Crisis Standards of Care: Summary of a Workshop Series (2010)

A lot of useful information was brought up at the workshop, but it seemed as though attendance beyond people who sat on panels was quite limited. It would be useful to encourage attendance by stakeholders who are not a part of the formal presentations.

We’re preaching to the choir. We need to be explaining these issues to the general public.

I found the most valuable portion of the workshop, for me, to be the beginning, when the focus was still on altered standards of care. When that focus was later lost, the workshop became less valuable for me.

It was great at raising awareness, but not at answering the problems.

Good questions posed by audience participants.

I think the answer to this question is very dependent upon individual exposure.

Lots of info, many propositions, even more questions left unanswered. Policies are new to all!

All participants were well versed in the matter and provided outstanding insights to build upon.

I was able to bring the technology issue into the debate, where it was not previously rated as important enough to be listed as a workgroup topic.

It is important to hear other perspectives on the topic. Good to know others are struggling with similar issues.

I think the topic of communication among agencies and communities would be a great topic for [a] workshop in the future.

Overviews of various organizations and their interactions, especially the Florida planning.

The idea of the continuum of standards to crisis care.

“Rationing” and setting standards versus keeping one standard and identifying the shortcomings.

“Lessons learned” discussions from panelists plus the Q and A.

Policies and procedures developed by other states as noted in the resource files.

“Disaster ethics”/bioethics discussion(s).

That we are all struggling to apply ethical principles of fairness and justice within standards that we are developing across the United States.

Medical ethics.

The enlightenment of the subject being taboo at all levels.

The importance of message during a mass casualty event, the importance of interjurisdictional license suspensions, and liability indemnification.

So many it would be unfair to choose.

Controversies surrounding rationing.

Too many to identify them all. Developing the ethic platform for a state standard. Implementing altered standards of care through

Views from all over the region.

Surge capacity breakdown into three categories; rationing of scarce resources.

Ethics issues.

The need to educate the docs in the trenches.

The discussions regarding the altered standards of care systems and to learn my local health department is not at the table. I understand the role the state health department plays; however, I feel that the LPHA has much more experience working with and within the local community than the state does.

The diversity of issues and approaches.

Triage process.

How expectations for care, along with the way we define good standards of care, must change in response to a mass casualty event.

Discussion [of] the questions/issues that need to be addressed on the local level—and strategies for creating regional/national guidelines.

Specifically what will be done, how, and by whom … protocol of hierarchy still needs more definition … and specific info as to resources and mass prophylaxis or actions.

Ethics of group selection, the standards proposed by the VA.

The concept of “rationing” equipment, care, and access.

The information about getting state to state recognition as an EMT. The [H1N1] flu information was a touch-and-go subject that I thought I would love to get more information or education about.

Interstate and neighboring community cooperation.

Local and state standards.

Discussions among presenters and attendees, and discussions with individuals during the break.

Ethical principles and their application to mass casualty events. How individual facilities and regions are handling this issue.

I was only able to attend the afternoon sessions … Session IV was outstanding … particularly Tim Conley, who related directly to municipality planning.

That everyone is facing the same problem and that there is no “one” solution to the question. It will depend on local resources.

The presentation on the need for coordination [among] various communities and sectors.

SOFA + criteria for vents, who will be seen/admitted to the hospital during a pandemic. I was most impressed by the work of some of the state and regional groups.

The overall discussion/definition of the topic was beneficial. The difficulties involved and general ideas of where the topic is headed were all helpful in determining how to help my organization respond.

Discussion of surge capacity classification and Tia Powell’s comments on the ethics of ventilator triage.

Will use the notes from the workshop to start focus group discussions in many forums around the state to formulate the process for our state.

Discuss with key hospital staff who will be involved with establishing altered standards of care and community emergency operations staff. Much of the info gathered from this conference will be included on hospital disaster preparedness webpage.

Will adapt those to our Medical Reserve Corps component in Marion County, FL.

Qualify current policy and procedures.

Presentation to intradisaster response team to stimulate discussion on a topic that—perhaps—has been treated too incidentally.

Serves as the foundation for further work at the local level.

Will bring into our discussion locally.

I will incorporate the information into telemedicine and apply it to the possible pandemic. The current reaction to the prepandemic is clearly a warning about preparedness for a pandemic event.

Working with state agencies.

Take topic to local and state committees dealing with pediatrics.

