Acknowledgements

Steering Committee

MEMBER AGENCY

Dave Abbott State DHS

Yolanda Baldovinos Alameda Co HCSA

Doug Buchanan Mountain Valley EMS Agency

John Celentano, MD Los Angeles Co EMS Agency

Paul Garrett Yolo Co. Health Department

Jeff Gidley California EMS Authority

Herbert Giese, MD Nevada Co. Health Officer

Darlene Isbell Los Angeles Co. EMS Agency

Art Lathrop Contra Costa EMS Agency

Linda Pryor State OES

Jeff Rubin California EMS Authority

Glennah Trochet, MD Sacramento Co. DHHS

Steve Andriese Mountain Valley EMS Agency

Diane Evans Santa Cruz Co. Dept. of Env Health

Wendi Dodgin State OES

Dave Herfindahl, MD Siskiyou Co Health Department

B.A. Jinadu, MD Kern Co. Dept of Public Health

Michael Osur Riverside Co. EMS Agency

Constance Perett Los Angeles Co OES

John Pritting Imperial Co EMS Agency

Advisory Group

MEMBER AGENCY REPRESENTING

Kim Zagaris, Asst. Chief Governor's OES State OES

Bob Petrucci, Disaster Spec. Santa Clara EMS Agency EMSAAC Multi-county LEMSAs

Dorel HarmsCalifornia Healthcare Assoc. Hospital Industry

David Herfindahl, MD Siskiyou County Health Dept. CCLHO

Steve Tharratt, MD Sacramento County EMS EMDAC

David G. Jones Fresno, Kings, Madera EMS MSAAC Rural LEMSAs

Steven C. Wood San Diego County EMS EMSAAC Urban LEMSAs

Barbara Center Region II RDMHS RDMHCs

Nancy LaPolla Santa Barbara County EMS EMSAAC Suburban LEMSAs

Carl Schultz, MD CAL/ACEP Emergency Physicians

Sherlene Stepp ENA Emergency Nurses

(Invited) CAA Ambulance Industry

(Invited) FIRESCOPE Fire Service

Dave Abbott State DHS Public and Env Health

Project Staff

MEMBER AGENCY POSITION

Jeff Gidley State EMS Authority Project Director

Doug Buchanan Mountain-Valley EMS Agency Project Coordinator

Calvin Freeman Calvin Freeman & Associates Project Consultant

TABLE OF CONTENTS

Acknowledgements	i
Executive Summary	iii



Introduction	1
Section 1: Project Background and Rationale	2
Standards Development Process	2
Project Steering Committee and Advisory Group	3
Priority Setting	4
Project Products	4
Section 2: Project Conceptual Framework	5
Introduction	5
Medical and Health Function Descriptions	6
Assignment of Functions to LEMSA	8
Overall LEMSA Disaster Responsibilities	9
Role of County Health Officer	10
Role of the Medical/Health Operational Area Coordinator	10
Proposed Legislation	11
Section 3: Draft Standards	12
Introduction	12
Function 1: Assess Immediate Medical Needs and Initiate Response	12
Function 2: Manage Disaster Medical and Health Resources	14
Function 3: Manage Patient Distribution/Evacuation	15
Function 4: Support Hospital Emergency Services	15
Function 5: Support the Provision of In-Hospital Care	16
Function 6: Support Out-of-Hospital Care	17
Function 7: Manage Medical Transport	17
Function 8: Coordinate Pre-Hospital Emergency Services	17
Function 9: Support Temporary Field Treatment Sites	18
Section 4: Oversight Organization	19
Appendices:	20
A: Disaster Medical System Functions and Elements	21
B: Glossary of Terms	24
C: Survey of Local EMS Agencies – 1999 Summary of Results	29
TABLES
Table 1: Disaster Medical and Health Function and Descriptions	6
Table 2: LEMSA Disaster Functions	9
Table 3: Government Response/Cooperative Assistance Standards	12
Table 4: Hospital Related Standards	15
Table 5: Field Response Standards & Proposed Regulations	17

Executive Summary

In cooperation with the EMS Administrators Association of California, Mountain-Valley EMS Agency began a project in July 1999, funded by the state EMS Authority, to develop disaster medical system standards to assist local EMS agencies (LEMSAs) in the development of local response plans. A multi-disciplinary Steering Committee and Advisory Group were formed from local, regional, and state representatives, as well as many stakeholder groups from throughout the state.

The committee identified 18 medical and health functions for which local government currently has primary or significant responsibility:

1. Assessment of Immediate Medical Needs*

2. Health Surveillance and Epidemiology

3. Disaster Medical and Health Resources *

4. Manage Medical Transport *

5. Manage Patient Distribution/Evacuation*

6. Coordinate Pre-Hospital Emergency Services*

7. Support Hospital Emergency Services*

8. Support the Provision of In-Hospital Care*

9. Support Out-of-Hospital Care*

10. Support Temporary Field Treatment Sites*

11. Food Safety

12. Manage Exposure to Hazardous Agents

13. Mental Health

14. Medical and Health Public Information

15. Vector Control

16. Potable Water

17. Waste Management

18. Communicable Disease Control

Since the scope of this project was to provide assistance to local EMS agencies, the group further identified the nine functions, identified with an (*) in bold type above, as areas for which local EMS agencies have some level of responsibility for preparedness, response, or recovery.

Project staff then grouped these functions into three categories for purposes of planning and development: (1) Government/Cooperative Assistance, (2) Hospital Support, and (3) Field Response. These functions were then further broken down into multiple elements, based upon a statewide survey of LEMSAs.

Both the Steering Committee and Advisory Group agreed that there was a need for a single point for medical and health disaster plans within each county, and proposed the need to assist local medical and health officials to seek legislation which would list the eighteen functions and name the Health Officer or designee as having primary oversight responsibility. The project has also developed draft regulations and guidelines to assist LEMSAs with implementation.

Representatives from various local and state agencies have unanimously recommended that the Department of Health Services undertake a similar project to assist local public and environmental health officials to establish statewide standards and guidelines and that an oversight body or bodies be created to maintain and update the statewide medical and health standards.

Project staff have recently submitted a request for second year funding in order to continue to work with local and state organizations to finalize the regulatory processes, and also to provide training and training standards for local disaster medical services personnel.

Introduction

· In July 1999, the California EMS Authority made a grant to the Mountain Valley EMS Agency to undertake a project to develop disaster medical standards for local Emergency Medical Services agencies (LEMSAs). This Final Report provides EMS System stakeholders and constituents with a summary of the Project’s progress during its first year of funding.

These results represent the combined efforts of the project’s Steering Committee, Advisory Group, staff, and consultant since July 1999.

The report is organized into the following sections:

· Introduction

· Section 1: Project Background and Rationale

· Section 2: Project Conceptual Framework

· Section 3: Draft Standards

· Section 4: Oversight Organization Issues

· Appendices:

A: Disaster Medical System Functions and Elements

B: Glossary of Terms

C: Survey of Local EMS Agencies – 1999 Summary of Results

Section 1: Background

In early 1999, the Mountain-Valley EMS Agency undertook a survey of local EMS agencies throughout California. A summary of the survey results is included as Appendix C of this report. Of the 32 local EMS agencies surveyed, 25 responded. Survey responses indicated a lack of standardization in the following significant areas:

· Only 60% of respondents have patient distribution systems consistent with neighboring jurisdictions.

· More than half of responding jurisdictions do not have formal plans for requesting and dispatching out-of-area ambulances.

· Almost 1/3 of respondents have not completed developing provisions for providing medical situation status reports to the state.

· Only 40% of respondents indicated that their plans contain criteria regulating the categories of triaged patients receiving facilities should receive.

· Twenty per cent of respondents do not have a formal process for ordering resources.

