
pediatric disaster victims to
avoid overcrowding near
scene
2) Expand hospital capacity
by altering standards of care
to provide only "essential
interventions"

Leiba, 200697

Findings
Simulated mortality was
reduced both by controlling
the distribution of disaster
victims and by relaxing
standards of care. The
greatest reduction was
achieved by employing both
strategies together.

Outcome Modulators

Quality
score

Findings are based upon a
3/9
variety of untested and
extrapolated assumptions.
Thus, "the reported results are
not intended to recommend
particular response
strategies."
A large urban center is
modeled; the applicability to
rural or suburban
environments is unclear.

Load sharing

Israel

Analysis of
single real
event

Post only with
comparison
group:
Benchmark
(implied)

Explosive

1) Central allocation of
patients to hospitals based on
available resources

Avoidance of individual
N/A
hospital overload - 5/13, 5/13
and 3/13 urgent patients
triaged to three nearest Level
2) Central information system I trauma centers
and local hospital information
offices remote from care areas Limited diversion of medical
care personnel to
3) Simplified field triage
family/media information
system - urgent (P1 & P2),
needs
non-urgent (P3), and
expectant (P4) to speed scene Speed of scene clearance - all
clearance
21 urgent (and 2 DOA)
casualties evacuated in 25
minutes. All ambulance
patients cleared within 35
minutes

2/8

Raiter, 200875 Load sharing

Israel

Analysis of
single real
event

Post only with
comparison
group:
Benchmark
(implied)

Explosive

1) Central Incident Command
System (ICS) which gathers
data and assigns patients to
receiving hospitals

3/8

2) Robust redundant
communications channels
between Command Center,
Responders, and Receiving
Hospitals

C-20

Optimal allocation of
N/A
resources (patients to
hospitals) - no overload of
capacity - nearest Level I got
5/9 severe patients, Level II
got 4/9, 59 mildly injured
patients distributed amongst 5
hospitals
Effective communication
between responding entities cell phone service
overloaded/failed, radio,
beeper & internet channels
functioned smoothly

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year

Subcategory

Wolf, 200970

Load sharing

Study
Location
Western
Europe

Study Type
Exercise,
drill, or
training
program

Study Design
Post only with
comparison
group:
Benchmark

Relevant type of
mass casualty
event
Unspecified

Strategy

Findings

Outcome Modulators

Quality
score

New model to accommodate
MCEs with >200 casualties,
including on-site triage and
stabilization and immediate
transport of severely injured
patients to modular “Initial
Care Hospitals” for further
stabilization and emergency
treatment including surgery

Mean time from registration
to entry into operating room
for 10 patients needing
emergency surgery was 19.5
minutes

N/A

8/8

National standard was met at
the designated “Initial Care
Clinic”: 60-minute lead time
(from alert to full
preparedness and maximum
influx of patients)

Gunal,
2004103

Medical
treatment

Asia

Analysis of
single real
event

Post only with
comparison
group:
Benchmark
(historical
comparison)

Natural Disaster:
Earthquake

An organized, on-site medical
intervention for the
prevention of acute renal
failure in crush victims after a
catastrophic earthquake.

Only 4 of 16 patients with
N/A
rhabdomyolysis required
hemodialysis. All 16
survived. This is compared to
dialysis rates of 60.8% and
77% for comparable patients
in two recent earthquakes,
and to other reported
mortality rates of 15%-40%
for patients who require
hemodialysis.

6/8

Vardi, 200482

Medical
treatment

Israel

Exercise,
drill, or
training
program

Randomized
controlled trial

Chemical

Spring-driven intraosseous
infusion device to replace IV
insertion in a chemical MCE
where providers are in full
protective gear.

Simulated survival
Anesthesiologists performed
with/without IO device use - faster in both treatment and
73.4% survival versus 3.3%
control groups
survival (under the simulation
rules)

6/8

Total average casualty
treatment time with/without
device - 207 seconds versus
590 seconds
Satterthwaite, Space
201064
optimization

Australia

Analysis of
single real
event

Retrospective
case review

Explosive,
Transportation
accident

Use reverse triage to create
surge capacity, including:
suspension of normal elective
activity, discharging patients
earlier in the day, and
increasing use of community
care options such as respite
nursing home beds and
community nursing services)

C-21

Nineteen patients were
discharged early (and would
not have been discharged
early under normal
conditions).
Seven patients were
ultimately readmitted,
however, early discharge did
not increase clinical risk.

N/A

2/7

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year
Scarfone,
2011105

Subcategory
Space
optimization

Study
Location
Philadelphia, PA

Study Type
Analysis of
single real
event

Study Design
Pre-post

Relevant type of
mass casualty
event
Infectious disease:
Influenza

Strategy
1) Appropriate space for other
uses, including: 1) converting
the hospital lobby to an ED
waiting room 2) using a
subspecialty clinic to care for
non-urgent patients, and 3)
using a 24-hour short stay
unit to care for ED patients.
2) Use physicians not board
certified in pediatric
emergency medicine and
inpatient-unit medical nurses
to care for ED patients.

Findings

Outcome Modulators

Both patients' average wait
Decision to abandon initial
time in the ED and the rate of plan to treat all children with
leaving the ED without being ILI in one or more unit
seen during the pandemic
were less than rates measured
during the peak of seasonal
influenza in the prior year.

Quality
score
2/8

The ED continued to accept
all children brought by local
ambulance crews, and never
went on divert status.

3) Other strategies included
stockpiling PPE, antiviral
medication, and bed surfaces,
and the use of a tiered
distribution of H1N1 vaccine.
Van Cleve,
2011107

Space
optimization

Seattle,
Analysis of
Washington single real
event

Pre-post

Infectious disease

Reverse triage to identify
patients for release and
increase inpatient surge
capacity

The hospital discharged
essentially the same number
of patients on November 4 as
on previous high-census days
when the surge plan was not
activated, suggesting that the
surge plan did not succeed in
creating excess discharges.

The hospital never declared a
disaster abd never
sytematically implmented
reverse triage

5/8

Andreatta,
201090

Training

Ann Arbor,
MI

Randomized
controlled trial

Explosive

Use virtual reality to teach
START triage

Virtual reality-based triage
performance did not lead to
improved performance
compared to (traditional)
standardized patient triage
training.

Higher up-front costs for VR
development

6/6

Exercise,
drill, or
training
program

C-22

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year
Hsu, 200481

Subcategory
Training

Study
Location
US,
Western
Europe,
Eastern
Europe,
Asia

Study Type

Study Design

Systematic
N/A
Review/Metaanalysis

Relevant type of
mass casualty
event
All-hazards,
Chemical,
Biological,
Radiological,
Nuclear, Explosive,
Transportation
accident

Strategy
1) Conduct hospital disaster
drills to train hospital staff to
respond to a mass casualty
event
2) Use computer simulations
to train hospital staff to
respond to a mass casualty
event
3) Conduct tabletop or other
exercises to train hospital
staff to respond to a mass
casualty event

Findings

Outcome Modulators

Disaster drills have the
N/A
potential to identify problems
with incident command,
communications, triage,
patient flow, materials and
resources, security, and
decontamination. Disaster
drills usually were not
designed to evaluate the
effectiveness of patient care.

Quality
score
7/10

Computer simulation was
able to identify bottlenecks in
patient care,
electromechanical failures,
crowd control issues and
other security problems, and
resource deficiencies.
Evidence is insufficient to
reach definitive conclusions
regarding the effectiveness of
computer simulations or
tabletop exercises.

Jarvis, 200988 Training

Western
Europe

Exercise,
drill, or
training
program

Randomized
controlled trial

Unspecified

Use computer game method
of triage training

C-23

Computer game participants
achieved higher triage tagging
accuracy (compared to
participants in a tabletop
exercise)

Providing interim feedback
improves step accuracy but
not accuracy of triage
classification.

4/8

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year
Sanddal,
200499

Subcategory
Training

Study
Location
US

Study Type
Exercise,
drill, or
training
program

Study Design
Pre-post

Relevant type of
mass casualty
event
Explosive,
Transportation
accident

Strategy

Findings

Outcome Modulators

A 1 hour training program to The training session improved Motivation and abilities of
improve pediatric triage
triage performance and that
trainees
performance ("JumpSTART") improvement was sustained at
3 months.
The generalizability of
performance improvement to
other scenarios (or to any
non-drill situation) is
unknown.

Quality
score
6/8

The sustainability of
performance improvement
beyond 3 months is unknown.
Using triage tags rather than
simulating them was found to
be helpful
Vincent,
200971

Vincent,
200873

Training

Training

US

US

Exercise,
drill, or
training
program

Pre-post

Exercise,
drill, or
training
program

Pre-post

Explosive

Unspecified

Teach triage skills using
podcasts and iterative multimanikin simulations

Teach mass casualty triage
skills using an immersive 3D
Virtual Reality environment.

Accuracy of triage, choice of
intervention, and rapidity of
triage all improved with
training.

Performance may vary with
mechanism of injury

Triage accuracy and
intervention scores improved
significantly after one
iteration of training. Time to
complete the scenario
improved with each iteration.

There may have been a
selection bias, with more
technologically savvy
learners signing up to
participate in this trial

Improvement might have
resulted from technical
familiarity with manikins
rather than improvement in
triage skills.

Apparent performance gains
could reflect familiarity with
VR equipment rather than
improved triage knowledge

C-24

3/5

4/7

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year
Adeniji,
201192

Subcategory
Triage

Study
Location
Western
Europe

Study Type
Validation
study

Study Design
Retrospective
case review

Relevant type of
mass casualty
event
Infectious disease:
Influenza

Strategy

Findings

Outcome Modulators

STSS (Simple Triage Scoring
System) to help triage critical
care admissions during
influenza pandemic

STSS had superior accuracy
in predicting ICU need
relative to SOFA score - the
Area Under the Curve (AUC)
of the Receiver Operator
Characteristic (ROC) was
0.88 versus 0.77

Low mortality of H1N1
patients prevented evaluation
of predictive accuracy for
mortality

Quality
score
3/6

STSS had superior accuracy
in predicting need for
mechanical ventilation
relative to SOFA score - the
Area Under the Curve (AUC)
of the Receiver Operator
Characteristic (ROC) was
0.91 versus 0.87
Aylwin,
200679

Triage
*Also in
Altered
standards

Western
Europe

Analysis of
single real
event

Retrospective
case review

Explosive

1) Trained/experienced triage Accuracy of on-scene triage
N/A
at scene
was much higher for locations
where fully trained
2) Simplified on-scene triage responders (versus by
(urgent (P1 & P2), not urgent medically trained bystanders)
(P3), expectant
performed triage (33%
overtriage versus 82%
3) Re-triage at every stage,
overtriage of critical patients)
directed by
trained/experienced providers Speed of scene clearance with explicitly designated
Average of 27 P1 & P2 (most
authority
seriously wounded) patients
per hour (= 2.2 minutes per
4) Damage Control approach patient)
(minimize use of all critical
hospital resources)
Second stage screening (at the
ED Door) reduced the surge
demand (by screening out
over-triage and identifying
under-triaged/deteriorating
patients) reducing initial
overtriage to 0% and
undertriage to 20% of critical
patients.
Increase available surge
capacity - created 10 ICU bed
spaces and made all ORs
available within 2 hours

C-25

5/8

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year
Beyersdorf,
199685

Subcategory
Triage

Study
Location
Spokane,
WA

Study Type
Analysis of
single real
event

Study Design
Post only with
comparison
group:
Benchmark
(implied)

Relevant type of
mass casualty
event
Mass shooting

Strategy
Preexisting/pre-tested MCE
response plan incorporating
interagency cooperation,
unified communications and
incident command, on-scene
provider triage, and allocation
of casualties based on
hospital resources.

Findings

Outcome Modulators

A total of 2/19 patients (11%) Pre-hospital vehicles
were over-triaged and 2/19
contained job descriptions
(11%) were under-triaged.
and duties printed on small
cards, and were utilized to
100% survival.
establish a command center
and chain of command at the
scene

Quality
score
2/6

Designation of a regional
disaster control hospital
allowed for minute-by-minute
knowledge of the capabilities
of area hospitals and efficient
dispersion of the victims to
appropriate facilities.
Surgical specialists were
preassigned to specific
facilities thereby avoiding
confusion.
Cancio,
200894

Triage

Iraq

Analysis of
multiple real
events
Validation
study

Medical record
review

Military/Combat

The use of the Field Triage
Score (FTS07) compared to
the Revised Trauma Score
(RTS) in predicting mortality
and massive transfusion.

C-26

FTS predicted mortality and
massive transfusion nearly as
well as the Revised Trauma
Score (RTS), but can be
calculated without computing
assistance in the field.

Often, study patients already 4/6
had field interventions (such
as intubation) performed prior
to RTS/FTS assessment

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year
Casagrande,
2011106

Subcategory
Triage

Study
Location
Not
relevant

Study Type
Computer
simulation

Study Design
N/A

Relevant type of
mass casualty
event
Nuclear

Strategy
Use Model of Resource and
Time-based Triage to
prioritize victims with
moderate life-threatening
injuries over victims with
severe life-threatening
injuries, and to prioritize
victims with different levels
of radiation exposure.