I will report to the Oklahoma state committee on Altered Standards of Care much of what I absorbed.

To take a second look at a couple of areas in our guidance. Appeals, triage officer.

To begin discussion and development of policies to address these issues and to lobby the state Department of Public Health to do the same.

Will activate in our Hospital Incident Command System (HICS) structure and proactively work with our ethics officer to help them prepare for disasters.

Enhance our education program.

If the goal is to be consistent, transparent, and fair, the local public health authority (LPHA) needs to be a part of the planning that is currently taking place if LPHAs are expected to assist in some sort of capacity.

Initiate further discussion in our region.

Will educate providers on possible roles and decisions required during a disaster.

I have raised the issue at our management discussions, and will continue to encourage that we do more practicing to prepare our response to a catastrophic event.

My hospital needs to work on this—and we need to work on it as a region with other hospitals. Not sure that we will have much state input.

I hope to use the information in a project on the legal aspects of

To tell all my coworkers, friends, and family … send out an alert for the need to prepare for any catastrophic event.

Discuss this with our county planning committee.

Will use triage guidelines in our walk-in clinic/urgent care setting, and telephone triage guidelines for call-in questions.

To continue my education and to assist others in other states in disasters as well as … our own state of New York.

Bring ideas to my organization.

Hope to follow up with individuals.

Will work to develop policies with the American College of Surgeons and with our local community.

It always reinvigorates me to attend anything on preparedness … I wish I would have been able to attend the morning sessions. I will take back to our regional group info. I received as well as shared it with our over 100 MRC members.

To help initiate additional communication in the planning process for emergencies.

I plan to start dialogue with our municipal fire department on issues heard at the workshop and attempt to [have a] dialogue with the supervisor and trustee of the township regarding the same.

Keep my organization involved in the decision-making process with our regulating agencies.

As a framework for further discussions.

Really are no “practical solutions” yet, really new untalked-about topic.

Essentially, there are no answers anyone can give right now—but this brought to light all the important issues that need to be addressed.

Format was excellent! Facilitated exchange of a large amount of information.

[It did not provide many practical solutions …] but, it was excellent in raising the issues that need to be solved.

We need to get more “in the weeds” and discuss things like disaster charting, contingency planning, etc.

Policies in place are still in their draft stage; until a more permanent issuance occurs it is difficult to take action of any kind, meanwhile examples of other states’ drafts help!

I wish there was a protocol course that was mandatory for all EMTs and above to take for hands-on tactics or at least directed in the right direction for such. There should also be refresher courses for something such as disasters here and in other states.

I think it’s important to exchange ideas to formulate new or refine existing concepts.

As expected at this type of event—more questions than answers!

The Interstate Disaster Medical Cooperative (IDMC) group was one practical effort discussed that I think has the potential to impact every community.

Don’t have to reinvent the wheel. Good contacts and references to learn from.

This workshop has validated many of the concerns shared by licensed healthcare providers in our area (FL). However, the policy makers and regulators in our state have not provided a forum for discussion and input from those in the trenches; perhaps this is something we can work on.

Use of quantifiable scoring systems to determine priorities in provision of vaccines and antivirals in a pandemic.

Policies need to pay particular attention to inclusive language, [that is,] consider population dynamics and demographics.

We need to have much more of a discussion with our communities. The public cannot have expectations of a usual standard of care in an extreme event that results in such an impact on capacity and capabilities to provide that care.

I think the workshop is a bit too esoteric and the panel’s thought process needs to be more focused on operationalizing the basic concepts.

Would like to have seen the conference a little more policy specific related to hospitals and redelegating roles to unlicensed personnel, and more about how and what to do just-in-time training.

I will move forward on the expenditure of $3 billion in the buildout of WNIS infrastructure in NYS with anticipation of a useful outcome if the pandemic should evolve into a major mass casualty, which is unclear as yet. The area of concentration will be to extend primary care into the community and minimize the assemblage of people around one or more infectious carriers in what a local hospital calls an alternate care area; to me it is an inoculation center and should be avoided. I find it especially risky to draw in potential carriers into close contact with patients with other illnesses, which may be impairing their ability to evoke an effective immune response. The expenditure will, in the current financial condition, require the assistance of the Federal Reserve to facilitate the issuance of debt directly or thru a participating primary dealer of the Federal Reserve System. The provisioning of funds will allow the purchase of empty St. John’s Hospital and Mary Immaculate Hospital in Queens, NYC, from bankruptcy court and the provisioning of those facilities for a possible increase in patient population.