· About half of responding LEMSAs have separate plans for disasters and multiple casualty incidents.

The results of the survey coupled with the experience of disaster medical planners throughout California clearly demonstrate that (1) many jurisdictions have not completed development of comprehensive disaster medical plans and (2) response systems are not sufficiently compatible in critical areas where cross-jurisdictional responses require coordination.

The experience of response agencies following the Loma Prieta Earthquake of 1989 and the Oakland Hills Fire of 1991 demonstrates the potential communications, organizational, and operational crises that a lack of standards can produce. Recent events, such as the floods of 1995 and 1996 and the flu epidemic of the winter of 1998, indicate a continuing need for standardized disaster medical systems in California.

The Standards Development Process

The purpose of the project was to develop a set of standards for LEMSAs, resulting in the establishment of effective and standardized disaster medical systems throughout California. The project also addressed the creation of an organization and process for the maintenance of the standards. The term “disaster medical systems” refers to the plans, policies, practices, procedures and management systems undertaken by government, voluntary and private sector organizations, and agencies to minimize the loss of life and suffering and ensure the protection of people and the healthcare infrastructure following disasters.

Project Steering Committee and Advisory Group

The framework for the standards development process was established by the project Steering Committee, while an Advisory Group assisted with the development of specific standards. The Steering Committee was appointed jointly by the California Emergency Medical Services Authority and Department of Health Services. Its members represent the primary disciplines and stakeholder organizations involved in the development and implementation of disaster health and medical systems in California. It laid the foundation for this project by:

1) Reaffirming the role of counties in preparedness, response, and recovery from disasters with severe medical and health consequences.

2) Identifying and defining the eighteen medical and health functions that local jurisdictions should address to develop comprehensive disaster medical and health systems.

3) Designating nine functions for which local EMS agencies should have primary preparedness, response, or recovery (PRR) responsibility.

The eighteen medical and health functions, as well as the subset of nine assigned to LEMSAs, are listed and defined in Section 2 of this report.

The Advisory Group was appointed jointly by the Project Director and Project Coordinator. The Advisory Group focused primarily on disaster medical issues. It provided guidance and technical input in the development of these standards. Its membership included representatives from the primary disciplines and stakeholder organizations throughout the state involved in the development and implementation of disaster medical systems.

The Advisory Group organized the nine functions for which LEMSAs have primary responsibility into the following broad categories in order to facilitate its work:

· Government Response/ Cooperative Assistance Functions

· Hospital and Other Facility Related Functions

· Field Response Functions

Each function in turn is assigned a group of disaster medical response elements. These elements represent the specific actions or system components required to establish the corresponding function. System elements also provide sufficient specificity to serve as a basis for the development of standards and proposed regulations. Functions, elements, and their related standards are displayed in Section 3 below.

Priority Setting

The Advisory Group recognized that the project would not be able to develop standards for all elements in a single year and that for many elements local flexibility was more appropriate than statewide standardization. It applied the following criteria for setting priorities for standardization:

· The importance of the element for meeting an acceptable standard of performance for a jurisdiction's disaster medical system.

· The importance of the element in promoting a coordinated inter-jurisdictional response.

· The existing degree of standardization for the element in California EMS systems.

· The availability of technical and financial resources and government authority for implementation of the standard.

In most instances, the Advisory Group achieved consensus on the recommended standard. For those standards for which full agreement could not be reached, a footnote provides a summary of issues discussed by the Advisory Group.

It is important to note that at the time of this writing there is no parallel effort to develop standards for public, environmental, and mental health functions.

Project Products

The primary products of this project are a set of disaster medical standards for LEMSAs. The development of standards, in and of itself, is not sufficient to create the system improvements envisioned by this project. To maximize the implementation of these standards by LEMSAs, the Advisory Group recommended:

· Developing legislation that establishes the framework for local disaster medical and health systems and defines organizational and leadership responsibilities.

· Promulgating regulations that codify the standards for LEMSAs.

· Developing guidelines, descriptions of best practices, training standards, and other tools that will assist LEMSAs to implement the regulatory requirements.

Section 2: Conceptual Framework

Introduction

In virtually every disaster, local government provides the initial response and in most emergencies, the local response is sufficient to meet the needs created by the emergency. While local governments may be supported by State and federal government agencies or by neighboring jurisdictions in major disasters, external assistance does not abrogate local authority.

Reviewing the disaster response experience of government and private agencies in California, the Steering Committee identified 18 medical and health disaster functions potentially required to meet the medical and health needs of impacted communities.

For nine of these 18 functions, the Steering Committee determined that LEMSAs are the most appropriate organizational entity for ensuring that systems, policies and procedures necessary for successful preparedness, response, or recovery are in place. County government may choose, however, to assign these functions to other organizational units or contract with external entities for all or part of the related responsibilities.

The Advisory Group used these functions as the starting point for its work and made some modifications in the LEMSA related functions defined by the Steering Committee to frame the functions in action-oriented language more conducive to standard setting.

Medical and Health Function Descriptions

Table 1 below lists and defines the 18 disaster medical and health functions identified by the Steering Committee. It also identifies the nine functions for which LEMSAs have or share a primary responsibility for preparedness, response, or recovery.

TABLE 1: Disaster Medical and Health Function and Descriptions

(Bolded Functions are assigned to local EMS agencies. Other functions are assigned to Public, Environmental, Mental and other health agencies)

*Function*	*LEMSA* *Primary Responsibility*	*Description*
1. Assessment of Immediate Medical Needs	Preparedness Response	Establish a system to (1) provide a rapid evaluation of the acute medical needs immediately following a disaster and the ability of the healthcare infrastructure in the impacted area to meet those needs; and, (2) notify the Disaster Medical/Health Operational Area Coordinator and other entities required to activate a response.
2. Health Surveillance and Epidemiology		An evaluation system designed to provide information about the relative health of the impacted population and to evaluate the potential for public health consequences as a result of the disaster event. This process is ongoing during the response and recovery phase of disaster operations.
3. Medical/Health Resources	Preparedness Response	Identify, mobilize, apply, and deactivate medical and health resources needed for the response to disasters. Resources include medical and health personnel, equipment and supplies acquired from local, regional, state, or federal governments or through contracts and agreements with the private sector.
4. Medical Transportion	Preparedness Response Recovery	Coordinate medical transport assets including ALS and BLS ambulances, air ambulances and other designated non-emergency medical transport assets.
5. Patient Distribution/ Evacuation	Preparedness Response Recovery	Direct (1) the movement of casualties from point of injury to designated receiving facility, (2) transfers among medical facilities and (3) transport of patients from medical facilities within the impacted area to other facilities either inside or outside the impacted area.
6. Pre-Hospital Emergency Services	Preparedness Response Recovery	Develop plans, policies and procedures to: (1) apply resources, including, equipment and personnel, required to treat, stabilize and transport victims of acute injury or illness to a medical facility capable of providing appropriate treatment and supportive care; (2) immediately dispatch medical response resources as permitted by standing order or plan; and (3) modify EMS system policies and protocols to maintain continuity of EMS services to the extent possible during a response to disasters.
7. Hospital Emergency Services	Preparedness Response Recovery	Support the provision of medical services at designated emergency departments or facilities designed to provide triage and initial treatment to victims of injury or illness.
8. In-Hospital Care	Preparedness Response Recovery	(1) Promote the development of standardized hospital internal and external disaster plans consistent with the medical response plan of the Operational Area. (2) Develop a system to support the provision of medical and health services provided by an acute care facility and associated personnel.
9. Out-of-Hospital Care	Response	Develop plans and procedures to respond to non-hospital facilities and services including skilled nursing facilities, board and care facilities, home health agencies, public health clinics, and community clinics.
10. Temporary Field Treatment Sites	Preparedness Response Recovery	Support the establishment/management of temporary medical triage and treatment sites following a disaster event to provide health care to disaster victims and displaced personnel.
11. Food Safety		The system of procedures, regulations and inspections designed to ensure that the public is protected from food borne disease during the production, processing, distribution and preparation of food
12. Management of Exposure to Hazardous Agents		The procedures implemented through guidelines, regulation, and training designed to protect the public and responders from injury due to exposure to chemical, biological, and radiological hazards and to effectively decontaminate exposed personnel. This function also includes provisions to protect equipment and the environment from secondary contamination and provide guidance on the decontamination and remediation of contaminated property and the environment.
13. Mental Health		Services to improve the emotional health of the public and responders during and following a disaster event. This function includes critical incident stress debriefing services as well as short- and long-term crisis counseling services.
14. Medical and Health Public Information		The procedures designed to provide public health information, disease and injury control information, and medical situation status to the general public and to responders during and following a disaster event.
15. Vector Control		The procedures implemented to assess the threat of vector borne disease, institute field investigations, provide technical assistance to local abatement districts, implement field control operations and provide consultation on the medical treatment of victims of vector borne disease.
16. Potable Water		The procedures and processes instituted to assess the availability and safety of drinking water during disaster operations and return damaged water supplies to full operation. This function includes field investigations and laboratory support resulting in the collection and analysis of water samples, technical consultation with suppliers and system operators, and advise to the public.
17. Waste Management		The procedures and processes instituted to ensure the safe collection and disposal of liquid and solid wastes including guidance on temporary handling of sewage, hazardous waste and medical waste during disaster operations. This function includes consultation with sewage and solid waste disposal providers, with responders for the removal and safe disposal of disaster-related rubble and waste, and advise to the public.
18. Communicable Disease Control		The procedures instituted to prevent, identify, or control the transmission of disease including epidemiological surveillance, outbreak investigation, laboratory services, and control activities such as vaccination programs, isolation or quarantine.