Findings

First, when the victim loading N/A
is low (i.e., less than or equal
to the baseline number of
surgical teams and patients),a
triage system that prioritizes
moderately injured victims
followed by severely injured
victims followed by mildly
injured victims (mod-sevmild) saves 10% more lives
than alternative approaches.
Second, as the victim loading
increases relative to the
resources available (up to 10fold more patients or 10-fold
fewer surgical teams as the
baseline), mod-sev-mild saves
more than 3-fold more
victims than a sev-mod-mild
system.
Delaying the care of victims
with trauma and >0.7 Gy of
irradiation increases the
number of lives saved by 1.4fold compared to a system in
which irradiated victims are
treated exactly like nonexposed victims.
The mod-sev-mild triage
scheme results in less demand
for ICU beds than a sev-modmild scheme (15,000 vs.
17,000 on the first day).

C-27

Outcome Modulators

Quality
score
6/9

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year

Subcategory

Cohen, 199884 Triage

Study
Location
Israel

Study Type
Analysis of
multiple real
events

Study Design
Retrospective
case review

Relevant type of
mass casualty
event
Explosive

Strategy
Use American College of
Surgeons Committee on
Trauma criteria during field
triage for blast MCE injuries.

Validation
study

Findings
Field undertriage rate - 0/26
(0%) critical patients, 4/28
(14%) severely injured, and
19/143 (13%) moderately
injured patients initially
classified as less severe

Outcome Modulators
Experience of field triage
providers

Quality
score
4/8

Field overtriage rate - 12/36
(33%) minor injury patients
initially classified as more
severe
Cone, 200969

Triage

US

Exercise,
drill, or
training
program

Post only with
comparison
group:
Benchmark

All-hazards

Use of the Sort- AssessLifesaving InterventionsTreatment/transport (SALT)
triage protocol.

Study participants
(paramedics) using SALT had
a 78.8% accuracy rate. The
overtriage rate was 13.5% and
the undertriage rate was
3.8%. The undertriage rate is
lower than the 5% the authors
assert is standard in the
literature.

Time elapsed between
5/8
training on triage method and
application of methodology.
Training level and experience
of triage provider (EMT,
Paramedic, MD, etc.) may
also influence accuracy

Average triage time was 15
seconds (median: 11.5
seconds; range 5-57 seconds).
Cone, 200874

Triage

New
Haven, CT

Exercise,
drill, or
training
program

Post only with
comparison
group: Gold
standard triage
category

Chemical

Use combined trauma/CBRN- Overtriage rate (1.8%, 1/56
Inaccuracy in triage mostly
specific triage method during patients)
due to missing signs of
an MCE.
chemical toxidrome
Undertriage rate (10.8%, 6/56
patients)
Triage speed - 19 seconds per
patient

C-28

6/8

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year
Cryer, 201095

Subcategory
Triage

Study
Location

Study Type

Los
Analysis of
Angeles
multiple real
County, CA events

Study Design
Pre-post

Relevant type of
mass casualty
event
Transportation
accident

Strategy
1) Use a trauma system
performance improvement
program to evaluate MCE
response, identify
shortcomings, and change
policy based upon the
findings.
2) Use air transport to
facilitate distribution of
"immediate" patients evenly
to area trauma centers.
3) Encourage EMS to
distribute all victims meeting
"trauma center criteria" to
trauma centers rather than to
non-trauma community
hospitals.

Guest,
2009102

Triage

Western
Europe

Prospective
cohort study

N/A

Infectious disease:
Influenza

Implement Christian et al.'s
triage protocol during an
influenza pandemic

prospective
data
collection
during
conventional
care
conditions

Findings
Regional EMS quality
improvement plan can
improve the distribution of
patients to appropriately
resourced hospitals in mass
casualty events. In the 2005
train crash only 44% (11/25)
of "immediate" patients were
taken to trauma centers, as
compared to 89% (55/62) in
2008.

Quality
score

N/A

5/8

N/A

5/7

In the 2005 crash, only 2
patients were transported by
air; in 2008, 34 were
transported by air.

For prioritizing ICU
admission,
sensitivity/specificity for "no
significant organ failure"
were 0.66/0.83, respectively.
For the "palliative treatment
only" category, sensitivity
and specificity were 0.29 and
0.84, respectively.
For prioritizing ongoing ICU
care, sensitivity/specificity for
"no significant organ failure"
were 0.76/0.86, respectively.
For the "palliative treatment
only" category, sensitivity
and specificity were 0.61 and
0.87, respectively.

C-29

Outcome Modulators

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year

Subcategory

Study
Location

Study Type

Study Design

Relevant type of
mass casualty
event

Strategy

Findings

Gutsch,
200696

Triage

Western
Europe

Exercise,
drill, or
training
program

Post only with
comparison
group:
Benchmark

Unspecified

Use mSTART triage
algorithm

Triage time by EMTs was a
median of 35 seconds each
(average 41 seconds), which
compares favorably with
emergency physician average
of ~3 minutes. EMT critical
red over-triage was 5.3% and
critical red under-triage was
3% (both are considered
excellent). Sensitivity was
88%, and specificity was
94%.

Hirshberg,
201066

Triage

Not
relevant

Computer
simulation

N/A

Explosive

1) Use a 2-stage triage system Single-step triage works well
for large-scale MCEs
for small-scale incidents.
When resources are
2) Use most experienced
overwhelmed, 2-stage triage
physician for the first step of substantially increases the
triage
"time to saturation" (point at
which ED is at full capacity).

Outcome Modulators

Quality
score

N/A

4/4

Value of 2-step procedure
varies with the ratio of
casualties to provider teams

6/9

Model does not deal well with
the possibility of under-triage
in two-step process

If two triage providers have
70% and 90% accuracy,
assigning the better provider
to the first step of a sequential
triage increases time to
saturation by approximately
50%.
Janousek,
199983

Triage

US

Exercise,
drill, or
training
program

Post only with Chemical,
The use of various providers
comparison
Biological, Nuclear, types in doing MCE triage.
group: Provider Trauma: War
groups
compared
against each
other.

C-30

Physicians had higher triage
N/A
accuracy scores than other
military healthcare providers
(nurses, dentists and medics,
using the NATO triage
classification system (mean
score of 54, compared to 50-denominator could not be
determined). There were no
statistically significant
differences between
emergency physicians,
surgeons and general medical
officers. Likewise, there were
no differences between
medics, nurses and dentists.

3/7

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year

Subcategory

Study
Location

Study Type

Study Design

Relevant type of
mass casualty
event

Strategy

Findings

Kilner, 201062 Triage

Not
relevant

Systematic
N/A
Review/Metaanalysis

Explosive, Natural
Disaster

Field triage tools for victims
of "big bang" incidents
(sudden onset MCEs rather
than slowly emerging MCEs).

Kuniak,
200876

US

Exercise,
drill, or
training
program

Radiological

Use Radiation Injury Severity Accuracy of raters’
Classification (RISC) for
classification was
early triage of radiation MCE approximately 95%.
casualties when dosimetry
data are unavailable

Triage

Post only with
comparison
group: Gold
standard
disposition
categories

Outcome Modulators

There is limited evidence for N/A
the validity of existing triage
tools. The authors identify
the Sacco triage system as
"the most promising" but state
that further evaluation of this
tool is required.
Trend towards training level
affecting triage accuracy
(MD>RN>EMT)

Quality
score
8/8

6/8

Hematologic component
proved most difficult to score
System allows for the rapid
assessment of ARS severity
without the availability of
dose information
Less complex than other
systems (e.g., METROPOL)
and is amenable to selfeducation.

Lerner,
201068

Triage

Augusta,
GA &
Milwaukee,
WI

Exercise,
drill, or
training
program

Post only with
comparison
group:
Benchmark
(START
protocol)

Explosive

Use of the Sort- AssessLifesaving InterventionsTreatment/transport (SALT)
triage protocol

Performance using the SALT N/A
protocol was comparable to
other studies using the
START triage protocol. Final
triage was correct 83% of the
time (CI: 78-88%), compared
to START studies (48-75%).
6% were overtriaged and 10%
were undertriaged.
Timing using the SALT
protocol was comparable to
other studies using the
START triage protocol. Mean
triage time was 28 seconds
(Std dev: 22 sec), compared
to 30 seconds for START.
Further, this study used
simulated 'patient'
interference, which may have
increased triage times.

C-31

5/8

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year

Subcategory

Study
Location

Study Type

Study Design

Relevant type of
mass casualty
event

Strategy

Findings

Outcome Modulators

Quality
score

Navin, 200998 Triage

Not
relevant

Computer
simulation

N/A

Unspecified

Use Sacco triage method (vs.
START triage) for patients of
military age with blunt,
penetrating, and blast injuries.

Simulated survivorship
improves by 20-300%
depending upon the
distribution of injuries and
resource constraints.

N/A

3/7

Nie, 201067

Asia

Analysis of
single real
event

Post only with
comparison
group:
Benchmark
(START
protocol)

Natural Disaster:
Earthquake

Use field triage method that
accounts for resources at the
accepting institution. In this
instance, a 'resuscitation'
category was added.

The addition of a
resuscitation group to
standard (START) protocols
led to lives saved within that
group. 4 of 6 patients in the
resuscitation group survived
to discharge. These patients
would have been classified as
'expectant' under START.

Strategy depends heavily on
local decisions.

2/8

Pre-post

Transportation
accident

TAS Triage Method for bus
crash type MCE (combines
triage Sieve for adults and
trauma tape for pediatric
patients)

Overtriage rate before
implementation of TAS: 9/74
(12.2%), versus 0/74 (0%)
after implementation of TAS

Need TAS Training

Rehn, 201065

Triage

Triage

Western
Europe

Exercise,
drill, or
training
program

Undertriage rate before
implementation of TAS: 9/24
(12.2%) , versus 0/24 (0%0
after implementation of TAS
Scene clearance rate - mean:
22 minutes (range 15-32)
before implementation of
TAS, versus mean: 10
minutes (range 5-21) after
implementation of TAS

C-32

Accuracy of triage may
depend on specialty of
physician who conducts
initial triage.

Need TAS Equipment
Probably easier to collect
accurate input data under
simulation conditions than in
real MCE

6/8

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year

Subcategory

Study
Location

Study Type

Study Design

Relevant type of
mass casualty
event

Strategy

Findings

Outcome Modulators

Quality
score

RodriguezNoriega,
201089

Triage

Mexico

Analysis of
single real
event

Prospective
case series

Infectious disease:
Influenza

Use Influenza-Like Illness
Scoring System to triage
adults seeking care at an ED
during an influenza
pandemic. Patients with high
scores are admitted and
treated with oseltamivir.
Those with intermediate
scores are sent home with
oseltamivir and followed up
by phone daily for 10 days.
Those with low scores are
discharged home without
treatment.

Of 1324 ambulatory patients N/A
who were discharged without
receiving oseltamivir, 14
(0.8%) returned after their
initial visit. Three of these
patients were hospitalized and
treated with oseltamivir (two
of them tested positive for
H1N1).

5/8

Romm,
201160

Triage

US,
Canada/
Australia/
New
Zealand,
Western
Europe,
Asia

Laboratory
test

N/A

Radiological,
Nuclear

Use fewer metaphase spreads
when using the dicentric
chromosome assay method of
biodosimetry for mass
radiological incidents.

Analyzing 50 metaphases
gives reliable and accurate
individual dose estimations
over the dose range of 0.75 to
4.5 Gy. Most of these dose
estimations are within 20% of
the actual doses. Dose
estimations based on analysis
of only 20–30 metaphases
allowed an accurate
evaluation in the higher dose
ranges. (Routine standard is
500-1000 metaphases)

Range of exposure doses and
uniformity of exposure will
impact effectiveness of
strategy.

5/5

Sacco,
2007101

Triage

Not
relevant

Computer
simulation

N/A

Any MCE
associated with
penetrating trauma

Use Sacco Triage Method (as
compared to START) for
victims with penetrating
trauma injuries during an
MCE

Under severe resource
restrictions, the Sacco Triage
Method may save up to an
additional 6 to 16 individuals
(among 60 simulated
victims); whereas the
minimum survival benefit is
between 0 and 7 victims.
When resources are not
constrained, the method saves
at most 5 additional victims
(out of 60).

Method requires interhospital coordination with
respect to reporting resource
availability and receiving
patients

5/7

C-33

Method also requires robust
communication systems

Appendix Table C-4b. Tested Strategies to optimize use of existing resources (KQ2)

Author, Year
Schenker,
2006100

Subcategory
Triage

Study
Location
New York,
NY

Study Type
Exercise,
drill, or
training
program

Study Design
Post only with
comparison
group:
Benchmark

Relevant type of
mass casualty
event
Chemical,
Explosive,
Transportation
accident

Strategy
Implement START triage
algorithm during mass
casualty event

Findings
A total of 88/121 patients
(70%) were triaged
accurately.

Outcome Modulators

Quality
score

N/A

6/8

Hospital capacity self-report
was inaccurate

4/6

A total of 29 of 47 patients
(62%) were managed
appropriately when their
clinical status was altered as
part of the exercise. Six
patients who underwent status
changes indicating a possible
myocardial infarction or
asthma attack were classified
as over-triaged according to
START but were judged to be
managed appropriately by
exercise staff.
Zoraster,
200778

Triage

Los
Angeles,
CA

Analysis of
single real
event

Retrospective
case review

Transportation
accident

Use of START triage by a
regional trauma network to
prioritize transport of MCE
patients and to distribute them
among area hospitals.

Trauma centers were
underutilized and community
hospitals received critical
patients that they were poorly
equipped to handle.