Meeting with stakeholders to develop consensus.

Developing our philosophical statement, including the ethical platform. Ideas for implementing altered standards of care via governor’s Executive Order at the time of crisis and implementing via the state EOC versus working through the state legislature to pass language.

Work with staff to create policies/procedures.

Further workshop, stay informed and current.…

I found there were people there that pointed me in the right direction on how to obtain a state-to-state registry, but what I can’t understand is why does not every state acknowledge this (NREMS) and why is there yet ANOTHER charge for taking the test for the first time?

Tools with their limitations for rationing scarce resources. Tools to begin the discussion with leadership.

We need to really address standards of care. I will contact our local CCDPH rep. concerning this and request guidelines that I can share with neighboring communities, as well as my own.

The effort [made by] the IDMC, spoken of by Tim Conley, is something I am going to look into to make sure my municipality is participating in.

I imagine it was more useful for the other people there who are from the same area.

I learned a great deal from the various experts. I was most disappointed that FL Board of Medicine and Nursing, Agency for Health Care Administration, and Emergency Management were not active participants. Lines of authority among these agencies once an emergency has been declared need to be established, especially among public and private healthcare providers who may have to resort to some form of altered standards of care. At present there is little interface.

Networking opportunities were tremendous. Would have liked more time to speak with other participants.

I greatly appreciated the significance of ongoing dialogues as noted above. However, my situation demands dialogues and communication within our institution, as well as without. I am concerned about these internal communications issues, as well.

I have made some important contacts and hope others have gained some insight.

I was sorry that more people were not able to attend due to H1N1 or other reasons.

Networking is always most helpful.

The dialogue that ensued was most interesting and informative, particularly hearing different viewpoints from different areas of expertise.

Good sound structure given for basic and advanced networking.

Listening to the panel discussions helped to raise awareness of the many different types of scenarios.

I was pleased to be able to meet others who are working in this area, and anticipate that now knowing them will be of great value to us in our anticipated project on legal issues involving altered standards of care.

I made contact with some stakeholders, and hopefully plans for networking will materialize.

It’s always interesting to hear differing opinions. Requesting clarification on those “differing opinions” allows us to better understand and therefore work more synergistically with one another should the need arise.

It was great to meet other “like minds” who are interested in this topic. I liked the way there was a panel of presenters on each topic.

My actions are dictated by my position as an MRC member.

It was very informative and will help to get the information that I have learned out to others, including other EMTs and higher that I work with.

I will maintain ongoing communication during mass casualty events.

Ability to know who individuals are, more than presentation content, which was quite rushed.

I became aware of experts in this area and who needs to be included in efforts to develop guidelines.

It always helps to put faces with names and begin to establish personal relationships with others concerned about the same issues.

I collected business cards from those states that were developing similar frameworks to Oklahoma.

Developed contacts in Illinois that will help with crossborder issues.

Although I knew many of the attendees, it is always helpful to hear this discussion together. And it is helpful to give feedback to the presenters.

I will need to meet with our local hospitals (one was represented at this workshop) and learn what their particular standards of care are in an emergency.

It helped me to identify the areas where we need to work on building relationships. Two such are with residents and doctors.

The workshop offered a forum with some “familiar local faces” that I now know are involved and can partner with as well as introducing new organizations/individuals that I can reach out to.

Will use the available links and resources for additional help and info.

Bring the Trial Lawyers of America on board.

I would like to have the opportunity to work with some of those who presented in the workshop when we begin our project on legal issues related to altered standards of care. Thank you for putting on this workshop and for giving us the opportunity to be involved.

(1) There needs to be transparency/accountability for federal funding; tracing the money has been impossible once it is released to the state (FL). Application/distribution/results of this funding are also a mystery. (2) Interface among county health departments, emergency management, and healthcare facilities and providers is weak. There is confusion about lead authority and roles/responsibilities. (3) Liability issues for healthcare providers/facilities have not been adequately addressed. (4) Suggestion for next workshop topic: View from the Trenches. It is my belief that there is not enough exchange of info between these levels and we could be missing some important issues/lessons. Next action: We will be meeting with hospital and community leaders to frame/discuss these issues and try to engage state officials. The panelists and experts were excellent sources of information, but as I stated on previous answers, the lack of participation by professional boards/regulators and public health preparedness from FL was quite troubling. Thank you for the opportunity to participate in the workshop and survey. Keep up the good work.