The following response functions are often organizationally closely related to public and environmental health or health care response functions.

1. Animal Control	Those activities necessary to control loose pets, feral animals, or domestic animals that present a hazard to human health or safety following a disaster. Medical and health support to animal control generally consists of coordination with responsible agencies and depending upon the discretion of the EOC director could include oversight and management at the EOC level.
2. Coroner and Mortuary Services	Those activities necessary to identify, register, hold and safely dispose of human remains to prevent health risks to the public and maintain the dignity of the deceased. Medical and health support to coroner and mortuary services generally consists of coordination with responsible agencies and may include reporting mortality statistics generated by the responsible agency.
3. Care and Shelter (Ancillary Services)	Medical and health support services, such as nursing or physician services, necessary to maintain the health of the individuals in mass care facilities. These services also include the provision or staffing of a temporary infirmary or medical shelter if necessary to meet the needs of the medically fragile.

Assignment of Functions to LEMSA

The Steering Committee considered the following factors in assigning responsibility for these functions to LEMSAs:

· Division 2.5 of the California Health and Safety Code lists disaster planning as one of the eight functions of LEMSAs.

· All LEMSAs currently have at least some minimal involvement in disaster medical preparedness.

· All LEMSAs have ongoing working relationships with 24-hour dispatch and/or communication centers.

· All LEMSAs have contractual or working relationships with major acute care hospitals.

· All LEMSAs have oversight, coordination, contract, or management relationships with components of EMS Systems traditionally responsible for medical response to emergencies, e.g. prehospital providers, receiving facilities, etc.

· All LEMSAs manage medical transport in their jurisdictions.

· Almost all LEMSAs have working relationships with local health officers and other local government and health officials.

· No other unit of government or government program is so positioned.

It is important to note that neither the definitions of the functions, their assignment to LEMSAs, nor the actual standards dictate how LEMSAs are to operationalize any requirements. The standards do not imply that LEMSAs must adopt the operational responsibility for creating those systems and elements or for managing the disaster medical response of their counties unless designated or contracted to perform those duties. Rather, they describe system characteristics that LEMSAs are to ensure. This project will develop guidelines, identify best practices, and gather other resources to illustrate the standards and assist LEMSAs with implementation.

Overall LEMSA Disaster Responsibilities

Table 2 displays the functions assigned to local EMS agencies through the deliberations of the Steering Committee. The functions and definitions incorporate revisions made by the Advisory Group.

Table 2: LEMSA Disaster Functions

Function	Description
LOCAL GOVERNMENT/ COOPERATIVE ASSISTANCE
1. Assess Immediate Medical Needs and Initiate Response	Establish a system to (1) provide a rapid evaluation of the acute medical needs immediately following a disaster and the ability of the healthcare infrastructure in the impacted area to meet those needs; and, (2) notify the Medical/Health Operational Area Coordinator and other entities required to activate a response.
2. Manage Disaster Medical and Health Resources	Identify, mobilize, apply, and deactivate medical and health resources needed for the response to disasters. Resources include medical and health personnel, equipment and supplies acquired from local, regional, state, or federal governments or through contracts and agreements with the private sector.
HOSPITAL AND OTHER FACILITIES RELATED
3. Manage Patient Distribution/Evacuation	Direct (1) the movement of casualties from point of injury to designated receiving facility, (2) transfers among medical facilities and (3) transport of patients from medical facilities within the impacted area to other facilities either inside or outside the impacted area.
4. Support Hospital Emergency Services	Support the provision of medical services at a designated emergency department or facility designed to provide triage and initial treatment to victims of injury or illness.
5. Support the Provision of In-Hospital Care	(1) Promote the development of standardized hospital internal and external disaster plans consistent with the medical response plan of the Operational Area. (2) Develop a system to support the provision of medical and health services provided by an acute care facility and associated personnel.
6. Support Out-of-Hospital Care	Develop plans and procedures to respond to non-hospital facilities and services including skilled nursing facilities, board and care facilities, home health agencies, public health clinics, and community clinics.
FIELD RESPONSE
7. Manage Medical Transport	Coordinate medical transport assets including ALS and BLS ambulances, air ambulances and other designated non-emergency medical transport assets.
8. Coordinate Pre-Hospital Emergency Services	Develop plans, policies and procedures to: (1) apply resources, including, equipment and personnel, required to treat, stabilize and transport victims of acute injury or illness to a medical facility capable of providing appropriate treatment and supportive care; (2) immediately dispatch medical response resources as permitted by standing order or plan; and (3) modify EMS system policies and protocols to maintain continuity of EMS services to the extent possible during the response to disasters.
9. Support Temporary Field Treatment Sites	Support the establishment/management of temporary medical triage and treatment sites established following a disaster event to provide health care to disaster victims and displaced personnel.

Management of the Operational Area Disaster Medical/Health System:

Role of the County Health Officer

In its deliberations regarding standards for LEMSAs, the Advisory Group recognized the need for definition of the management structure through which LEMSAs must coordinate the development of their disaster medical plans, policies, and practices. To this end, the Advisory Group recommended that the County Health Officer or designee should be formally designated through legislation as the position responsible for the overall management of the Operational Area’s disaster/medical health system. As such, the Health Officer or designee will direct the preparedness, response, and recovery activities related to the eighteen medical/health functions listed above. The Health Officer may work through or coordinate with LEMSAs and other local and regional governmental, quasi-governmental, non-profit organizations and other entities to develop and manage the disaster medical/health system.

Examples of the Health Officer’s disaster medical and health responsibilities should include:

· Developing governmental disaster medical and health plans for the operational area.

· Coordinating the operational area disaster medical and health plans with the overall emergency plan of the operational area and the plans of related response functions.

· Directing disaster medical and health operations within the Operational Area and ensuring coordination of Medical, Mental Health and Public and Environmental Health response activities.