START categorization
scheme was imperfectly
understood
START triage categories
differ from trauma center
criteria, causing confusion

C-34

Appendix Table C-4c. Tested Strategies to augment existing resources (KQ2)

Author, Year
Corvino,
2006108

Subcategory
Resource
conversion

Study
Location
US

Study Type
Laboratory
experiment

Study Design
N/A

Relevant type of
mass casualty
event
Chemical

Strategy
Convert Pralidoxime (2PAM) in autoinjectors into IV
form if needed to respond to
nerve agent MCE

C-35

Findings
Resulting formulation is
potent and stable - Greater
than 90% potency at 28 day
post-preparation, with no
bacterial contamination or
detected physical changes

Outcome Modulators
N/A

Quality
score
6/7

Appendix Table C-4d. Tested Strategies for crisis standards of care (KQ2)

Author, Year
Aylwin,
200679

Subcategory
Trauma
surgery
*Also in
Optimize
resources

Study
Location
Western
Europe

Study Type
Analysis of
single real
event

Study Design
Retrospective
case review

Relevant type of
mass casualty
event
Explosive

Strategy

Findings

Outcome Modulators

1) Trained/experienced triage Accuracy of on-scene triage
N/A
at scene
was much higher for locations
where fully trained
2) Simplified on-scene triage responders (versus by
(urgent (P1 & P2), not urgent medically trained bystanders)
(P3), expectant
performed triage (33%
overtriage versus 82%
3) Re-triage at every stage,
overtriage of critical patients)
directed by
trained/experienced providers Speed of scene clearance with explicitly designated
Average of 27 P1 & P2 (most
authority
seriously wounded) patients
per hour (= 2.2 minutes per
4) Damage Control approach patient)
(minimize use of all critical
hospital resources)
Second stage screening (at the
ED Door) reduced the surge
demand (by screening out
over-triage and identifying
under-triaged/deteriorating
patients) reducing initial
overtriage to 0% and
undertriage to 20% of critical
patients.
Increase available surge
capacity - created 10 ICU bed
spaces and made all ORs
available within 2 hours

C-36

Quality
score
5/8

Appendix Table C-4d. Tested Strategies for crisis standards of care (KQ2)

Author, Year

Subcategory

Dhar, 2008110 Trauma
surgery

Study
Location
Asia

Study Type
Analysis of
single real
event

Study Design

Relevant type of
mass casualty
event

Post only with Natural Disaster:
comparison
Earthquake
group:
Comprehensive
care (implied)

Strategy
"Damage control" surgery for
the orthopedic injuries of
MCE polytrauma patients if
referral to hospital is delayed
or comprehensive care
resources unavailable

Findings

Outcome Modulators

Acceptable outcome at 1 year Results inferior for intracompared with
articular (joint involved)
comprehensive care = 49/62
fractures
(79%) "excellent" or "good"
outcomes; only 3 non-unions
(unhealed fractures)

Quality
score
5/8

Mortality - 0%
Operating Room Time
(relative to definitive repair) mean: 38.5 minutes for
external fixation (37% of
internal fixation time)
Kanter,
200777

Pediatrics

Not
relevant

Computer
simulation

N/A

Unspecified

*Also in
Optimize
resources

1) Control distribution of
pediatric disaster victims to
avoid overcrowding near
scene
2) Expand hospital capacity
by altering standards of care
to provide only "essential
interventions"

Simulated mortality was
reduced both by controlling
the distribution of disaster
victims and by relaxing
standards of care. The
greatest reduction was
achieved by employing both
strategies together.

Findings are based upon a
3/9
variety of untested and
extrapolated assumptions.
Thus, "the reported results are
not intended to recommend
particular response
strategies."
A large urban center is
modeled; the applicability to
rural or suburban
environments is unclear.

Labeeu,
1996111

Orthopedics

Rwanda

Analysis of
single real
event

Post only with Trauma: War
comparison
group: Standard
care (implied)

External fixation of fractures
rather than definitive
orthopedic care

External fixation used for
N/A
1,129 fractures. Average
time of placement was 30
minutes. Numerous
complications, not quantified.
Authors consider this to be
the best compromise between
nonoperative methods and
definitive care.

1/6

Merin,
2010109

General

Haiti

Analysis of
single real
event

Post only with Natural Disaster:
comparison
Earthquake
group: Standard
care (implied)

Altered standards of care, and
allocation of resources
towards patients most likely
to benefit.

Authors assert that they
treated more patients than
they would have if they had
not relaxed standards of care
or had they not allocated
resources with the goal of
maximizing the number of
lives saved.

1/6

C-37

N/A

Appendix Table C-5. Tested Strategies Lacking Comparisons Groups (KQ2)

Author, Year
Bouman, 2000123

Strategy
Optimize resource
use

Curtis, 2008122

Optimize resource
use

Dan, 2009112

Mass Casualty
Context
All-hazards

Innovation
Information
technology

Description
Register patients using a bar code
to facilitate patient flow

All hazards

Information
technology

Optimize resource
use

Earthquake

Imaging

Use of the SMART (Scalable
Medical Alert Response
Technology) to monitor
unattended patients (exercise)
Use ultrasonography as a key
triage tool (actual event)

Gunawan, 2009121

Optimize resource
use

All-hazards

Information
technology

Use of a simple navigation aid for
the walking wounded (simulation)

Jokela, 2008120

Optimize resource
use

All-hazards

Information
technology

Körner, 2009115

Optimize resource
use
Optimize resource
use

All-hazards

Imaging

All-hazards

Information
technology

Ma, 2007114

Optimize resource
use

All-hazards

Imaging

Malik, 2004116

Optimize resource
use

Trauma

Triage tool

Use of Radio Frequency
Identification (RFID) technology
to provide online triage system
for mass casualty
Use of a CT triage protocol for
MCIs (simulation)
IT- hospital administration
system, EMR, picture archiving
and communication system
Utilization of ultrasound as a
triage tool to aid clinicians in
rapid screening (simulation)
Use of multiple scoring systems
in the triage process

Mazur, 2009113

Optimize resource
use
Optimize resource
use

Hurricane

Imaging

All-hazards

Training

Okumura, 2007117

Optimize resource
use

Chemical

Triage tool

Probst, 2008118

Optimize resource
use

Cemical, explosive

Provider coordination

Roth, 2009126

Optimize resource
use

All-hazards

Information
technology

Levy, 2010125

Nilsson, 2008128

Use of ultrasound by DMATs as a
MCI triage adjunct (Actual event)
Educational tool that links
resource allocation decisions to
patient outcomes
Triage and decontamination with
colored clothes pegs (CCP)
(simulation)
Medical Rescue Task Force that
combines hospital rescue and
ambulance staff to support care at
an initial care hospital
Web based healthcare related all
hazards electronic disaster
manangement system (simulation)

C-38

Results
The patient bar system has been in effect in the Netherlands since the late
90s. It has had positive effects on the Major Incident Management Plan and
has reduced registration errors.
An initial evaluation in the ED via a pilot and a city-wide disaster drill
showed promise. Future plans include modification of algorithms to
reduce number of false positives and increasing integration of the system
within the ED.
Ultrasonography was used during the Wenchuan Earthquake. It played an
important role in the triage of earthquake victims, provided accurate and
timely diagnosis of closed injury, bedside examination of severe cases, and
interventional treatments.
Use of an arrow-pointing prototype device provides sufficient guidance for
the walking wounded to reach the targeted destination, sparing first
responders as escorts.
A simulation exercise demonstrated that use of RFID is feasible for use in
the field.

Results from 2 large scale exercises demonstrated that a CT triage protocol
was feasible and produced similar findings among the exercises conducted.
IT, including EMR, is feasible in a field hospital operation.

Ultrasound imaging is feasible and may be applied to MCIs.

Triage effectively accomplished at 3 levels using 3 different scoring
systems (e.g. on site "Triage sieve", at the primary health care center "field
categories of trauma patients", tertiary referral center "Advanced Trauma
Life Support" (ATLS) secondary survey").
US is feasible to use in MCI and can assist in triage decisions.

Pilot study conducted as part of a national training program.
Effective use of CCP for triage and decontamination in a drill.

In the course of three separate exercises, the protocol was shown to be
highly efficient.

Describes the tool and its potential uses.

Appendix Table C-5. Tested Strategies Lacking Comparisons Groups (KQ2)
Author, Year
Urban, 2007127

Strategy
Optimize resource
use

Young, 2006124

Optimize resource
use

Zhao, 2006119

Mass Casualty
Context
All-hazards

Innovation
Information
technology

Description
Automated call-down system to
mobilize staff during MCE

Infectious disease

Information
technology

Optimize resource
use

All-hazards

Information
technology

Albanese, 2007153

Augment resources

Radiological

Load sharing

Web-based triage tool for
bioterror or ID outbreak
(simulation)
Use of a portable tool by first
responders in documenting and
communicating triage of victims
(e.g. TACIT software)
(simulation)
Establisment of a Biodosimetry
Laboratory in Connecticut for
surge capacity

Baldwin, 2006143

Augment resources

Hurricane

Mass transfer

Barillo, 2010137

Augment resources

Burns

Response teams

Björnsson, 2008140

Augment resources

Tsunami

Mass transfer

Chen, 2009141

Augment resources

Earthquake

Mass transfer

Chung, 2011139

Augment resources

All-hazards

Load sharing

Cryer, 2009144

Augment resources

All-hazards

Load sharing

ECRI Institute,
2009132

Augment resources

All-hazards

Mechanical
ventilation

ECRI
Institute,2008133

Augment resources

All-hazards

Mechanical
ventilation

Can the mass interstate transfer
of pediatric patients be
accomplished during a hurricane?
(acutal event)
Use of Special Medical
Augmentation Response TeamsBurn for rapid ICU expansion
(actual event)
Conversion of a charter plane to
mass transport patients (actual
event)
Trans-province transfer of
patients (China - actual event)
Use of pediatric alternate care site
during 2009 H1N1 pandemic

Use of a trauma system structure
during multicasualty events
(actual events)
Use of automatic gas-powered
resuscitators (AGPRs) for
respiratory support in MCI as an
alternative to ventilators
Use of automatic gas-powered
resuscitators (AGPRs)for
respiratory support in MCI as an
alternative to ventilators
(simulation)

C-39

Results
In two tests, up to 50% of all workers could be reached (up to 18% could
report in under 30 minutes; up to 32% could report within 60 minutes).
Among trauma room team members, up to 53% could be reached (up to
21% could report in under 30 minutes; up to 36% could report within 60
minutes).
Safely reduces the number of clinical positions in managing the Point-ofDispensing (POD).
Two field trials verified that a portable tool could efficiently work in
prehospital response e.g. reduced triage collection time, improved
collection accuracy.

Identified 30 of 32 labs qualified and willing to perform initial
biodosimetry processing. Additionally a functional exercise involving a
subset of these labs and their technicians was conducted with promising
feedback.
Despite successful interstate transfer of pediatric patients, there remains a
need for planned regionalization of children's services.

Description of a method for and lessons learned from creating a temporary
burn center

Alterations of a Boeing 757-300 in 2 days to accommodate 18 patients on
stretchers and 78 seated passengers was deemed a success with regard to
safe transport from Thailand to Sweden.
Successful trans-province transfer of 10,373 patients (no casualties)
On the days the ASC was open, the mean ED volume was 42% greater than
the baseline rate for the same period in the prior year. There were
no adverse reports concerning the ASC filed, and none of
the patients who returned for evaluation within 72 hours were
admitted to the hospital.
The Medical Alert Center for Los Angeles County can coordinate the
distribution of casualties among the hospitals serving the region (e.g. most
critical patients triaged to level 1 centers)
AGPRs do not have all features needed for full respiratory support.
Usefulness and limitations of APGRS discussed

Conclude that the respiratory needs of most pt in a MCI will exceed what
AGPRs can provide.

Appendix Table C-5. Tested Strategies Lacking Comparisons Groups (KQ2)
Author, Year
Epstein, 2010151

Strategy
Augment resources

Mass Casualty
Context
All-hazards

Innovation
Communications

Fuzak, 2010142

Augment resources

All-hazards

Mass transfer

Gao, 2008149

Augment resources

All-hazards

Information
technology

Hamilton, 2003146

Augment resources

All-hazards

Information
technology

Hammer, 1996154

Augment resources

All-hazards

Devices

Hanley, 2008136

Augment resources

All-hazards

Mechanical
ventilation and crosstraining

Jacobs, 2006145

Augment resources

Explosive

Information
technology

Killeen, 2006147

Augment resources

All-hazards

Information
technology

Körner, 2010152

Augment resources

All-hazards

Communications

Lin, 2009135

Augment resources

All-hazards

Mechanical
ventilation and crosstraining

Little, 2009134

Augment resources

Infectious Disease

Oxygen delivery

Lucas da Silva,
2008150

Augment resources

All-hazards

Information
technology

Mead, 2004156

Augment resources

Infectious Disease

Infection control

Description
Text messages for staff recall
(simulation)
Mass inpatient pediatric transfer
using parallel circuits - actual
event (nondisaster)
Use of miTag (medical
information tag) to track patients
throughout the disaster response
process (simulation)
Institute a Web based tool - a
mass casualty tracking system- to
help reduce the amount of
confusion at a MCI (simulation)
Use of unilateral external fixation
device for stabilization prior to
major surgery
Implementing a program that
trains non-respiratory therapists to
assist in providing mechanical
ventilation (Project XTREME
(Cross-training Respiratory
Extenders for Medical
Emergencies))
Web application designed to be
the primary communication and
resource management tool during
a terrorist event or public health
emergency (simulation)
Wireless handheld device with an
electronic medical record (EMR)
for use by rescuers responding to
MCEs (simulation)
Use of electronic call down
system for radiology staff during
an MCE
Bag-valve-mask technique
training for medical students ias
an alternative to mechanical
ventilation
Method of providing an
improvised oxygen delivery
system (simulation)
Use of pervasive computing
technology to non-obtrusively
capture contextual information
Method to establish airborne
infection isolation areas using a

C-40

Results
Successful test of system to rapidly mobilize staff. Text messaging is
simple, inexpensive, and easy to implement
Successful transfer of 111 pediatric pts (64 critical) with no adverse
outcomes. Describe pediatric considerations and equipment, lessons
learned
Two separate pilots demonstrated feasibility of the miTag in terms of
increasing patient care capacity in the field as well as successful transfer of
information within radio-interference-rich settings.
The alpha test of the Emergency Patient Tracking System (EPTS)
demonstrated that it is possible to coordinate efforts and reduce confusion
during MCIs.
The device allowed soft tissue recovery in nearly all cases.