Minimal attention was paid to the relatively large psychological footprint of a multicasualty disaster, especially to the value of group crisis intervention when staff [are] limited. Individual psychological first aid would be quite impractical in large-scale incidents.

Great job presenting the issues and bringing the stakeholders together.

I thought it was done overall very well.

It was time well spent. A few folks seemed to use the time to “vent,” which is fine—there is nothing wrong with expressing a real concern over an important issue or frustration; however, at times it seemed redundant. After the worries are expressed, we should concentrate on solutions.

Need a clinical workshop directed at the operational side of provision of care during an extreme event. This workshop could provide guidelines for the evidence base to support contingency planning when resources are scarce.

More workshops with the experts in the field are extremely satisfying.

Future workshops should utilize speakers who are focused on the issues, not focused on their personal accomplishments or showing off their vocabulary.

Have the next event posted on listservs for American College of Physicians, American College of Emergency Physicians, and other professions.

I would like to see someone come out with a better way to bring all the states together so that certification would not be so difficult to get and not only in disasters. I feel that if we as emergency medical services give of ourselves in disasters/mass casualties and we are recognized then, we should be recognized nationally without having to take other exams. If we are capable at those times, is it not feasible that we are just as capable when there is not?

I think a separate committee must be established to coordinate the development of e-tel nursing medicine as a viable intervention in mass casualty events. I will chair such a committee.

I felt the presentations were hurried; I’m not sure what solutions exist to this problem other than follow-up information, notes, etc., that will be provided.

No, it was well designed, attended, and implemented.

Too much emphasis on bio events, which is understandable as the participants were mainly public health and government agency types who work in bio fields. But bio events are real outliers in the realm of disasters, being one of the least likely mass casualty scenarios and having a prolonged time course unlike virtually all other forms of disaster. [They] give time for surge to develop and to discuss altered standards that most disasters do not, as most disasters occur immediately with immediate overwhelming of resources with no warning—there is no progression from conventional to contingency to crisis over days to weeks in most disasters—it is conventional to crisis in 15 minutes. And therefore some of the issues and challenges, especially the time constraints and chaos. are quite different. An honest effort must be made in meetings such as these to broaden the perspective and understand that as important as bio events are to prepare for, their actual level of threat is quite low—look at history and read the newspapers to see what threats face us everyday. The feds and the AMA and CDC must get themselves out of this fixation on bio while ignoring the more likely scenarios. Ethical and moral and medical issues cut across all disasters and should not be just applied to influenza pandemics.

Pediatrics always needs more emphasis, since 25 percent of the population in the United States is children; people are developing tools (Akron, OH, for example), but then “they are not applicable for children.” It was helpful to hear the debate on whether scoring tools developed for adults can be transferred to children. The organization of the workshop was easy to follow and helpful to obtain a wide perspective. The audience participation was also useful. I only wish a number of my colleagues could have participated.

I would have benefited from more discussion regarding the different states’ strategies to actually implement their altered standards of care within the political climate of their state. For example, MO has made progress, but has a new governor. If the state is relying on a governor’s Executive Order, what happens with a new governor? Are any states trying to pass language within the state legislature?

We could have talked all day on this topic! Perhaps more time for just open discussion.

Please find ways to engage the physician stakeholders.

Thank you!

I would have liked to hear how EMS Incident Command will interact.

It was a very interesting workshop. I am not sure if I will use the info, but it was reassuring to know that we are on the right track in our planning.

The organization was excellent!

Thank you to the AMA for hosting the workshop and to the IOM for making it available to those of us in the community.

Overall, I was very impressed with the workshop planning and facilitation. I would like to see continued follow-up information and contact (such as this survey) to maintain channels of communication. The workshops offered a method of outreach to regional, state, and local participants and I would encourage you to cultivate those contacts.

It would have been helpful to better understand the IOM’s eventual overall goals with defining standards of care in a mass casualty event. Will a guideline be published as a result of these workshops? The frustrating thing is that so many efforts are happening on many different levels, and I feel that there is much reinventing the wheel going on that might be unnecessary. I was hoping this workshop would help in outlining general accepted standards to be adopted and supported everywhere.