· Assist medical, public and environmental health resources to recover from the impact of disasters and where feasible, recoup response costs and participate in state and federal reimbursement programs.

· Promoting the development of disaster plans by ambulance, hospital, and other medical and health related entities that are consistent with government plans.

Role of the Medical/Health Operational Area Coordinator (OAC)

The Health Officer or designee may assume or delegate the duties of the position of Medical/Health Operational Area Coordinator (OAC), previously know as the Operational Area Medical/Health Coordinator.[1] The Medical/Health OAC acts as the conduit for requesting and providing resources to and from other jurisdictions through the Regional Disaster Medical/Health Coordinator. Both the Steering Committee and the Advisory Group agreed that while the most logical point for overall management of disaster medical and health services is the County Health Officer or designee, it is reasonable to delegate the duties of the Medical/Health OAC to other staff.

Largely based on the model of the Fire Operational Area Coordinator, the Medical Health OAC could be assigned responsibility for the following tasks:

· Ensuring establishment and operation of a 24-hour point of contact capable of communication with local, regional, and state government agencies and officials with emergency management responsibilities; hospitals and other healthcare entities; and individuals who are to be notified/mobilized in the event of activation of disaster medical response system.

· Ensuring that key disaster response personnel receive periodic training.

· Developing and testing plans, policies, procedures, and structures for the activation and implementation of the disaster response system,

· Ensuring that information management plans are developed and tested.

· Providing authorization and direction for activation of the medical/health branch of the operational area EOC and ensuring management systems are in place for managing the Medical/Health Branch of the Operational Area EOC.

· Coordinating the procurement and allocation of public and private medical, health and other resources required to support disaster medical and health operations in affected areas.

· Communicating requests for out-of-county assistance to and responding to requests from the Regional Disaster Medical Health Coordinator.

· Developing a capability for identifying medical and health resources, medical transportation, and communication resources within the Operational Area.

· Maintaining liaison with the Operational Area Coordinators of other relevant emergency functions, e.g., communications, fire and rescue, law, transportation, care and shelter, etc.

· Ensuring that the existing Operational Area medical and health system for day-to-day emergencies is augmented in the event of a disaster requiring utilization of out-of-area medical and health resources.

· Maintaining records and filing required reports.

Proposed Legislation

The Advisory Group recommends the introduction of legislation to provide a foundation for the development of effective standardized local disaster medical and health systems. The legislation should establish in statute:

· The 18 medical and health functions defined by the Steering Committee.

· The respective roles and responsibilities of LEMSAs and Public Health Departments.

· The role of the Health Officer or designee as the leader of the Operational Area’s disaster medical and health organization.

· The establishment of structures managed by the California EMS Authority and Department of Health Services to maintain and update disaster medical and health system standards.

Section 3: LEMSA Standards

Introduction

The table below contains the standards drafted, to date, by the project.

· Bolded Arial typeface designates standards that should be codified through regulation.

· Normal typeface designates guidelines that help to clarify the basic standard and provide guidance for implementation.

The following subsections display standards and proposed regulations developed by the project for several of the listed disaster elements.

Table 3: Government Response/ Cooperative Assistance Standards

Function 1: Assess Immediate Medical Needs and Initiate Response
Establish a system to (1) provide a rapid evaluation of the acute medical needs immediately following a disaster and the ability of the healthcare infrastructure in the impacted area to meet those needs; and, (2) notify the Medical/Health Operational Area Coordinator and other entities required to activate a response.
Element 1.1 Procedures for gathering assessment information (includes scale and type of emergency) and for evaluating, reporting, and disseminating information.	Standard: LEMSAs shall establish policies for: (1) acquiring and analyzing information on the medical situation of the Operational Area, the status of major health facilities and other resources, and the immediate medical needs of the OA and (2) submitting requested reports to the Medical/Health OAC, other operations within the Operational Area, and the Regional Disaster Medical/Health Coordinator. (See Function 5 for hospital reporting standard).
Element 1.2 Notify key positions of disaster medical and health system	Standard: LEMSAs shall ensure the development and testing of plans, criteria, policies, procedures, and structures, and related training for the notification of key positions and organizations of the disaster medical and health response system. Specific responsibilities include: 1. Ensuring county has a 24-hour point of contact with at least two means of communications capable of two-way communications with local, regional, and state government agencies and officials with emergency management responsibilities; hospitals and other healthcare entities; and, individuals who are to be notified in the event of a medical or health disaster. 2. Maintaining an up-to-date contact list for disaster medical and health system alert and activation which should include the Director, Local EMS Agency, Local Health Officer(s), Environmental Health Director(s), Local Health Agency Director, Local Emergency Management Agency, and others as required by local plans and policies.
Element 1.3 Immediate Reporting Requirements	LEMSAs shall ensure development of reporting requirements that include: 1. Information items to be reported and transmitted to the MHOAC. 2. Data that are consistent with and allow completion of RIMS data elements. 3. Casualty estimates and an assessment of acute medical care needs. 4. Medical response system capabilities including hospital status reporting standard (Element 5.1) and the availability of medical transport resources. 5. An overall assessment of the medical situation.

Function 2: Manage Disaster Medical Resources
Identify, mobilize, apply, and deactivate medical and health resources needed for the response to disasters. Resources include medical and health personnel, equipment and supplies acquired from local, regional, state, or federal governments or through contracts and agreements with the private sector. (Refer to Function 8 for related Elements and Standards)
Element 2.1 Procedures for resource acquisition and application (ordering & authorization procedures)	Standard: LEMSAs shall ensure development of policies and procedures to: 1. Define criteria for evaluating initial requests for assistance from both within and outside of the Operational Area. 2. Rapidly mobilize and dispatch medical and health resources within the Operational Area to meet immediate response needs.
Element 2.2 Resource planning and preparedness (resource inventories, prior agreements)	Standard: LEMSAs shall develop and maintain an up-to-date inventory of disaster medical and health resources in the operational area. Inventories shall include the following categories of resources: hospitals, medical suppliers, medical transport, skilled nursing facilities / residential care facilities, and sources of information.
Element 2.3 System for accessing, acquiring, using and supporting external resources (including interface with RDMHC)	Standard: LEMSAs shall seek to develop cooperative agreements with neighboring jurisdictions for sharing prehospital resources across jurisdictions in response to disasters. LEMSAs shall include provisions in contracts with ambulance providers requiring out-of-county response to disasters when authorized by the LEMSA and when local conditions and resources permit. LEMSAs shall ensure development of policies and procedures to guarantee necessary logistic support has been arranged for all requested resources responding from outside the jurisdiction prior to their arrival. LEMSAs shall ensure development of policies and procedures to support the operations of out-of-jurisdiction ambulances requested to respond to local emergencies. Support should include, but not be limited to: · Ensuring communication support. · Providing local maps and directions to receiving facilities. · Providing fuel, food and other support.
Element 2.4 Resource Tracking	Standard: LEMSAs shall ensure development of systems for tracking the location and status of out-of-county resources from their time of arrival to their assignment to an incident and from their release from an incident to assignment to another incident or deactivation.
Element 2.5 Deactivation / Demobilization	<to be developed>

Table 4: Hospital Related Standards

Function 3: Manage Patient Distribution and Evacuation
(1) Direct the movement of casualties from point of injury to designated receiving facility, (2) assist transfers among medical facilities and (3) coordinate transport of patients from medical facilities within the impacted area to other facilities either inside or outside the impacted area.
Element 3.1 Patient dispersal system (plan, & procedures, criteria for destination, etc.)	Standard: LEMSAs shall develop plans, policies and procedures that: (1) direct the movement of casualties from point of injury to designated receiving facility, (2) assist transfers among medical facilities and (3) coordinate transport of patients from medical facilities within the impacted area to other facilities either inside or outside the impacted area. LEMSAs shall establish a single point of contact within the Operational Area disaster medical/health organization responsible for coordinating casualty evacuation to or casualty receipt from other Operational Areas.
Element 3.2 Communications.	<Standards for this element are under development by the Statewide Emergency Communications Systems Project>