Pilot testing of Project XTREME demonstrated that evaluated individuals
could successfully complete training based on cognitive and performance
scores.

State of CT participated in a DHS exercise. The web application was
successfully implemented to assess surge capacity and other resources.

Records real-time data electronically for simultaneous access by providers
and incident command.

Successul test of system. Automated alarm procedure might be helpful and
testing allows for estimation of the manpower reserve and calculation of
maximum service capacities.
The majority of students (93%) knew proper head positioning technique in
non-trauma cases after a 30 minute didactic session. All 31 students
completed and passed the competency checklist.
An improvised system to deliver oxygen in the event of a disaster can be
easily assembled and is both feasible and functional.
Describes the concept of the technology, but prototype has not been built or
tested.
The best-performing designs showed no measurable source migration out
of the inner isolation zone. The cost of constructing the filtration unit was

Appendix Table C-5. Tested Strategies Lacking Comparisons Groups (KQ2)
Author, Year

Strategy

Mass Casualty
Context

Innovation

Neyman, 2006129

Augment resources

All-hazards

Mechanical
ventilation

Noordergraaf,
1996148

Augment resources

All-hazards

Information
technology

Paladino, 2008130

Augment resources

All-hazards

Rosenbaum, 2004155

Augment resources

Infectious disease

Mechanical
ventilation
Re-purpose space

Sandlin, 200951

Augment resources

Chemical

Information
technology

Voelker, 2006138

Augment resources

All-hazards

Williams, 2010131

Augment resources

Infectious Disease

Capacity
augmentation
Mechanical
ventilation

Ytzhak, 2012157

Crisis standards of
care

Infectious disease

Triage tool

Description
commercially available portable
filtration unit and common
hardware supplies
Simulation study to determine if
one ventilator could be modified
to provide mechanical ventialtion
for four adults simultaneously
(simulation)
Use barcoded identifiers to
represent patients, injuries,
facilities, and locations
(simulation)
4-limbed ventilator circuit
connected in parallel (simulation)
Conversion of existing space to
create a negative-pressure room
for respiratory isolation
(simulation)
Use of a customized laboratory
information system (LIMS), the
Emergency Response
Management System (ERMS), at
the Centers for Disease Control
and Prevention (CDC) for rapid
analysis of clinical samples (e.g.
chemical warfare agents) and
reporting of this data
Fully equipped mobile surgical
hospital (MED-1)
Use of a low oxygen consumption
pneumatic ventilator for
emergency construction
(simulation)
Application of a decision support
tool previously developed for
ventilator allocation during an
influenza pandemic to evaluate
ventilator allocation decisions
during the Haitian Earthquake of
2010.

C-41

Results
less than US$2,300 and required fewer than 3 person-hours to construct.

Single ventilator could sustain four 70-kg individuals for a limited
duration.

Minimized errors and made exchange of data possible. The system
communicates with the permanent hospital information system. Extensive
training to use the tool was shown to be unnecessary.
Successful oxygenation and ventilation of 4 sheep with a single vent.
Use of portable HEPA filtered forced air was successful in establishing an
operational negative-pressure room.

A customized LIMS was developed to support emergency response
laboratory activities at the CDC among all users.

The hospital treated 350 patients per day during Hurricane Katrina.
Three prototypes demonstrated acceptable performance in a test lung
model with regard to compliance and rate settings.

Decision support tool appeared to be a useful tool in the allocation of
ventilators by basing decisions on three dimensions.

Appendix Table C-6. Proposed strategies to allocate scarce resources during mass casualty events (KQ2)
Author,
Year
Altevogt,
200913

Organization, Task
Force, or Panel
Institute of Medicine

Title of Report or
Article
Guidance for
Establishing Crisis
Standards of Care
for Use in Disaster
Situations: A
Letter Report

Proposed Strategy

ATS Board
of Directors,
1997168

American Thoracic
Society Bioethics Task
Force

Fair allocation of
intensive care unit
resources

One of the aims of the task force was to provide guidelines defining ethically appropriate and inappropriate criteria for
admitting and discharging ICU patients and for the use of scarce resources in the ICU. The Task Force determined that
patients meeting thresholds for medical need and benefit should be admitted on a first-come, first-served basis. Similarly,
patients who continue to meet criteria for medical need and benefit should continue to receive ICU care. They should not be
discharged prematurely with medical care inadequate for their needs in order to make room for a new ICU admission with
even greater potential benefit. The Task Force considered it an error to use ICU prognostic systems alone to deny ICU
admission. Criteria for use and discontinuation of a specific scarce resource were analogous to those for ICU admission and
discharge based on thresholds of sufficient medical need and potential benefit and should be offered on a first-come, firstserved basis.

Bone,
1994167

Society of Critical Care
Medicine Ethics
Committee

Consensus
statement on the
triage of critically
ill patients

In general, patients with good prognoses for recovery have priority over patients with poor prognoses. While uncertainty of
prognosis is a crucial problem in critical care, providers should utilize predictive instruments with a full understanding of
their strengths and limitations. Decisions to be made between patients with equivalent prognoses should be made on a first
come, first served basis. Factors that should be considered are: 1) likelihood of a successful outcome; 2) patient's life
expectancy due to disease(s); 3) anticipated quality of life of the patient; 4) wishes of the patient and/or surrogate; 5) burdens
for those affected, including financial and psychological costs and missed opportunities to treat other patients; 6) health and
other needs of the community; and 7) individual and institutional moral and religious values.

Bradt,
2009170

Australasian College for
Emergency Medicine
Disaster Medicine
Subcommittee

Emergency
Department Surge
Capacity:
Recommendations
of the Australasian
Surge
Strategy Working
Group

Proposed strategies to guide surge management in the Emergency Department (ED). Proposed strategies include dealing with
space, staffing, supplies and equipment, and flow both preceding and during surge conditions. For example,
recommendations relating to actual surge conditions in each category include: maximizing cohort care and minimizing oneon-one care (space), requesting surgical and critical care liaison points in ED (staffing); having a team member dedicated to
restocking supplies in main cohort areas, allowing staff in these areas to maintain clinical roles (supplies and equipment), and
considering the use of Focused Assessment with Sonogram in Trauma (FAST) to assist early disposition. A total of 22
specific strategies are proposed to optimize the use of resources prior to a mass casualty event, and 10 specific strategies are
proposed for implementation during a mass casualty event.

Chapman,
2008172

Center for Disease
Control and Prevention

Post-exposure
interventions to
prevent infection
with HBV, HCV,
or HIV, and
tetanus in people
wounded during

Recommendations on the use of immunization and post-exposure prophylaxis for tetanus and occupational and
nonoccupational exposures to bloodborne pathogens in mass casualty events. Pathogens considered include Hepatitis B virus,
Hepatitis C virus, and HIV. Recommended interventions are tailored to risk category (penetrating injuries vs. mucous
membrane exposure vs. superficial exposure). Recommendations do not directly address altered standards of care when
vaccines are in short supply. Local authorities are directed to rely on local and state health departments, mutual aid
agreements, and commercial vendors, and if necessary work with CDC to make up for shortfalls

The IOM committee was convened to develop guidance that state and local public health officials and health-sector agencies
and institutions can use to establish and implement standards of care to be applied in disaster situations. The committee
recommended the development of consistent state crisis standards of care protocols with five key elements: 1) A strong
ethical grounding; 2) Integrated and ongoing community and provider engagement, education, and communication; 3)
Assurances regarding legal authority and environment; 4) Clear indicators, triggers, and lines of responsibility; and 5)
Evidence-based clinical processes and operations. Recommendations on specific implementation strategies included: 1)
Using “clinical care committees,” “triage teams,” and a state-level “disaster medical advisory committee” that will evaluate
evidence-based, peer-reviewed critical care and other decision tools and recommend and implement decision-making
algorithms to be used when specific life-sustaining resources become scarce; 2) Providing palliative care services for all
patients; 3) Mobilizing mental health resources to help communities and providers; 4) Developing specific response
measures for vulnerable populations and those with medical special needs; and 5) Implementing robust situational awareness
capabilities to allow for real-time information sharing.

C-42

Appendix Table C-6. Proposed strategies to allocate scarce resources during mass casualty events (KQ2)
Author,
Year

Organization, Task
Force, or Panel

Title of Report or
Article
bombings and
other mass
casualty events

Proposed Strategy

Christian,
2011165

Task Force for Pediatric
Emergency Mass Critical
Care

Treatment and
Triage
recommendations
for pediatric
emergency mass
critical care

Christian,
2010169

European Society of
Intensive Care
Medicine’s Task Force
for Intensive Care Unit
Triage during an
Influenza Epidemic or
Mass Disaster
Task Force for Mass
Critical Care Working
Group

Chapter 7. Critical
care triage

The Task Force proposed minimum resource requirements for pediatric emergency mass critical care (PEMCC), which are
largely consistent with those developed by the adult task force on emergency mass critical care161-163. The Task Force also
developed specific recommendations for non-pediatric hospitals, including a recommendation that adult ICUs should keep
adolescent patients without consultation (and patients aged 5-8 years following after consulting with pediatrics). The Task
Force was unable to recommend a pediatric prognostic scoring system to triage pediatric victims of MCEs due to the poor
performance of existing systems. Moreover, the Task Force declined to endorse exclusion criteria for the use of life support
based on patients’ pre-existing conditions despite the fact that other groups have proposed such criteria. The Task Force was
also unable to develop recommendations on criteria for withdrawing life support for pediatric patients during MCEs. Finally,
the Task Force called for the development of a triage protocol that not only took into account a patient’s likelihood of
survival but also the likelihood that a patient would require a prolonged ICU stay. (This latter point is a notable difference
from the adult recommendations that did not consider prolonged use of ICU resources).
Proposed elements of a standard operating procedure for providing critical care services during a mass casualty events,
including: implementation of central triage committee integrated within incident management structure, clear lines of
authority for all relevant actors, allocation of ICU care by triage officers according to inclusion/exclusion criteria, basis on
which to reassess triage categories, medical record documentation criteria, and recommended components of triage officer
training.

Devereaux,
2008163

Lerner,
2011160

Work group convened by
the National Association
of EMS Physicians
(2006), and subsequently
augmented

Lyznicki,
2007174

American Medical
Association and
American Public Health
Association

Definitive Care for
the Critically Ill
During a Disaster:
A Framework for
Allocation of
Scarce Resources
in Mass Critical
Care
Mass Casualty
Triage: An
Evaluation of the
Science and
Refinement of a
National Guideline

The Task Force presents a framework for resource allocation during MCEs that included inclusion criteria for the receipt of
medical or palliative care. The inclusion criteria recommended by the Task Force are based on those developed by Christian
et al.164, and recommended exclusion criteria take into account both the Sequential Organ Failure Assessment (SOFA) score
and a patient’s chronic illnesses. The Task Force proposed a SOFA score cutoff that correspond to an 80% risk of mortality.
The Task Force enumerated the chronic illnesses that should be used as exclusion criteria. The Task Force recommends
prioritizing patients in the order of their latest SOFA score and daily SOFA trend. The Task Force describes the
recommended responsibilities of the triage officer and the recommended composition of the triage team (a critical care nurse,
respiratory therapist, and/or clinical pharmacist).
Aside from recommending conventional triage categories, the workgroup proposed criteria for the use of lifesaving
interventions, defined as: controlling life-threatening external hemorrhage, opening the airway using basic maneuvers (for an
apneic child, consider 2 rescue breaths), performing chest decompression, and providing autoinjector antidotes. The
workgroup determined that lifesaving interventions should be performed only if the equipment is readily available, the
intervention is within the provider’s scope of practice, the intervention can be performed quickly (ie, in less than 1 min), and
the intervention does not require the provider to stay with the patient.
The workgroup also made recommendations for individual assessment during field triage, including: 1) refraining from the
use of counting or timing vital signs and instead using yes–or-no criteria; 2) avoiding the use of diagnostic equipment for
initial assessment; 3) refraining from the use of capillary refill as a sole indicator of peripheral perfusion; and 4) classifying
patients who are not breathing after 1 attempt to open their airway (in children, 2 rescue breaths may also be given) as dead
and visually identifying them as such. The workgroup also delineated specific criteria for each of 5 triage categories.

Improving health
system
preparedness
for terrorism and
mass casualty
events.

One of eight priority areas dealt with expanding health system surge capacity. Specific recommendations included: funding
IOM to conduct additional studies and to make recommendations; development and dissemination of model plans and
strategies; development of inventories of community surge capacity assets; stimulate growth of volunteer emergency
response teams; and ensuring that local emergency response plans provide appropriate distribution of patients across
facilities.