Function 4: Support Hospital Emergency Services
Support the provision of medical services at a designated emergency department or facility designed to provide triage and initial treatment to victims of injury or illness.
Element 4.1 Support for initial triage, stabilization, and disposition	<to be developed>

Function 5: Support the Provision of In-Hospital Care
(1) Promote the development of standardized hospital internal and external disaster plans consistent with the medical response plan of the Operational Area. (2) Develop a system to support the provision of medical and health services provided by an acute care facility and associated personnel.
Element 5.1 Hospital status / damage assessment	Standard: LEMSAs shall provide a single 24-hour point of contact through which (1) hospitals can report their status and request emergency assistance and (2) the medical response can disseminate contact information and procedures to acute care hospitals within the Operational Area. Standard: All local EMS agencies shall establish a hospital information reporting system capable of gathering, compiling, and reporting information on the functional status, casualty receipt capability, and needs of local hospitals according to local, regional, and state plans. Specific data elements include: 1.a. Is hospital functional? Yes Partial No b. Is the hospital capable of maintaining the health status of current patients? Yes No c. For how long? ______________ 2.a. Can hospital accept any additional patients? b. If yes, in which categories? Emergency? Yes No Medical/surgical? Yes No ICU? Yes No Pediatric? Yes No Psychiatric? Yes No Obstetrics? Yes No 3. What are hospital needs? Note: LEMSAs and Hospitals may agree to additional reporting requirements.
Element 5.2 Support standardized hospital disaster plans	Standard: All local EMS agencies shall develop plans and procedures to promote the adoption of the Hospital Emergency Incident Command System by all acute care hospitals for their emergency response plans.
Element 5.3 Support in-hospital care through personnel, supply, equipment, and evacuation support	Standard: LEMSAs shall ensure the development and testing of plans, policies, and procedures to provide support to hospitals during response to disasters. Hospital support should include: · Assistance in identifying and obtaining resources when hospitals were unable to access, communicate with, or arrange transportation from their own sources of supply. · Providing a conduit for providing critical information to and gathering status information from hospitals.

Function 6: Support Out of Hospital Emergency Services
Develop plans and procedures to respond to non-hospital facilities and services including skilled nursing facilities, board and care facilities, home health agencies, public health clinics, and community clinics.
Element 6.1 Support Out-of-Hospital Care	<to be developed>

Table 5: Field Response Standards & Proposed Regulations

Function 7: Manage Medical Transport
Coordinate medical transport assets including ALS and BLS ambulances, air ambulances and other designated non-emergency medical transport assets.
Element 7.1 Coordinate medical transport assets.	<to be developed>

Function 8: Coordinate Pre-Hospital Emergency Services
Develop plans, policies and procedures to: (1) apply resources, including, equipment and personnel, required to treat, stabilize and transport victims of acute injury or illness to a medical facility capable of providing appropriate treatment and supportive care; (2) immediately dispatch medical response resources as permitted by standing order or plan; and (3) modify EMS system policies and protocols to maintain continuity of EMS services to the extent possible during a response to disasters.
Element 8.1 Pre-hospital system transformation to disaster status (9-1-1 triage, standing orders, etc.)	<to be developed>
Element 8.2 Triage systems and methods (including categories & tag)	Standard: 1. Local EMS Agencies shall designate the START Triage System as the method of initial triage for all incidents with multiple casualties. 2. Triage categories for initial triage shall be defined as: · Immediate · Delayed · Minor · Deceased 3. Field responders will employ a triage tag with the following characteristics for initial triage: (a) Tag will include perforated tabs of the following colors and corresponding triage categories: Green = Minor Yellow = Delayed Red = Immediate Black = Deceased (b) Each tag will have a unique identification number printed on both sides of the tag and on the left and right corners which are perforated. (1) Tag will have dimensions of 4 ½ inches by 9 ¼ inches. (2) Tag will include provisions for recording the following information: a) Time of triage. b) Date of triage. c) Name of the patient. d) Home address of the patient. e) Home city and state of the patient. f) Other important information (medical treatment, history, decontamination, etc.) g) Caregiver number. h) Injuries / Exposures. i) Vital signs and the time taken. j) IVs and any drugs given. (3) Tag will be approved by the Director, EMS Authority.
Element 8.3 Austere medical care	Standard: LEMSAs shall prepare a plan and policies for implementation of austere medical care procedures when response resources are overwhelmed.
Element 8.4 Field operations management	Standard: Local EMS Systems shall designate the organization structure, position names, and position descriptions for field responses to incidents with multiple casualties as defined in the Multiple Casualty Incident Plan Section of the FIRESCOPE Field Operations Guide in effect as of April 28, 2000.
Element 8.6 Command / tactical communications	<to be developed>
Element 8.7 Consistency with adjacent counties	<to be developed>

Function 9: Support Temporary Field Treatment Sites
Support the establishment/management of temporary medical triage and treatment sites established following a disaster event to provide health care to disaster victims and displaced personnel.
Element 9.1 Designation / Activation	<to be developed>
Element 9.2 Personnel, supplies, and other resources	<to be developed>
Element 9.3 Integration into system	<to be developed>

Section 4: Standards Maintenance Organization

In its discussion of the organization to maintain and update the Disaster Medical Standards, the Advisory Group made the following recommendations / observations:

· The oversight of disaster medical standards and public and environmental health standards (when developed) should be closely coordinated.

· Two separate organizational entities or units may be needed to oversee the standards for disaster medical systems and for public and environmental health, respectively.

· Oversight bodies should include representation from all major EMS system stakeholders and other organizations.

· Oversight bodies will require staff support and a stable source of funding for their work.

· A number of policy and process issues still remain to be addressed including frequency of review of standards, use of external committees, decision processes, etc.

Appendix A: Disaster Medical System Functions and Elements

The chart below displays information used to organize and give priority to the standards development process. Column 1 displays the eight disaster medical system functions assigned to LEMSAs by the Steering Committee and accepted by the Advisory Group. Column 2 displays the elements selected to further define the system functions. Columns 3 – 5 display information gathered from a 1998 survey of LEMSAs on disaster medical response issues. Column 3 displays the degree to which the respondents of the survey indicated their local systems have addressed the system element. Column 4 displays the degree to which LEMSAs across California have standardized their approach to each system element. In Columns 3 and 4 “***” indicates that the survey did not address that specific issue. Column 5 provides comments and notes that summarize the survey data.

DMS Function	System Elements	Degree of Development	Degree of Standardization	Comments
Assessment of Immediate Medical Needs	Procedures for gathering assessment information (includes scale and type of emergency).	***	***	All LEMSAs have designated responsibility for acquiring information. Responsible entities vary from LEMSA to LEMSA. Survey did not address actual procedures for gathering assessment information or the content of assessments.
	Process for evaluating information	***	***
	Procedures for gathering assessment information (includes scale and type of emergency).	Moderate	Low	Addresses only reports to state, not internal reports. 5 counties report “under development”, 2 counties “no plans”
Medical / Health Resources (see below for ambulances)	Resource planning and preparedness (resource inventories, prior agreements, activation)	***	***
	Resource acquisition process (Medical/Health OAC, ordering & authorization procedures)	High	Low	All respondents reported designating Medical/Health OACs. Almost all were Health Officers or EMS Agency staff. Fifteen LEMSAs place all resource orders through Medical/Health OAC, 7 do not. All respondents have resource ordering procedures, 5 only have informal procedures. All have authorization procedures - 21 formal and 4 informal.
	Access to resources external to system.	High	***	All respondents currently have plans or plans under development. Degree of standardization is unknown
	System for using and supporting external resources.	***	***
	Resource tracking	***	***
	Deactivation / demobilization	***	***
Medical Transport (Survey addressed only resources external to system).	Resource planning and preparedness (resource inventories, prior agreements, activation)	***	***
	Resource acquisition process (Medical/Health OAC, ordering & authorization procedures)	High	Low	See above. Several LEMSAs reported that ambulance acquisition procedures differed from procedures for acquiring other resources. For example, in MCIs in which the EOC is not activated, provider agencies may use own acquisition channels. One respondent also raised issue of private provider calling in out of area vehicles it owns without going through formal channels.
	Access to resources external to system.	High	***	All respondents currently have plans or plans under development. Degree of standardization is unknown
	System for using and supporting external resources.	***	***	11 respondents report formal procedures for establishing communications with mutual aid ambulances. 2 additional respondents have informal procedures. Seventeen reported the ability to dispatch those ambulances from their own dispatch centers and 4 use informal procedures. Almost all respondents have formal or informal procedures to provide directions to out-of-county ambulances. 13 respondents provide fuel or food to mutual aid ambulance crews, 6 through informal arrangements. 13 respondents have mechanisms to reimburse responding mutual aid ambulances.
	Resource tracking	***	***
	Deactivation / demobilization	***	***
Patient Disbursement / Evacuation	Patient dispersal system (plan, & procedures, criteria for destination , etc.)	High	Low	All but 3 respondents have systems in place for distribution of patients to hospitals. However, 13 reported no formal criteria for determining the capacity of receiving facilities to receive patients.
	Communications.	High	Low	All but one respondent have capabilities to communicate with receiving hospitals in their Operational Area(s). Methods of communications vary widely, ranging from dedicated computerized radio systems to land-line and cellular phones.
	Consistency with adjacent counties. (for pt. Disbursement only)	N/A	Low	Eight respondents reported full consistency, 5 inconsistency, 7 partial consistency, and 5 did not know.
	Casualty tracking and reporting.	***	***
Pre-Hospital Emergency Services	Pre-hospital system activation and transformation to disaster status (9-1-1 triage, standing orders, etc.)	***	***
	Triage systems and methods (including categories & tag)	High	High	All but one respondent use START for initial triage, all but four use START for secondary triage. Twenty reported using START categories, three our use a similar system with different names for the same categories (e.g., colors).
	Austere medical care	***	***
	Field operations management	High	Moderate	Generally consistent positions but sometimes differing terminology (coordinators, team leaders, chiefs, etc.)
	Command / tactical communications	Moderate	Low	7 respondents have not formally designated frequencies. Respondents use a variety of frequencies including 800-Mhz, Calcord, and various ambulance frequencies.
	Consistency with adjacent counties	Low	Low	7 responded “not consistent” or “not sure” ; 5 were “partially consistent.
Hospital Emergency Services (not addressed by survey)	Initial triage, stabilization, and disposition	***	***
In-Hospital Care (not addressed by survey)	Hospital status / damage assessment	***	***
	Hospital Response Management	***	***
	Personnel, supply, equipment, and evacuation support	***	***
Support Out-of-Hospital Care		***	***
Temporary Field Sites (not addressed by survey)	Designation / Activation	***	***
	Personnel, supplies, and other resources	***	***
	Integration into system	***	***
Cross-Cutting Elements	Planning (responsibility and content for both overall plan and separate elements)	High	Low	Most LEMSAs are responsible for planning – Health Depts are responsible in three LEMSAs, OES in one. Only 6 LEMSAs are responsible for health response planning. 10 LEMSAs use the same plan for Disaster and MCIs, 11 use different plans.
	Plan and procedure consistency with adjacent counties, region, and state	***	***
	Medical/Health OAC designation, roles & responsibilities	***	***	See Resources above for partial discussion.
	Response terminology (except field response management terminology described above)
	EOC Activation / De-activation	High	Moderate	17 respondents report plans for EOC activation, 4 have plans under development.
	EOC Management	***	***
	Communications / Command & Control System	***	***
	Reporting / Information Dissemination	Moderate	Low	See above
	Training Requirements and Exercises	Moderate	Moderate	Most respondents require / suggest and support training. Most require SEMS.
	After-Action Reports	***	***

Appendix B: Glossary of Terms Revised – February 13, 2000

Disaster Medical System Functions and Elements

Draft (9/12/99)

Term	Function Definition	DMS Elements
Assessment of Immediate Medical Needs	A system to provide a rapid evaluation of the acute medical needs within the impacted area immediately following an event and the ability of the healthcare infrastructure in the impacted area to meet those needs.	Procedure for gathering assessment information (includes scale and type of emergency). Procedures for reporting / disseminating information.
Medical / Health Resources	Those medical and health resources that can be requested by an impacted community and provided through local, state or federal assistance or through contracts an agreements with private industry. Resources include medical and health personnel, equipment and supplies.	Resource planning and preparedness (resource inventories, prior agreements, activation) Resource acquisition process (Medical/Health OAC, ordering & authorization procedures) Access to mutual aid system
Medical Transport	The provision and coordination of medical transport assets including ALS and BLS ambulances, air ambulances, and other designated non-emergency medical transport assets.	Ordering process for medical transport Authorization process for requests System for using and supporting private mutual aid ambulances from outside jurisdiction.
Patient Disbursement / Evacuation	The process of directing the movement of victims from point of injury to designated receiving facility, transfer among medical facilities and the transport of patients from medical facilities within the impacted area to other facilities either inside or outside the impacted area due to patient or facility status.	Patient dispersal system (plan, criteria, etc.) Communications. Consistency with adjacent counties. Casualty tracking and reporting.
Pre-Hospital Emergency Services	Those services, including organizations, equipment and personnel, provided to treat, stabilize and transport victims of acute injury or illness to a medical facility capable of providing appropriate treatment and supportive care.	Triage systems and methods (including categories & tag) Field operations management Command / tactical communications Consistency with adjacent counties
Hospital Emergency Services	Those services provided at a designated emergency department or facility, including a designated trauma center, designated to provide triage and initial treatment to victims of injury or illness.
In-Hospital Care	Medical and health services provided by an acute care facility and associated personnel including definitive, resuscitative and restorative treatment services and patient support in appropriate patient care units to victims of injury or illness.	Hospital Assessment Personnel, supply, equipment, and evacuation support
Temporary Field Sites	Medical triage and treatment sites established following a disaster event on a temporary basis to provide healthcare support to disaster victims and displaced personnel.	Designation / Activation Personnel, supplies, and other resources Integration into system
Cross-Cutting Elements		Planning (overall and separate elements) Activation / De-activation EOC Resources Response Management Reporting / Information Dissemination Training Requirements Exercises After-Action Reports

START Triage System Definitions

Term	Definitions from START Training Manual	Criteria
S.T.A.R.T.	Acronym for “Simple Triage and Rapid Treatment.” This is the initial triage system that has been adopted by almost all LEMSAs and FIRESOPE’S Multi-Casualty Branch of the Incident Command System.
Delayed	Second priority in patient treatment. These patients require aid, but injuries are less severe. These patients may have a wide range of injuries. They should receive more thorough secondary assessment when in a treatment area.	Criteria: Respirations under 30/minute and Palpable radial pulse and Can follow simple commands
Immediate	A patient who requires rapid assessment and medical intervention for survival.	Criteria: Respirations greater than 30/minute or Non-palpable radial pulse or Cannot follow simple commands
Minor	Patients whose injuries require rudimentary first aid.	Criteria: Ambulatory
Deceased