C-43

Appendix Table C-6. Proposed strategies to allocate scarce resources during mass casualty events (KQ2)
Author,
Year

Organization, Task
Force, or Panel

Title of Report or
Article
Recommendations
for action

Proposed Strategy

No Author,
2010171

Centers for Disease
Control and Prevention

In A Moment’s
Notice: Surge
Capacity
for Terrorist
Bombings

Proposed strategies to accommodate surge following terrorist activities using templates tailored to disciplines to address
known challenges associated with surge capacity. Templates were created for EMS, ED Departments, Surgical Departments,
ICU, Radiology, blood banks, hospitalists, administration, pharmaceuticals, and nursing care.

No Author,
2008158
Lerner,
2008159

American College of
Emergency Physicians,
American Trauma
Society, State and
Territorial Injury
Prevention Directors
Association
Task Force for Mass
Critical Care Working
Group

Mass Casualty
Triage: An
evaluation of the
Data and
Development of a
Proposed National
Guideline
Definitive Care for
the Critically Ill
During a Disaster:
A Framework for
Optimizing
Critical Care Surge
Capacity
Definitive Care for
the Critically Ill
During a Disaster:
Medical Resources
for Surge Capacity

Proposed triage strategy known as SALT (Sort-Assess-Lifesaving Interventions-Treatment and/or transport), to serve as
national all-hazards mass casualty initial triage standard for all patients. SALT begins with a global sorting of patients for
prioritization of treatment based on ability to walk, follow commands or move. The next stage, assess, involves limited lifesaving interventions such as controlling hemorrhages or opening airways. Patients are then prioritized for treatment and/or
transport based on an assignment to one of 5 categories: immediate, expectant, delayed, minimal and dead. The prioritization
process is dynamic and condition-specific.

Rubinson,
2008162

The Task Force proposed a bundle of 7 services that comprise emergency mass critical care (EMCC). Each of these services
does not require expensive equipment and can be implemented without consuming extensive staff or hospital resources. The
Task Force also developed a framework for optimizing surge capacity that includes various activites along a continuum from
minimal patient need to overwhelming patient need and consists of 5 major types of activities: substitution, adaptation,
conservation, reuse, and reallocation. The Task Force provided examples of each. The Task Force also adopted a multitiered critical care surge capacity framework that delineated specific triggers for escalation to higher tiers.

Rubinson,
2008161

Task Force for Mass
Critical Care Working
Group

The Task Force developed recommendations on the use of equipment and space for creating surge capacity during MCEs.
Specifically, the Task Force recommends the use of one mechanical ventilator per patient (rather than the use of a multiplelimb ventilator circuit). It also produced a list of ideal characteristics for stockpiled surge mechanical ventilators,
recommended equipment for surge PPV, and recommended non-respiratory medical equipment. The Task Force also
recommended (in order) the following treatment spaces after ICUs, post-anesthesia care units, and emergency departments
have reached capacity: 1) intermediate care units, step-down units, and large procedure suites; 2) telemetry units; and 3)
hospital wards. The Task Force strongly discouraged the use of nonmedical facilities to serve as alternate care sites. Finally,
the Task Force endorsed a collaborative team model for staffing during critical care surge.

Rubinson,
2005166

Working group on
Emergency Mass Critical
Care

Augmentation of
hospital critical
care capacity after
bioterrorist attacks
or epidemics

The Work group recommends that triage decisions regarding the provision of critical care should be guided by the principle
of seeking to help the greatest number of people survive the crisis. This would include patients already receiving ICU care
who are not casualties of an attack.

Taylor,
2010173

European Society of
Intensive Care
Medicine’s Task Force
for Intensive Care Unit
Triage

Chapter 6.
Protection of
patients and staff
during a pandemic

Recommendations and standard operating procedures to protect patients and staff during a pandemic or mass casualty event.
Key recommendations include (1) preparing infection control and occupational health policies for clinical risks relating to
potential disease transmission; (2) decreasing clinical risks and provide adequate facilities through advanced planning to
maximize capacity by increasing essential equipment, drugs, supplies and encouraging staff availability; (3) creating robust
systems to maintain staff confidence and safety by minimizing non-clinical risks and maintaining or escalating essential
services; (4) preparing formal reassurance plans for legal protection; (5) providing assistance to staff working outside their
normal domains.

C-44

Appendix Table C-7. Public perceptions and concerns about allocating scarce resources during mass casualty events (KQ3)

Author,
Year
Bailey,
2011 181

Type of
Study
Web-based
survey

Objective
(Type of MCE)
To investigate the views
of students and staff at
the university on the
allocation of scarce
resources during an
influenza pandemic

Study
Location
Edmonton,
Canada

Population
Characteristics
(n = sample size)
Students and staff
at University of
Alberta; 70%
females
(n = 5,220)

(pandemic influenza)

BraunackMayer,
2010 176

Deliberative
forum

To elucidate informed
community perspectives
on the allocation of
scarce pharmaceuticals
in a pandemic

Adelaide,
Australia

6 females
(n = 9)

Interviewbased
survey

To explore the public's
views regarding
priorities for allocating
scarce resources during
surge/emergencies

Priority Criteria:
1. Most respondents gave the highest priority to health care workers and
emergency workers , followed by children;
2. Lower priority was given to politicians;
3. "First come, first served" was least preferred.
Resource Allocation Policy:
1. Preserving society in the long run, rather than saving the most lives, was
the goal if forced to choose between the two.

3

Priority Criteria:
1. Priorities should be given to the following potential recipients in the order
of: health care workers, researchers and laboratory staff dealing with
pandemic influenza, essential services (water, power, waste, etc.), and
military;
2. The elderly and the chronically ill were explicitly excluded from the list
of potential recipients.

(pandemic influenza)

de Carvalho
Fortes,
2002183

Key Findings
Resource Allocation Policy:
1. The goals of the allocation system include: save the most lives, follow a
ranking system, and save those most likely to die, with most respondents
supporting "save the most lives".

Quality
Score
(of 7)
5

São Paulo,
Brazil

Persons visiting
patients in one
public hospital
n=395; 147 male,
248 female

Majority of survey respondents accept social values driving decisions
regarding allocation of scarce resources, largely based on justice, equity, and
priority for the most vulnerable
Examples: In hypothetical scenarios, majority favored scarce resources for a
7-yr old over 65-yr old; 7-yr old over 1-yr old; 65-yr old over 25-yr old
males; mother of more children over mother of fewer children; married
female over single female; out-of-town male over male resident; poor
female over rich female; unemployed over employed person

C-45

5

Appendix Table C-7. Public perceptions and concerns about allocating scarce resources during mass casualty events (KQ3)
Author,
Year
Docter,
2011 175

Type of
Study
Deliberative
forum

Objective
(Type of MCE)
To test how the
resource allocation plan
of the Australian
government (for
antiviral drugs and
vaccines) corresponds
with community views
about the priority
groups in a severe
pandemic

Study
Location
Adelaide,
Australia

Population
Characteristics
(n = sample size)
Participants in the
age group 20 - 29
were absent;
oversampling of
female members
(n < 12)

Key Findings
Resource Allocation Policy:
1. A committee consisting of a variety of experts and policy makers, but not
politicians, should make allocation decisions. They are essential for the fair
and effective allocation of scarce resources.

Quality
Score
(of 7)
4

Priority Criteria:
1. Both antiviral drugs and vaccines were allocated to groups in the
following order: primary health-care workers, viral and vaccine researchers
and workers, essential workers and military;
2. Lowest priority groups include: political decision makers; elderly,
chronically ill and disabled people were excluded.

(pandemic influenza)
Poll, 2010
177

Telephone
survey

To understand the
public's opinion about
prioritizing children's
needs in disaster
planning and response

United
States

U.S. residents
(n = 1,030)

Deliberation
meeting and
feedback
session

To pilot test a new
model for engaging
citizens on vaccine
related policy decisions
when supplies of
vaccine are limited and
scarce resources need to
be allocated efficiently
in a severe pandemic
(pandemic influenza)

2

Priority Criteria:
1. If resources are limited and tough decisions must be made, children
should be given a higher priority for life-saving treatments rather than adults
with the same medical condition.

(disaster – unspecified)
PEPPPI,
2005 178

Resource Allocation Policy:
1. The same medical treatments currently available for adults should also be
readily available for children .

GA
(Atlanta),
MA, NE,
OR

Adults aged 18-78;
a larger proportion
of participants
aged 55-64; more
females, more
participants with
higher education
(n = 250)

Resource Allocation Policy:
1. The goals of the allocation system should be 1) assuring the functioning
of society using the minimum number of vaccine doses, and 2) reducing the
individual deaths and hospitalizations due to influenza (protecting those who
are vulnerable and at risk);
2. Transparency and open communication are key to ensure the fairness and
trust essential to the plan's success;
3. The federal government role should be providing broad guidance;
responsibility for more specific interpretation and implementation should
remain with state and local health authorities;
4. Public health experts rather than political appointees should make the
vaccine priority decisions.
Priority Criteria:
1. Top priorities should be given to society's caretakers and persons at high
risk;
2. Little support for giving priorities to young people, using a lottery system,
or "first come, first served".

C-46

5

Appendix Table C-7. Public perceptions and concerns about allocating scarce resources during mass casualty events (KQ3)
Author,
Year
Public
Engagement
Project,
2009 180

Type of
Study
Public
engagement
forum

Objective
(Type of MCE)
To better understand the
public's values and
priorities regarding the
delivery of medical
services during a severe
influenza pandemic

Study
Location
WA
(Seattle /
King
County)

Population
Characteristics
(n = sample size)
70% females; 2/3
Whites; diverse
age span and
education level;
large number of
participants living
near poverty line

(pandemic influenza)
(n = 123)

Key Findings
Resource Allocation Policy:
1. Altered decision-making processes and protocols will be required to
determine allocation of scarce medical resources during an influenza
pandemic;
2. The system should be relatively simple to support successful
implementation and administration but should be consistent at state or
national level;
3. Guidelines should allow some flexibility to facilities;
4. The goals of the allocation decisions should be 1) treat as many people as
possible even if it means compromised standard of care; 2) The
prioritization system should be fair and accessible to all people.
Priority Criteria:
1. Priority treatment should be given to health care providers and first
responders;
2. Children and pregnant women should receive some priority when all other
factors are equal;
3. Survivability is a priority treatment consideration;
4. Strategies rejected: "first come, first served", randomization, ability to
pay, strategies that discriminate according to race, gender, culture, legal
status, nationality, or language.
Other:
1. Decisions for withdrawing life-saving care should be made by the patient
or patient's family with input from a doctor or health care provider.

C-47

Quality
Score
(of 7)
5

Appendix Table C-7. Public perceptions and concerns about allocating scarce resources during mass casualty events (KQ3)
Author,
Year
SSA
Consultants,
2011184

Vawter,
2011182

Type of
Study
Deliberative
forum with
exercises
and
consensus
development

Community
forum, small
group
discussion,
solicitation
of written
comments

Objective
(Type of MCE)
To better understand the
public's values, beliefs,
and opinions regarding
the implementation of
crisis standards of care

To solicit broader
public input on
rationing scarce health
resources in Minnesota
in a severe influenza
pandemic, with a
particular focus on
attending to the needs
of the socially
vulnerable when
rationing resources

Study
Location
Baton
Rouge, LA
and
Shreveport,
LA

Minnesota,
United
States

Population
Characteristics
(n = sample size)
Age 20-69;
68% female;
63% Caucasian,
33% AfricanAmerican

Not stated.
Referred to other
document for
details

Key Findings
Highest priorities:
1. First responders (fire fighters, police, ambulance workers) should have
priority for medical care because they are important to everyone’s
safety.
2. Saving the greatest number of people, even if it means that some people
aren’t going to be treated and will die.
3. Give priority for medical care to patients with the best chance of
survival. Otherwise, it’s not the best use of resources.
4. Doctors, nurses, and medical workers should have priority for medical
care because they can help everyone else when they recover.
5. It’s a better use of medical resources to help the most people even if we
can’t give the same level of care as we could in non-emergencies.
Lowest priorities:
1. People without transportation should be given priority for medical care.
It may take them a lot longer just to get to the hospital and then they
will be at the end of the line.
2. People who do not speak English very well have greater difficulty
accessing the health care system so they should be given priority for
medical care.
3. People should be given medical care on a first come, first serve basis.
People should be treated in the order they arrive in the hospital.
4. People who can afford to pay should be given priority for medical care.
5. Patients should be randomly selected for medical care because it is too
difficult to figure out a way to give anyone priority.
Findings were remarkably similar to similar exercises performed in Seattle,
particularly:
•
Providing treatment to the most numbers of people
•
Survivability criterion
•
Prioritization of first responders
•
Rejection of first come, first served, randomization, ability to pay.
Resource allocation policy:
•
Ensure that health disparities are not exacerbated.
•
Protect the population’s health
•
Protect public safety and social order
Rationing:
•
Do not ration on the basis of race, ethnicity, income, geography, or
first-come first-served.
•
Do not prioritize based on differences in social vulnerability.

C-48

Quality
Score
(of 7)
2

3

Appendix Table C-7. Public perceptions and concerns about allocating scarce resources during mass casualty events (KQ3)
Author,
Year
Vawter,
2010 179

Type of
Study
Community
forum, small
group
discussion,
solicitation
of written
comments

Objective
(Type of MCE)
To solicit broader
public input on
rationing scarce health
resources in Minnesota
in a severe influenza
pandemic
(pandemic influenza)

Study
Location
MN

Population
Characteristics
(n = sample size)
66% females, 9%
Hispanic/Latino,
82% White
(n = 441)

Key Findings
Resource Allocation Policy:
1. Three objectives should be balanced when rationing health care resources
allocation: 1) reduce deaths, 2) treat people fairly, and 3) protect public
health and infrastructure;
2. Transparency and public education are important to ensure fairness.
Priority Criteria:
1. Priority rationing should not be based on gender, race, ability to pay, or
first-come first served;
2. A large majority supported age-based rationing and prioritized children
and young adults before seniors; seniors over age 85 were de-prioritized by
some;
3. It is important to pay attention to the needs of vulnerable populations.

C-49

Quality
Score
(of 7)
3

Appendix Table C-8. Strategies to engage providers in allocating scarce resources during mass casualty events (KQ4)
Author,
Year
Albanese,
2007153

Dayton,
2008193

Leader of
Engagement

Study
Location

Study design

Type of mass
casualty
event

Providers

CT (state
level)

Observational,
2 post-tests

Radiological,
nuclear

Providers

Central
Brooklyn
, NY

Descriptive –
surge plan
development

All-hazards

Outcome Modulators
(Facilitators or Barriers)

Engagement Strategy

Who Engaged Whom

Findings (Outcome)

Enrollment, education,
training and exercise of
qualified laboratory staff
for preparing
biodosimetry specimens
(to test radiation
exposure)

State biodosimetry
laboratory engaged
hospital and
commercial
laboratories statewide

Augmentation of critical
laboratory capacity,
skills retained 6 months
after training (functional
drill):
30 of 33 labs were
qualified;
Staff in 30 labs were
trained
22 of 30 labs volunteered
to participate in surge
network
79 personnel trained to
date in 19 of these labs
37 participated in drill: (a)
every specimen met
standards; (b) average
turnaround time
(specimen preparation)
= 199 minutes

Facilitators: most laboratories
were already qualified because
of existing equipment;
education allayed safety
concerns

Organization of de novo
regional hospital
planning group and
cooperative hospital
level surge planning for
central Brooklyn

Hospitals engaged city
PH to develop
planning group; new
hospital consortium
organization engaged
individual hospitals

De novo planning group
created; surge space/beds
designated at each hospital
to meet regional needs
(+22% beds: 987 baseline
to 1207 surge); protocol
for notification and plan
activation developed

Facilitators: Willingness of
hospitals to plan
cooperatively; national
standards provided planning
target

C-50

Quality
score
(of 4)
4

Barrier: Many laboratories
had safety concerns (before
training)

4

Appendix Table C-8. Strategies to engage providers in allocating scarce resources during mass casualty events (KQ4)
Author,
Year
Grier,
2006186

Kanter,
2009189

Kelen,
2006191

Leader of
Engagement

Study
Location

Providers,
Policy
makers

CA, FL,
IL, OR,
LA, MO
(state
level in
each)

Providers

Providers

US
(experts
drawn
from
different
states)

MD

Study design
Case studies –
planning
process

Descriptive –
planning
process

Descriptive –
planning
process

Type of mass
casualty
event
Unspecified

Unspecified

Unspecified

Engagement Strategy

Who Engaged Whom

Findings (Outcome)

1. Top-down county
planning model,
master Mutual Aid
Agreement (CA, IL)
2. Decentralized
regional planning
(FL, LA)
3. Decentralized rural
planning (OR)
4. Hospital-directed
tiered regional
planning model (IL,
LA, MO)
5. Third-party directed
planning model
(MO)

1. State PH engaged
local PH, hospitals
2. Hospitals, state
hospital
association
engaged hospitals
3. Regional medical
center engaged
hospitals
4. Designated
regional hospital
engaged hospitals
5. State PH and
designated
hospital engaged
hospitals

Multiple surge capacity
planning models based on
plans in 8 localities in 6
different US states

Systematic development
of consensus on
appropriate pediatric
crisis standards of care
through modified Delphi
process involving
hospital pediatricians

Hospital pediatric
leaders engaged other
acute care hospitalbased pediatricians

Consensus on non-ICU
interventions but not on
ICU interventions

Development of
evidence-based “reverse
triage” classification
system through
systematic expert
consensus process using
formally-defined realtime anonymous virtual
network

Academic medical
center leaders engaged
39 clinician and nonclinician experts

Outcome Modulators
(Facilitators or Barriers)
Facilitators: Planning
centered on hospitals (no
major mix of organizational
cultures); third-party-directed
planning model minimized
competition among hospitals

Quality
score
(of 4)
4

Barriers: Culture differences
between PH and hospitals,
competition among hospitals

Facilitators: Structured
process, conducted via email
(cheap, efficient), anonymity
of experts, flexible approach,
use of established scoring
system as endpoints

3

Barriers: No face-to-face
discussion among experts, no
full consensus on some
elements, need to coordinate
with government regulations
potentially over-rides expert
consensus

C-51

Evidence-based 5category patient
classification system
based on agreed-upon risk
tolerance levels

Barriers: absence of evidence
that expert opinion-based
system would result in safe
practice; did not include
experts from broad range of
hospital types

4

Appendix Table C-8. Strategies to engage providers in allocating scarce resources during mass casualty events (KQ4)
Author,
Year

Leader of
Engagement

Study
Location

Lurie,
2008194

Providers

2 US
localities
and 3
regions
(not
specified
)

Tabletop
exercises

Terriff,
2001192

Providers

Spokane,
WA
(regional
level)

Descriptive –
planning,
tabletop
exercise

Study design

Type of mass
casualty
event

Outcome Modulators
(Facilitators or Barriers)

Quality
score
(of 4)

Engagement Strategy

Who Engaged Whom

Findings (Outcome)

Pandemic
influenza

Pilot testing of local,
regional and national
level tabletop exercises
for the Veterans Health
Administration (VHA)

Central federal health
provider agency
(VHA) engaged local
and regional VA
hospitals and nonhospital facilities,
local hospitals, state
and local PH and local
first responders

Tested tabletop exercise
templates for local and
regional use by VA
system, engaging
government and public
and private providers

Facilitators: ability to share
and use exercise templates
across VA system nationwide,
VA engagement with local
communities, mutual respect
between local VA providers
and their communities,
integrated VA health system
with electronic health records
and hotlines enable patient
flow management
Barriers: unclear who decides
on resource sharing between
VA and local facilities,
different levels of care
between VA and local
hospitals, organizational
culture differences between
VA and local providers
(command vs. collaboration)

4

Biological

Pharmacy-led
development of regional
pharmaceutical
preparedness policies
and procedures
(protocol) for response
to BT event -- pre-911

Hospital pharmacy
department, county
EMS and Army
engaged first
responders, hospitals,
non-hospital facilities,
FEMA, USPHS, FBI,
and state PH

Technical documentation
& city-wide policy and
protocol for medical
management of BT
(obtaining antidotes),
including plan for local
stockpiles, resource
sharing across region
(city)

Facilitator: Initiative of
pharmacy department in one
hospital and interest of all
participants in city-wide
planning

4

C-52

Appendix Table C-8. Strategies to engage providers in allocating scarce resources during mass casualty events (KQ4)
Author,
Year

Leader of
Engagement

Study
Location

Study design

Buehler,
2006187

Policy makers

GA
(metropolitan
level)

Descriptive -case study of
operational
partnership

Type of mass
casualty
event
Unspecified

Engagement Strategy
Public health-business
partnership for mass
dispensing

Who Engaged Whom

Findings (Outcome)

State and local PH and
voluntary business
coalition engaged
local PH, schools,
businesses

1200 business volunteers
participated in 3 mass
dispensing drills at public
and business sites

Outcome Modulators
(Facilitators or Barriers)
Facilitators: Personal
relationships, business
commitment to service,
strategic engagement by
senior business and
government officials, business
model, conceptual link
between business and
community continuity, links to
multiple government agencies

Quality
score
(of 4)
4

Barriers: government
procurement regulations;
potential shifts in government
priorities; different
management styles; occasional
government disorganization;
confidentiality of proprietary
information; liability; ongoing
differences in perspective
Dausey,
2006195

Policy makers

Three
US
metropol
itan areas
(not
specified
)

Tabletop
exercises

Ginter,
2010188

Policy makers

AL, MI,
FL, LA,
TN

Descriptive –
planning
process

Pandemic
influenza

Development and pilot
testing of tabletop
exercise template for
local level governments
and providers

State PH and RAND
engaged local PH &
elected officials,
hospitals and private
practitioners, law
enforcement

Tested tabletop exercise
template applicable to
localities across the U.S.

Facilitators: Excellence of
technical partner, willingness
of participants

4

All-hazards
(“natural and
manmade”)

Organization of five
neighboring states into a
voluntary disaster
pediatric surge network

2 state PH and
regional PH
preparedness center
engaged pediatric
hospitals and major
clinics, state PH, and
emergency responders

Established pediatric surge
network, operational
handbook, formal MOU

Facilitators: “Highly-reliable
organization” model
previously established and
adaptable to surge network
development

4

C-53

Barriers: Planning process is
time-consuming (5 yrs), interstate agreements are more
complicated than intra-state
ones

Appendix Table C-8. Strategies to engage providers in allocating scarce resources during mass casualty events (KQ4)
Author,
Year
Koh,
2006190

Leader of
Engagement

Study
Location

Policy makers

Boston,
MA

Study design
Descriptive –
surge plan
development,
observational
testing

Type of mass
casualty
event
Unspecified

Engagement Strategy
Incorporation of CHCs
into surge plan, with
training for CHCs and
three event-based tests

Who Engaged Whom

Findings (Outcome)

Outcome Modulators
(Facilitators or Barriers)

City PH & state
primary care
association engaged
hospitals, CHCs, EMS
in planning; City PH,
EMS & academia
engaged CHCs in
training and first
responders, hospitals
and CHCs in tests of
plan

Surge-related roles and
responsibilities for CHCs
delineated in plan; plan
tested in city-wide
preparation for
Democratic National
Convention and 2
outbreak investigations
(e.g., screened 1500
persons for TB in one
investigation)

Facilitators: CHCs were
willing to participate and
some were already integrated
with nearby hospital; excellent
academic partner provided
high quality technical
assistance

Quality
score
(of 4)
4

Barriers: Variability in CHC
sizes and resources precluded
“one size fits all” approach;
CHC staff had limited time &
resources for training, testing

Levin,
2009185

Policy makers

MA
(state
level)

Descriptive –
planning
process

Pandemic
influenza

State level planning to
establish framework and
ethical principles to
guide development of
altered standards of care
protocols

State PH and academia
engaged local PH,
hospitals, non-hospital
healthcare facilities,
other health agencies,
non-government
entity, general public

Consensus state-level
framework (guidelines)
and decision making
protocol for altered
standards of care (ASC); 4
goals, 7 principles –
decision-making protocol
to determine ASC

Facilitators: Excellence of
academic institution;
involvement of ethicists, legal
counsel, and broad stakeholder
base

3

Moser,
2005196

Policy makers

Utah
(regional
level)

Descriptive –
planning
process

Unspecified

Broadly inclusive
regional hospital level
planning process to
identify 1250 additional
(surge) beds state-wide;
regional approach to be
replicated throughout
state

State PH and state
university medical
center engaged
multiple hospital and
non-hospital facilities,
professional
associations, state and
local PH, transit, EMS
and church groups

State coordinating group
identified broad range of
public and private sector
task force members and
created regional surge
plan through systematic
iterative process

Facilitators: Broadly inclusive
and iterative process; begin
with small group; identify key
personnel early; use prominent
players for credibility; central
planning office

3

Vawter,
2010179

Policy makers

MN
(state
level)

Descriptive –
planning
process

Pandemic
influenza

Developing proposed
ethical frameworks and
procedures for rationing
scarce health resources
within a state

State government,
university and health
care ethics center
engaged local
governments, experts,
general public and a
few (not many ) health
care providers
(hospital, non-hospital,
other)

Decision tools – ethics
guidance: Multiple ethical
frameworks for setting
rationing priorities (for
vaccine, N95 respirators,
surgical masks, antiviral
drugs for prophylaxis and
for treatment, mechanical
ventilators) -- principles,
objectives, general
strategies

Facilitators: involvement of
ethicists, extensive public
input, specific resource items

3

C-54

Barriers: resulted in decision
tool (not plan); one size does
not fit all; very few providers
were reported as involved

Appendix D. Excluded Studies
Short Form Rejects
No Key Questions Addressed (N=692)
1.
A 2002 national assessment of state trauma system development, emergency
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2.
Supplement A. Command and Control , Incident Command and Management
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3.
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4.
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5.
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6.

Expect 2 waves of patients after terrorist attack. ED Manag. 2000 Jan;12(1):8-9.

7.
VETERANS HEALTH ADMINISTRATION EMERGENCY MANAGEMENT
PROGRAM PROCEDURES. Department of Veteran s Affairs Veterans Health
Administration; 2000.
8.

What's the ASC's role for mass casualties? OR Manager. 2002 Nov;18(11):23-5.

9.
New aspects in mass casualties. Anasthesiol Intensivmed Notfallmed
Schmerzther. 2002 Sep;37(9):537-8.
10.
Collaboration and coordination in mass casualty disaster plans. Healthc Hazard
Manage Monit. 2002 Jan;15(5):1-7.
11.
Guidelines for the use of foreign field hospitals in the aftermath of sudden-impact
disaster. Prehosp Disaster Med. 2003 Oct-Dec;18(4):278-90.
12.
Checklists for mass casualty disaster plans. Disaster Management and Response.
2003;1(1):31.
D-1

13.
Is it OK to have someone very quickly screen incoming patients? ED Manag.
2004 Jan;16(1):8-9.
14.

Staffing up helps EDs handle Katrina surge. ED Manag. 2005 Oct;17(10):112-3.