Field Medical Response Position Definitions (adapted from Firescope)

Position	Definition
Multi-Casualty Branch Director	Responsible for the implementation of the Incident Action Plan within the Branch. This includes the direction and execution of branch planning for the assignment of resources within the Branch. The Branch Director reports to the Operations Section Chief and supervises the Medical Group/Division and Patient Transportation Group Supervisors.
Medical Group/Division Supervisor	Reports to the Multi-Casualty Branch Director and supervises the Triage Unit Leader, Treatment Unit Leader and Medical Supply Coordinator. Establishes command and controls the activities within a Medical Group/Division, in order to assure the best possible emergency medical care to patients during a multi-casualty event.
Medical Supply Coordinator	Reports to the Medical Group/Division Supervisor and acquires and maintains control of appropriate medical equipment and supplies from units assigned to the Medical Group
Triage Unit Leader	Reports to the Medical Group/Division Supervisor and supervises Triage Personnel/Litter Bearers and the Morgue Manager. The Triage Unit Leader assumes responsibility for providing triage management and movement of patients from the triage area.
Triage Personnel	Report to the Triage Unit Leader and triage patients on-scene and assign them to appropriate treatment areas.
Morgue Manager	Reports to the Triage Unit Leader and assumes responsibility for Morgue Area activities until relieved of that responsibility by the Office of the Coroner.
Treatment Unit Leader	Reports to the Medical Group/Division Supervisor and supervises the Treatment Managers and the Treatment Dispatch Manager. Assumes responsibility for treatment, preparation for transport, and coordination of patient treatment in the Treatment Areas and directs movement of patients to loading location(s).
Treatment Dispatch Manager	Reports to the Treatment Unit Leader and is responsible for coordinating with Patient Transportation Group, the transportation of patients out of the Treatment Area.
Immediate Treatment Manager	Reports to the Treatment Unit Leader and is responsible for Treatment and re-triage of patients assigned to Immediate Treatment Area.
Delayed Treatment Manager	Reports to the Treatment Unit Leader and is responsible for Treatment and re-triage of patients assigned to Delayed Treatment Area.
Minor Treatment Manager	Reports to the Treatment Unit Leader and is responsible for Treatment and re-triage of patients assigned to Minor Treatment Area.
Patient Transportation Group Supervisor	Reports to the Multi-Casualty Branch Director and supervises the Medical Communications Coordinator and the Air and Ground Ambulance Coordinators and is responsible for the coordination of patient transportation and maintenance of records relating to patient identification, injuries, mode of off-incident transportation and destination.
Medical Communications Coordinator	Reports to the Patient Transportation Group Supervisor and supervises the Transportation Recorder and maintains communications with the hospital alert system and/or other medical facilities to assure proper patient transportation and destination and coordinates information through Patient Transportation Group Supervisor and The Transportation Recorder.
Air/Ground Ambulance Coordinators	Report to the Patient Transportation Group Supervisor and manage the Air/Ground Ambulance Staging Areas and dispatch ambulances as requested.

Operational Area: An intermediate level of the state emergency services consisting of a county and all political subdivisions within the county area. Political subdivisions include cities, a city and county, counties, districts, or other local government agency, or public agency authorized by law.

Medical/Health Operational Area Coordinator (OAC): Individual responsible for the overall direction and coordination of medical and health resources within the operational area, and activation of the appropriate positions within the Medical/Health branch of the operational area EOC.

Bold = Multicounty Regional Agency

Planning

1. Who has primary responsibility for medical disaster planning in your county(ies)?

OES (1) EMS (20) Health Dept. (3) Other (0)

2. Who has primary responsibility for health disaster planning in your county(ies)?

OES (3) EMS (8) Health Dept. (12) Other (1)

3. Do you have a Multi–Casualty Incident (MCI) / Medical Disaster Plan?

1 = Yes (25) 2 = No

If so:

(a) Does this plan contain a different response plan for MCIs vs Major Disasters?

Different Plans (13) Same Plan (12)

(b) Does this plan contain a component for:

	Yes	No	Under Development	No Answer
1) Medical Field Operations?	23	1	0	1
2) Medical Mutual Aid?	19	0	4	2
3) Patient Dispersal?	21	2	1	1
4) Medical/Health Branch Activation in the EOC?	17	1	5	1
5) Providing Medical Situation Status Reports to the State?	15	3	5	2

4. Medical Field Operations:

(a) Please list your triage categories for initial triage of injured patients in an MCI/Disaster.

LEMSA	Categories
ALAMEDA	IMMEDIATE, DELAYED, MINOR, DECEASED
CONTRA COSTA	MINOR, DELAYED, IMMEDIATE, DECEASED
FRESNO/KINGS/MADERA	IMMEDIATE, DELAYED, MINOR, DECEASED
HUMBOLDT	START
ICEMA
IMPERIAL	IMMEDIATE, DELAYED, WALKING WOUNDED, NON-SALVAGEABLE
KERN	RED, YELLOW, GREEN, BLACK ALSO DIFFERENTIATE ISOLATE, PEDS, OB & NEURO
LOS ANGELES	IMMEDIATE, DELAYED, MINOR
MARIN	IMMEDIATE, DELAYED, MINOR, DEAD
MONTEREY	IMMEDIATE, DELAYED
MOUNTAIN-VALLEY	IMMEDIATE, DELAYED, DECEASED, MINOR
NOR-CAL EMS	IMMEDIATE, DELAYED, MINOR, DECEASED
NORTH COAST	START
ORANGE	IMMEDIATE, DELAYED, MINOR, EXPECTANT/DECEASEDI
SACRAMENTO	MINOR, DELAYED, IMMEDIATE, DECEASED
SAN BENITO
SAN DIEGO	IMMEDIATE, DELAYED, WALKING WOUNDED
SAN FRANCISCO	SAME AS START CATEGORIES
SAN JOAQUIN	IMMEDIATE, DELAYED, MINOR, DECEASED
SAN LUIS OBISPO	WE USE THE CALIFORNIA FIRE CHIEFS ASSOCIATION TAG
SANTA BARBARA	RED, YELLOW, GREEN, BLACK
SANTA CLARA	IMMEDIATE, DELAYED, MINOR, DECEASED
TULARE	PRIORITY I RED, II YELLOW, III MINOR, IV BLACK
TUOLUMNE	NOTE: USES OES REGION IV MCI PLAN MANUAL 1 "MCI FIELD OPERATIONS" IMMEDIATE, DELAYED, MINOR, DECEASED
VENTURA	START SYSTEM IMMEDIATE, DELAYED, MINOR, DECEASED

(b) Please list the titles of your medical field operation positions.