15.
Disaster relief. Hurricane victims with HIV/AIDS overwhelm resources. AIDS
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16.
Health care system surge capacity recognition, preparedness, and response. Ann
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17.
Riding out the surge. JEMS: Journal of Emergency Medical Services.
2005;30(11):42-.
18.
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Healthcare Research and Quality; 2005.
19.
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20.
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23;72(77):20117-28.
21.
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22.
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23.
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24.
DEPARTMENT OF VETERANS AFFAIRS AND DEPARTMENT OF
DEFENSE
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Administration; 2007 Contract No.: Document Number|.
25.
HIV PEP rarely warranted after mass casualties. CDC guidelines for HIV,
hepatitis and tetanus. AIDS Alert. 2008 Sep;23(9):107-8.
26.

ED handles 30 burn patients after plant fire and explosion in Georgia. ED

D-2

management : the monthly update on emergency department management.
2008;20(4):37-9.
27.
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28.
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International Airport. JEMS. 2009 Sep;34(9):36-43, 5.
29.

'Reverse triage' adds to surge capacity. ED Manag. 2009 Jun;21(6):64-5.

30.
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31.
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Summary. Washington DC: National Academy of Sciences.; 2011.
32.
EDs credit drills, community engagement with helping them manage casualties
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33.
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34.
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35.
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36.
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37.
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43.
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D-4

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101. van Harten SM, Welling L, Perez RS, Patka P, Kreis RW. Management of
multiple burn casualties from the Volendam disaster in the emergency departments of
general hospitals. Eur J Emerg Med. 2005 Dec;12(6):270-4.
102. Vanholder R, Van Biesen W, Hoste E, van der Tol A, Sever MS. The role of the
Renal Disaster Relief Task Force in the prevention and treatment of Crush syndrome in
mass disasters. Acta Clin Belg Suppl. 2007(2):405-7.
103. Villarreal MS. Quality management tool for mass casualty emergency responses
and disasters. Prehosp Disaster Med. 1997 Jul-Sep;12(3):200-9.
104. Vincent DS, Berg BW, Ikegami K. Mass-casualty triage training for international
healthcare workers in the Asia-Pacific region using manikin-based simulations. Prehosp
Disaster Med. 2009 May-Jun;24(3):206-13.
105. Wolinsky PR, Tejwani NC, Testa NN, Zuckerman JD. Lessons learned from the
activation of a disaster plan: 9/11. Journal of Bone and Joint Surgery - Series A.
2003;85(9):1844-6.
106. Xiang B, Cheng W, Liu J, Huang L, Li Y, Liu L. Triage of pediatric injuries after
the 2008 Wen-Chuan earthquake in China. J Pediatr Surg. 2009 Dec;44(12):2273-7.

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Appendix D. Excluded Studies at Long Form Screening

Insufficient Evidence for KQ1 Proposed Strategies (N=8)
1.
Bascetta CA. Veterans health care: VA's medical support role in emergency
preparedness Washington, D.C.: United States Government Accountability Office; 2005
[cited RAND Library-NYAM.
2.
Bascetta CA, United States Congress.Senate.Committee on the Budget, United
States Congress.Senate.Committee on Finance, United States Congress.House.Committee
on Homeland Security, United States Congress.House.Committee on Oversight and
Government Reform. Emergency preparedness : states are planning for medical surge,
but could benefit from shared guidance for allocating scarce medical resources : report to
congressional requesters Washington, D.C. : Government Accountability Office; 2008
[cited RAND Library-NYAM.
3.
Carpenter M, Hodge JG, Jr., Pepe RP. Deploying and using volunteer health
practitioners in response to emergencies: proposed uniform state legislation provides
liability protections and workers' compensation coverage. Am J Disaster Med. 2008 JanFeb;3(1):17-23.
4.
Conn R, Welch FJ, Popovich ML. Management of vaccine inventories as a
critical health resource. IEEE Eng Med Biol Mag. 2008 Nov-Dec;27(6):61-5.
5.
Eastman N, Philips B, Rhodes A. Triaging for adult critical care in the event of
overwhelming need. Intensive Care Medicine. 2010;SO- 36(6):1076-82.
6.
Hodge JG, Jr., Gable LA, Calves SH. The legal framework for meeting surge
capacity through the use of volunteer health professionals during public health
emergencies and other disasters. J Contemp Health Law Policy. 2005 Fall;22(1):5-71.
7.
Knebel A, Phillips SJ, Institute A, United States Agency for Healthcare Research
and Quality., United States Dept. of Health and Human Services.Office of the Assistant
Secretary for Preparedness and Response., Centers for Disease Control and Prevention
(U.S.). Home health care during an influenza pandemic issues and resources. Rockville,
MD Agency for Healthcare Research and Quality; 2008 [cited RAND Library-NYAM.
8.
WHO (World Health Organization). Project on addressing ethical issues in
pandemic influenza planning: Equitable access to therapeutic and prophylactic measures.
2006 [updated 2006; cited 2009 September, 08]; Available from:
http://www.who.int/eth/ethics/PIEthicsdraftpaperWG120oct06.pdf.

D-94

Appendix D. Excluded Studies at Long Form Screening

Insufficient Evidence for KQ2 Proposed Strategies (N=70)

1.
Best practices for hospital-based first receivers of victims from mass casualty
incidents involving release of hazardous substances. [Washington.
2.

Medical ethics in the event of disasters. Bull Med Ethics. 1994 Oct;No. 102:9-11.

3.
Ethical considerations in the allocation of organs and other scarce medical
resources among patients. Council on Ethical and Judicial Affairs, American Medical
Association. Arch Intern Med. 1995 Jan 9;155(1):29-40.
4.
Special Issue: Definitive care for the critically ill during a disaster. Chest.
2008;SO- 133(5 supplement):1s-66s.
5.
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Ventilators during a Severe Influenza Pandemic or Other Public Health Emergency.:
Prepared by the Ventilator Document Workgroup for the Ethics Subcommittee of the
Advisory Committee to the Director; 2009 Contract No.: Document Number|.
6.
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Biosecur Bioterror. 2010 Mar;8(1):93-5.
7.
A Regional Planning Guide for Maintaining Essential Health Services in a Scarce
Resource Environment: Recommendations from Georgia Hospital Region F Essential
Health Services Project: The Georgia Hospital Association Research and Eduation
Foundation, Inc. (GHAREF) in conjuction with the Medical Center of Central Georgia
(MCCG) and Health Districts 4 and 5.2 with CDC funding for the Georgia Division of
Emergency Preparedness-Georgia Department of Community Health; July 30, 2010
Contract No.: Document Number|.
8.
A Framework for Maintaining Essential Health Services in a Crises Care
Environment: Recommendations from Georgia Hospital Region F Essential Health
Services Project: The Georgia Hospital Association Research and Eduation Foundation,
Inc. (GHAREF) in conjuction with the Medical Center of Central Georgia (MCCG) and
Health Districts 4 and 5.2 with CDC funding for the Georgia Division of Emergency
Preparedness-Georgia Department of Community Health; July 30, 2010 Contract No.:
Document Number|.
9.
We Stand On Guard for Thee: Ethical Considerations in Preparedness Planning
for Pandemic Influenza. : A report of the University of Toronto Joint Centre for Bioethics
Pandemic Influenza Working Group.; November 2005 Contract No.: Document Number|.
10.
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ventilators to meet demands for pandemic flu and mass casualty incidents. 2008 [updated
2008; cited 2008 July 01]; Available from:

D-95

Appendix D. Excluded Studies at Long Form Screening

http://www.aarc.org/resources/vent_guidelines.pdf.
11.
American College of Emergency Physicians. Best Practices for Hospital
Preparedness; April 2009 Contract No.: Document Number|.
12.
Ashkenazi I, Kessel B, Olsha O, Khashan T, Oren M, Haspel J, et al. Defining the
problem, main objective, and strategies of medical management in mass-casualty
incidents caused by terrorist events. Prehosp Disaster Med. 2008 Jan-Feb;23(1):82-9.
13.
Barnett DJ, Taylor HA, Hodge JG, Jr., Links JM. Resource allocation on the
frontlines of public health preparedness and response: report of a summit on legal and
ethical issues. Public Health Rep. 2009 Mar-Apr;124(2):295-303.
14.
Barnitz L, Berkwits M. The health care response to pandemic influenza. Ann
Intern Med. 2006 Jul 18;145(2):135-7.
15.
Ben-Abraham R, Shapira I, Kalmovich B, Rudick V, Weinbroum AA.
Supraglottic devices: a possible role in prehospital toxic mass casualty event? J Med.
2004;35(1-6):105-14.
16.
Benjamin G, McGeary MGH, McCutchen SR, Institute of Medicine (U.S.)
Committee on Medical Preparedness for a Terrorist Nuclear Event. Assessing medical
preparedness to respond to a terrorist nuclear event workshop report / [electronic
resource] Washington, D.C.: National Academies Press; 2009 [cited RAND LibraryNYAM.
17.
Bennett D, Jahankhani H. The UK Government's Critical National Infrastructure
Policy for Emergency Services Communications Platforms: Vulnerabilities in the
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Safety, and Sustainability, Proceedings; 2009. p. 43-55.
18.
Borra A, Perez LJ, Min T, Puavilai W, Seo N, Tipsunthonsak N. Panel 2.5: masscasualty management and hospital care. Prehosp Disaster Med. 2005 Nov-Dec;20(6):4123.
19.
Boyer EW, Fitch J, Shannon M. Pediatric hospital surge capacity in public health
emergencies. Pub. No. 09-0014. Rockville, MD: Agency for Healthcare Research and
Quality (AHRQ); 2009 Contract No.: Document Number|.
20.
Chan TC, Killeen J, Griswold W, Lenert L. Information technology and
emergency medical care during disasters. Acad Emerg Med. 2004 Nov;11(11):1229-36.
21.
Christian MD, Hawryluck L, Wax RS, Cook T, Lazar NM, Herridge MS, et al.
Development of a triage protocol for critical care during an influenza pandemic.
Canadian Medical Association Journal. 2006 Nov;175(11):1377-81.

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Appendix D. Excluded Studies at Long Form Screening

22.
Coleman CN, Hrdina C, Bader JL, Norwood A, Hayhurst R, Forsha J, et al.
Medical response to a radiologic/nuclear event: integrated plan from the Office of the
Assistant Secretary for Preparedness and Response, Department of Health and Human
Services. Ann Emerg Med. 2009 Feb;53(2):213-22.
23.
Coleman CN, Weinstock DM, Casagrande R, Hick JL, Bader JL, Chang F, et al.
Triage and treatment tools for use in a scarce resources-crisis standards of care setting
after a nuclear detonation. Disaster Med Public Health Prep. 2011 Mar;5 Suppl 1:S11121.
24.
Cone DC, Koenig KL. Mass casualty triage in the chemical, biological,
radiological, or nuclear environment. Eur J Emerg Med. 2005 Dec;12(6):287-302.
25.
Crippen D, Krin C, Lorich D, Mattox K. Disaster medicine: the caring
contradiction. Crit Care. 2010;14(2):133.
26.
Crupi RS, Asnis DS, Lee CC, Santucci T, Marino MJ, Flanz BJ. Meeting the
challenge of bioterrorism: lessons learned from West Nile virus and anthrax. Am J Emerg
Med. 2003 Jan;21(1):77-9.
27.
De Jong MJ, Benner R, Benner P, Richard ML, Kenny DJ, Kelley P, et al. Mass
casualty care in an expeditionary environment: developing local knowledge and expertise
in context. J Trauma Nurs. 2010 Jan-Mar;17(1):45-58.
28.
DeBruin D, Parilla E, Liaschenko J, Leider J, P.,, Brunnquell DJ, Garrett JE, et al.
Implementing ethical frameworks for rationing scarce resources in Minnesota during
severe influenza pandemic. 2010. Reference Mining; 2010.
29.
Devereaux A, Christian MD, Dichter JR, Geiling JA, Rubinson L. Summary of
suggestions from the Task Force for Mass Critical Care summit, January 26-27, 2007.
Chest. 2008 May;133(5 Suppl):1S-7S.
30.
Ferrer RR, Balasuriya D, Iverson E, Upperman JS. Pediatric disaster preparedness
of a hospital network in a large metropolitan region. Am J Disaster Med. 2010 JanFeb;5(1):27-34.
31.
Flynn DF, Goans RE. Nuclear terrorism: triage and medical management of
radiation and combined-injury casualties. Surg Clin North Am. 2006 Jun;86(3):601-36.
32.
Foltin G, Tunik M, Curran J, Marshall L, Bove J, van Amerongen R, et al.
Pediatric nerve agent poisoning: medical and operational considerations for emergency
medical services in a large American city. Pediatr Emerg Care. 2006 Apr;22(4):239-44.
33.
Gomersall CD, Tai DYH, Loo S, Derrick JL, Goh M, Buckley TA, et al.
Expanding ICU facilities in an epidemic: recommendations based on experience from the
SARS epidemic in Hong Kong and Singapore. Intensive Care Medicine. 2006;SO-

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Appendix D. Excluded Studies at Long Form Screening

32(7):1004-13.
34.
Greenberg MI, Hendrickson RG. Report of the CIMERC/Drexel University
Emergency Department Terrorism Preparedness Consensus Panel. Acad Emerg Med.
2003 Jul;10(7):783-8.
35.
Hadef H, Bartier JC, Pelaccia T. SAGEC 67, a free-access database linking at
least three countries, for finding spare beds in the event of a mass casualty incident. Eur J
Emerg Med. 2009 Aug;16(4):183-7.
36.
Hick JL, Christian MD, Sprung CL. Surge capacity and infrastructure
considerations for mass critical care. Intensive Care Medicine. 2010 Apr;36:S11-S20.
37.
Hick JL, Hanfling D, Burstein JL, DeAtley C, Barbisch D, Bogdan GM, et al.
Health care facility and community strategies for patient care surge capacity. Ann Emerg
Med. 2004 Sep;44(3):253-61.
38.
Hick JL, Hanfling D, Cantrill SV. Allocating Scarce Resources in Disasters:
Emergency Department Principles. Ann Emerg Med. 2011 Aug 18.
39.
Hick JL, O'Laughlin DT. Concept of operations for triage of mechanical
ventilation in an epidemic. Acad Emerg Med. 2006 Feb;13(2):223-9.
40.
Hoejenbos MJ, McManus J, Hodgetts T. Is there one optimal medical treatment
and evacuation chain for all situations: "scoop-and-run" or "stay-and-play". Prehosp
Disaster Med. 2008 Jul-Aug;23(4):s74-8.
41.
Hrdina CM, Coleman CN, Bogucki S, Bader JL, Hayhurst RE, Forsha JD, et al.
The "RTR" medical response system for nuclear and radiological mass-casualty
incidents: a functional TRiage-TRansport-treatment medical response model. Prehospital
and Disaster Medicine. 2009;SO- 24(3):167-78.
42.
Kanter RK, Cooper A. Mass critical care: pediatric considerations in extending
and rationing care in public health emergencies. Disaster Med Public Health Prep. 2009
Dec;3 Suppl 2:S166-71.
43.
Kirby J. Enhancing the fairness of pandemic critical care triage. J Med Ethics.
2010 Dec;36(12):758-61.
44.
Kobrinskiy BA, Petlakh VI, Wootton R, Patil NG, Scott RE, Ho K. Telepaediatric
support for a field hospital in Chechnya
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45.
Kopp JB, Ball LK, Cohen A, Kenney RJ, Lempert KD, Miller PE, et al. Kidney
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Am Soc Nephrol. 2007 Jul;2(4):825-38.

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Appendix D. Excluded Studies at Long Form Screening

46.
Lang JL, Croker K. H1N1 09 influenza—An aeromedical perspective.
Australasian Emergency Nursing Journal. 2010;13(3):53-60.
47.
Leo JD, Thomas D, Alhadeff G. A unique hospital physician disaster response
system for a nonemployed medical staff. Am J Disaster Med. 2009 Mar-Apr;4(2):95-100.
48.
Lin JY, Anderson-Shaw L. Rationing of resources: ethical issues in disasters and
epidemic situations. Prehosp Disaster Med. 2009 May-Jun;24(3):215-21.
49.
Lowe CG. Pediatric and neonatal interfacility transport medicine after mass
casualty incidents. J Trauma. 2009 Aug;67(2 Suppl):S168-71.
50.
Mahoney EJ, Biffl WL, Cioffi WG. Mass-casualty incidents: how does an ICU
prepare? J Intensive Care Med. 2008 Jul-Aug;23(4):219-35.
51.
Malish R, Oliver DE, Rush RM, Jr., Zarzabal E, Sigmon MJ, Burkle FM, Jr.
Potential roles of military-specific response to natural disasters -- analysis of the rapid
deployment of a mobile surgical team to the 2007 Peruvian earthquake. Prehosp Disaster
Med. 2009 Jan-Feb;24(1):3-8.
52.
Matzo M, Wilkinson A, Lynn J, Gatto M, Phillips S. Palliative care
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Jun;7(2):199-210.
53.
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Development of a state medical surge plan, Part II: Components of a medical surge plan.
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54.
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55.
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56.
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Medical student disaster medicine education: the development of an educational resource.
Int J Emerg Med. 2010;3(1):9-20.

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Appendix D. Excluded Studies at Long Form Screening

58.
Rice MJ, Gwertzman A, Finley T, Morey TE. Anesthetic practice in Haiti after
the 2010 earthquake. Anesth Analg. 2010 Dec;111(6):1445-9.
59.
Rubin GJ, Dickmann P. How to reduce the impact of "low-risk patients"
following a bioterrorist incident: lessons from SARS, anthrax, and pneumonic plague.
Biosecur Bioterror. 2010 Mar;8(1):37-43.
60.
Saffle JR, Gibran N, Jordan M. Defining the ratio of outcomes to resources for
triage of burn patients in mass casualties. Journal of Burn Care and Rehabilitation.
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61.
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solutions. Am J Disaster Med. 2010 Mar-Apr;5(2):95-105.
62.
Sever MS, Kellum J, Hoste E, Vanholder R. Application of the RIFLE criteria in
patients with crush-related acute kidney injury after mass disasters. Nephrol Dial
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63.
Shirley PJ, Mandersloot G. Clinical review: the role of the intensive care
physician in mass casualty incidents: planning, organisation, and leadership. Crit Care.
2008;12(3):214.
64.
Stratton SJ, Tyler RD. Characteristics of medical surge capacity demand for
sudden-impact disasters. Acad Emerg Med. 2006 Nov;13(11):1193-7.
65.
Taiminen T, Tuominen T, Strandberg J, Sourander A, Salokangas RK.
[Emergency psychiatric treatment of survivors of the Estonia disaster]. Nord Med.
1995;110(2):62-4.
66.
Temte JL. Preparing for an influenza pandemic: vaccine prioritization. Fam Pract
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67.
Viswanathan K, Wizemann T, Altevogt BM. Forum on Medical and Public
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68.
Wagner SK. Disaster preparedness. D.C. medical center unveils mass casualty
design concepts. Hosp Health Netw. 2008 May;82(5):22.
69.
Washington ML, Mason J, Meltzer MI. Maxi-Vac: planning mass smallpox
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70.
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Appendix D. Excluded Studies at Long Form Screening

Did not address resource allocations for KQ 3 (N=23)
1.
Ambarish P, Nivedita P, Mansher S, Akshay S, Gayatri S. YouTube as a source of
information on the H1N1 influenza pandemic. American Journal of Preventive Medicine.
[Journal article]. 2010;38(3):e1-e3.
2.
Andrulis DP, Siddiqui N, Purtle J, Drexel University SoPHCfHE, , . California's
emergency preparedness efforts for culturally diverse communities : status, challenges
and directions for the future Philadelphia, Pa.: Drexel University School of Public Health;
2008 [cited RAND Library-NYAM.
3.
Beaton RD, Oberle MW, Wicklund J, Stevermer A, Boase J, Owens D.
Evaluation of the Washington State National Pharmaceutical Stockpile dispensing
exercise: Part I--Patient volunteer findings. J Public Health Manag Pract. 2003 SepOct;9(5):368-76.
4.
Blando JD, Robertson C, Bresnitz E. Communicating information in an
emergency preparedness pill distribution campaign. Biosecur Bioterror. 2008
Mar;6(1):57-65.
5.
DeLia D, C CJ, Brownlee S, Abramo J, Rutgers Center for State Health Policy,
Schulman R, & Bucuvalas (Firm),,. New Jersey Health Care Opinion Poll : public
concern about hospital capacity New Brunswick, NJ: Rutgers Center for State Health
Policy; 2008 [cited RAND Library-NYAM.
6.
Gullo K, Harris Interactive (Firm). Vast majorities of U.S. adults believe federal,
state and local governments should have been better prepared to look after sick and frail
residents in New Orleans in the wake of Hurricane Katrina Rochester, N.Y.: Harris
Interactive Inc; 2005 [cited RAND Library-NYAM.
7.
Guth D, ,, Alloway GA, ,, University of Kansas School of Journalism and Mass
Communications. Untapped potential : evaluating state emergency management agency
web sites 2008 Lawrence, KS University of Kansas, School of Journalism and Mass
Communications
2008 [cited RAND Library-NYAM.
8.
Henderson JN, Henderson LC, Raskob GE, Boatright DT. Chemical (VX)
terrorist threat: public knowledge, attitudes, and responses. Biosecur Bioterror.
2004;2(3):224-8.
9.
Lake Snell Perry and Associates, Robert Wood Johnson Foundation. Americans
speak out on bioterrorism and U.S. preparedness to address risk Princeton, N.J.: Lake
Snell Perry & Associates, Inc; 2002 [cited RAND Library-NYAM.
10.
Lasker RD. Redefining readiness : terrorism planning through the eyes of the
public: appendix to the study report New York, NY: Center for the Advancement of

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Appendix D. Excluded Studies at Long Form Screening

Collaborative Strategies in Health, New York Academy of Medicine; 2004 [cited RAND
Library-NYAM.
11.
Lasker RD, Center for the Advancement of Collaborative Strategies in Health,
New York Academy of Medicine. With the public's knowledge : a user's guide to the
Redefining Readiness small group discussion process New York, NY New York
Academy of Medicine; 2009 [cited RAND Library-NYAM.
12.
Lasker RD, New York Academy of Medicine Center for the Advancement of
Collaborative Strategies in Health. Redefining readiness: terrorism planning through the
eyes of the public New York, NY: Center for the Advancement of Collaborative
Strategies in Health, New York Academy of Medicine; 2004 [cited RAND LibraryNYAM.
13.
Mathew AB, Kelly K, Tomás Rivera Policy Institute, Asian Pacific American
Legal Center of Southern California. Disaster preparedness in urban immigrant
communities : lessons learned from recent catastrophic events and their relevance to
Latino and Asian Communities in Southern California Los Angeles, California Tomás
Rivera Policy Institute; 2008 [cited RAND Library-NYAM.
14.
May AL, Aspen Institute. First informers in the disaster zone : the lessons of
Katrina Washington, DC: Aspen Institute; 2006 [cited RAND Library-NYAM.
15.
McGough M, Frank LL, Tipton S, Tinker TL, Vaughan E. Communicating the
risks of bioterrorism and other emergencies in a diverse society: a case study of special
populations in North Dakota. Biosecurity and Bioterrorism: Biodefense Strategy, Practice
and Science. 2005;SO- 3(3):235-45.
16.
Mullin S. New York City's communication trials by fire, from West Nile to
SARS. Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science. [Journal
article]. 2003;1(4):267-72.
17.
National Council on Disability (U.S.). Effective emergency management : making
improvements for communities and people with disabilities Washington, D.C: National
Council on Disability; 2009 [cited RAND Library-NYAM.
18.
Rinchiuso-Hasselmann A, Starr DT, McKay RL, Medina E, Raphael M. Public
compliance with mass prophylaxis guidance. Biosecur Bioterror. 2010 Sep;8(3):255-63.
19.
Rowel R, Maryland Dept. of Health and Mental Hygiene. A guide to enhance
grassroots risk communication among low-income populations [electronic resource]
Annapolis, MD: Maryland Dept. of Health and Mental Hygiene; 2009 [cited RAND
Library-NYAM.
20.
Shugarman LR, Chandra A, Taylor SL, Stern S, Beckjord EB, Parker AM, et al.
Analysis of risk communication strategies and approaches with at - risk populations to

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Appendix D. Excluded Studies at Long Form Screening

enhance emergency preparedness, response, and recovery Santa Monica, CA Rand
Health; 2008 [cited RAND Library-NYAM.
21.
University of California BSoPH. Lessons learned from Hurricane Katrina : how
local health departments can prepared to meet the needs of vulnerable populations in
emergencies Berkeley, Calif: University of California, Berkeley School of Public Health;
2006 [cited RAND Library-NYAM.
22.
Veatch RM. Disaster preparedness and triage: justice and the common good. Mt
Sinai J Med. 2005 Jul;72(4):236-41.
23.
Wray RJ, Becker SM, Henderson N, Glik D, Jupka K, Middleton S, et al.
Communicating with the public about emerging health threats: lessons from the PreEvent Message Development Project. Am J Public Health. 2008 Dec;98(12):2214-22.

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Appendix D. Excluded Studies at Long Form Screening

Did not assess the public’s opinions directly (N=4)
1.
Lowrey W, Evans W, Gower KK, Robinson JA, Ginter PM, McCormick LC, et
al. Effective media communication of disasters: pressing problems and recommendations.
BMC Public Health. 2007;7:97.
2.
Trotter G. The ethics of coercion in mass casualty medicine. Baltimore: Johns
Hopkins University Press; 2007.
3.
University of Toronto Joint Centre for Bioethics Pandemic Influenza Working
Group. “Stand on Guard for Thee: Ethical considerations in preparedness planning for
pandemic influenza,” November 2005. See also L. Rubinson, et al. “Augmentation of
hospital critical care capacity after bioterrorist attacks or epidemics: Recommendations of
the Working Group on Emergency Mass Critical Care,” Critical Care Medicine, 2005,
33(10):E1-13. See also J. D. Arras, “Ethical Issues in the Distribution of Influenza
Vaccines,” Hastings Center Report, In Press. 2005.
4.
Wolf L, Hensel W. Valuing lives: Allocating scarce medical resources during a
public health emergency and the Americans with Disabilities Act (perspective). PLoS
Curr. 2011;3:RRN1271.

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