LEMSA	Titles
ALAMEDA	INCIDENT COMMANDER, MEDICAL GROUP SUPERVISOR, OPERATIONS, TREATMENT UNIT LEADER, AMBULANCE STAGING, TRIAGE UNIT LEADER, MEDICAL COMMUNICATIONS, TRANSPORT GROUP SUPERVISOR
CONTRA COSTA	REFER TO PLAN
FRESNO/KINGS/MADERA	MEDICAL GROUP SUPERVISOR, MEDICAL BRANCH DIRECTOR, EMS STAGING MANAGER, TRANS GROUP LEADER, TREATMENT GROUP LEADER
HUMBOLDT
ICEMA
IMPERIAL	CONSISTENT WITH SEMS AND ICS
KERN	MEDICAL BRANCH DIRECTOR, MEDICAL GROUP SUPERVISOR, TRIAGE TEAM LEADER, TREATMENT TEAM LEADER, LOADING & TRANSPORT OFFICER
LOS ANGELES	SEE FIRESCOPE
MARIN
MONTEREY	MEDICAL GROUP DIRECTOR, EXT/TRIAGE SUPERVISOR TRANSPORTATION GROUP SUPERVISOR AMBULANCE STAGING TREATMENT GROUP SUPERVISOR MORGUE GROUP SUPERVISOR
MOUNTAIN-VALLEY	SAME AS FIRESCOPE
NOR-CAL EMS	FOR MCI - BRANCH DIRECTOR, MEDICAL GROUP SUPERVISOR, TRIAGE UNIT LEADER, TRIAGE PERSONNEL, MORGUE MANAGER, TREATMENT UNIT LEADER, TREATMENT DISP. MGR., IMMEDIATE TX MGR, DELAYED TX MGR., MINOR TX. MGR, PATIENT TRANSPORTATION GROUP SUPERVISOR, MEDICAL COMMUNICATION COORDINATOR, AIR AMBULANCE COORDINATOR, GROUND AMBULANCE COORDINATOR
NORTH COAST	INCIDENT COMMAND, LAW ENFORCEMENT, MEDICAL SUPERVISOR, EMT-1,II,P, ETC. SEE ATTACHED ORGANIZATIONAL CHARTS AS A SAMPLE FOR HUMBOLDT COUNTY
ORANGE	NCIDENT COMMANDER, LOSGISTICS CHIEF, MEDICAL BRANCH UNIT LEADER, MEDICAL TRASPORT OFFICER, AMBULANCE STAGING MANAGER, AMB LOADING MGR, MEDICAL COMMUNICATIONS OFFICER, TRIAGE UNITY LEADER, TREATMENT AREA OFFICER, IMMEDIATE AREA OFFICER, DELAYED TREATMENT AREA, MINOR TREATMENT AREA MANAGER, MORGUE AREA MANAGER
SACRAMENTO	SUPPLY COORDINATOR - TRIAGE UNIT LEADER - TREAMENT LEADER - DISPATCH MANAGER - TRIAGE PERSONNEL - MORGUE MANAGER - IMMEDIATE RX MANAGER - DELAYED RX MANAGER - MINOR RX MANAGER - TRANSPORTATION GROUP SUPERVISOR – MEDICAL COMMUNICATIONS COORDINATOR - GROUND AMBULANCE COORDINATOR – CONTROL FACILITY
SAN BENITO
SAN DIEGO	IC, TX/TRIAGE, TRANSPORTATION OFFICER, SAFETY OFFICER, MEDICAL COMMUNICATIONS
SAN FRANCISCO	MEDICAL GROUP SUPERVISOR, TRIAGE OFFICER, TREATMENT OFFICER, TRANSPORTATION OFFICER, MEDICAL COMMUNICATIONS OFFICER, RESCUE COORDINATOR, SECURITY OFFICER, MORGUE ATTENDANT
SAN JOAQUIN	IC TO OPS TO MULTI-CASUALTY BRANCH DIRECTOR MEDICAL GROUP SUPERVISOR, MEDICAL SUPPLY COORDINATOR, TRIAGE UNITY LEADER, TRIAGE PERSONNEL, MORGUE MANAGER, TREATMENT UNIT LEADER, TREATMENT DISPATCH MANAGER, IMMEDIATE TREATMENT MANAGER, DELAYED TREATMENT MANAGER, MINOR TREATMENT MANAGER, PATIENT TRANSFORMATION GROUP SUPERVISOR, MEDICAL COMMUNICATIONS COORDINATOR, AIR AMBULANCE COORDINATOR, GROUND AMBULANCE COORDINATOR, CONTROL FACILITY, AIR OPS DIRECTOR, AIR OPS BRANCH
SAN LUIS OBISPO	WE USE THE FIRESCOPE FIELD OPERATIONS GUIDE
SANTA BARBARA	PER ICS
SANTA CLARA	SEE ATTACHED
TULARE	MEDICAL SUPERVISOR, MEDICAL SUPPLY COORDINATOR, MEDICAL COMMUNICATIONS COORDINATOR, TRIAGE LEADER, MEDICAL TRASPORT LEADER, TREATMENT LEADER (RED TEAM LEADER, GREEN LEADER, YELLOW TEAM LEADER)
TUOLUMNE	MED BRANCH DIRECTOR - MEDICAL GROUP SUPERVISOR - PATIENT TRANSPORT GROUP SUPERVISOR - TRIAGE UNIT LEADER - TREATMENT UNIT LEADER
VENTURA	MEDICAL GROUP SUPERVISOR, MEDICAL COMMUNICATIONS, TRANSPORTATION GROUP SUPERVISOR, TRIAGE UNIT LEADER, TREATMENT UNIT LEADER, MEDICAL SUPPLY COORDINATOR, MORGUE MANAGER, IMMEDIATE TX MGR, DELAYED TX MGR, MINOR TX MGR, AIR AMBULANCE STAGING MANAGER, GROUND AMBULANCE STAGING MANAGER, MCI BRANCH DIRECTOR,

S.T.A.R.T. (23) Locally Developed Model (0) Other (1) No Answer (1)

(d) What method have you adopted for secondary patient triage?

S.T.A.R.T. (17) Locally Developed Model (3) Other (2) No Answer (3)

(e) Have you formally identified command and/or tactical communication frequencies specifically for medical field operations?

Yes (16) No (7) No Answer (2)

(f) Is your system of patient distribution consistent with your adjacent counties’ field operations plans?

Yes (11) No (2) With Some (6) Not Sure (5) No Answer (1)

5. Mutual Aid:

(a) Do you have ordering process in place for acquiring medical resources during an MCI or Disaster?

Yes (19) No (0) Informally (5) No Answer (1)

(b) Do you have authorization process in place for acquiring medical resources during an MCI or Disaster?

Yes (21) No (0) Informally (4)

Yes (24) No (1)

(d) Are all disaster medical/health resources ordered through the OADMHC?

Yes (15) No (9) No Answer (1)

(e) Does your disaster plan include a mechanism to utilize outside private mutual aid ambulances in your system during a disaster?

Yes (20) No (2) If so, does it include a specific mechanism to:

	Yes	No	Informally	No Answer
1) Stage incoming private ambulances?	16	0	4	5
2) Dispatch those ambulances from your dispatch centers?	11	7	2	5
3) Establish radio communication with those ambulances?	12	4	4	5

Final Report

August 21, 2000

Acknowledgements

Introduction

1

Section 1: Project Background and Rationale

2

Section 2: Project Conceptual Framework

5

Section 4: Oversight Organization

19

Executive Summary

Section 1: Background

The Standards Development Process

Project Steering Committee and Advisory Group

Priority Setting

Project Products

Section 2: Conceptual Framework

Introduction

Medical and Health Function Descriptions

Assignment of Functions to LEMSA

Overall LEMSA Disaster Responsibilities

Table 2: LEMSA Disaster Functions

Management of the Operational Area Disaster Medical/Health System:

Role of the County Health Officer

Proposed Legislation

Section 3: LEMSA Standards

Introduction

The table below contains the standards drafted, to date, by the project.

Function 1: Assess Immediate Medical Needs and Initiate Response

Element 1.2 Notify key positions of disaster medical and health system

Element 1.3 Immediate Reporting Requirements

LEMSAs shall ensure development of policies and procedures to guarantee necessary logistic support has been arranged for all requested resources responding from outside the jurisdiction prior to their arrival.

LEMSAs shall ensure development of policies and procedures to support the operations of out-of-jurisdiction ambulances requested to respond to local emergencies. Support should include, but not be limited to:

Table 4: Hospital Related Standards

Table 5: Field Response Standards & Proposed Regulations

Function 7: Manage Medical Transport

Element 7.1 Coordinate medical transport assets.

<to be developed>

Section 4: Standards Maintenance Organization