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Informing the Next Stage of Crisis Standards of Care
While crisis standards of care (CSC) have evolved and advanced over the past 10 years of meetings, reports, and exercises, there are still important lessons to be gleaned from that process to inform future work. John Hick, professor of emergency medicine and medical director of emergency preparedness, Hennepin Healthcare, University of Minnesota, moderated a panel to discuss how CSC fits within the landscape of preparedness and response, and priorities for enhancing it. This chapter highlights some of the concerns around the terminology used, the importance of including lawyers during the planning process and of putting legal protections in place, and future opportunities as those in the field push toward the next planning stage.
CRISIS STANDARDS OF CARE TERMINOLOGY AND IMPLICATIONS
While CSC terminology is only about 10 years old, said Anita Patel, senior special advisor for pandemic medical care and countermeasures lead at the Centers for Disease Control and Prevention (CDC), it is really something that has been done within the fabric of preparedness and response for much longer. Hick emphasized Hanfling’s point that it is not the binary “on” or “off” switch of having resources or not, but more of a gradual degradation. Patel added that having CSC become a focal point has allowed those in the field to break it down in a systematic way and navigate the legal, clinical, and political issues. But the biggest issue, she said, is how massive it is, and being able to scale up the relevant pieces. Charles Little,
associate professor of emergency medicine at the University of Colorado, agreed that health care entities, such as his, drift in and out of contingency care many days of the week. But a true crisis is much more extreme and comes with the legal ramifications that often make many people concerned about getting involved, Little elaborated.
Hick asked about using the word “standards” in the terminology, and whether that caused additional challenges for those involved in the planning process. James G. Hodge, Jr., professor of law, Sandra Day O’Connor College of Law, Arizona State University, explained that in 2009 during the committee process, using the word “standards” made a lot of sense. Lawyers understand what it means. It helps to define what we are talking about—but not if we do not understand what is driving it. What is driving CSC is not what an individual patient needs, he said, but rather what the population needs in times of public health emergencies. Lawyers are often triaging these types of legal issues in real time. How do we create a standard, driven by population needs that will impact the patients at a particular hospital, sometimes even to their detriment, he asked? This is why the definitions of terms such as “crisis” and “standards” can be critically important.
Declarations of CSC also become important, said Hodge, because different crises have various responses and characteristics. He highlighted the vaping phenomenon that became a serious health issue in 2019, noting how CDC was at the forefront in labeling it as a public health emergency. At the state level, these assessments vary. Planners and providers working on CSC have to be conscious of what these declarations allow, he said, and what types of authorization they give. What constitutes a public health emergency 5 years from now may look very different from what it was in 2009 when the committee first convened. Hick followed up by asking whether the field relies too much on declaring something an emergency in order to mobilize funding and awareness. Hodge noted that it is a smart, politically accountable option. Without clearer definitions, he said, events are too generalizable, which may become problematic. How do we decide what constitutes an emergency? Would it differ across states based on different criteria? At the same time, Hick said, we cannot have clinicians thinking they should wait for this state-level trigger to get the legal declarations they need to be protected in their work. Patel added that having this ability to make the declaration and define the crisis is important, but she sees it as more of a dial that can be turned up or down. For example, she said, we have to think about what we are planning against: Is it a 1918-like pandemic? Or is it Ohio struggling to respond to 29 cases of botulism? When thinking of CSC, we always have the worst-case scenario in our heads, she admitted, but that may not be needed all of the time. When you have that mindset, it can be difficult to scale back to the response that is needed. A participant added that not only are triggers for increased response impor-
tant, but “down triggers” are as well, and understanding when to shift back into contingency and conventional modes. The participant called for more objective measures that can help analyze supply and demand in real time, to aid in this downshifting process. If we put this into place on a daily routine, we could gain a lot of insight at both the strategic and micro tactical levels, the participant stated. Hick added that although the analytical tools are not yet in place to make that kind of real-time support possible, there is a lot of information that is not being used, and he thinks there is an obligation to those involved to work on this more.
IMPORTANCE OF LEGAL FRAMEWORKS
Patel continued discussing the role of having many legal frameworks. Without the legal pieces and protections in place, she said, organizations will not be able to scale up. Work 10 years ago unveiled these needs and required people to have tough conversations and think outside the box. This planning even started to shift the policy environment to the point where now, for CDC, there is a caveat to their typical risk communication strategy of “be first, be credible, be right” for these types of scenarios. It adds, “with the information we have available at the time.” The work has also helped to shift the environment in terms of operations, resulting in resources such as the nurse triage line, she explained, allowing concerned citizens to get accurate information from well-informed personnel ready to respond.
How to legally pull this off, Hodge added, is controversial when we must create an environment where first come, first served, is not how health care will be delivered. These are politically hot issues. This is why CSC can be so powerful—it can be legally defended when other options cannot. Having CSC helps mitigate the tangible liability claim of “failing to plan,” as seen post–Hurricane Katrina in 2005. There is potential for legal peril if you do not take on this kind of planning in advance, well before an event, concluded Hodge.
Little agreed that without the legal pieces in place it is difficult to move any efforts forward. Emergency planners and providers have developed a pretty robust framework across most states, he said, and have good penetration across the public health environment, but it is not as pervasive in emergency management or in the hospital sectors.
OPPORTUNITIES FOR THE FUTURE OF CRISIS STANDARDS OF CARE
Multiple speakers from the panel highlighted various opportunities for the field moving forward. Little said that when this conversation started in
2009, it was mostly focused on massive crises such as nuclear detonation. These huge events, which had a low likelihood of occurring but would have had an extremely negative impact, tended to disengage people who were working at the point-of-care level. For those who were busy working on day-to-day needs, this concept was too big for them to engage with and really dedicate time to think about. So, socializing the concept and getting more people engaged was not as successful as it could have been, he surmised. Little continued, saying that initially, this was the right way to start the conversation, but the process seemed too big and overwhelming and it did not adequately filter down to the local level. But the infrastructure has evolved since then, and health care facilities are able to do a better job of mitigating some events and staying out of the contingency and crisis phases. Hick added that the crisis really depends on who is defining it, but no matter what, there is still a need to make patient-driven decisions.
Patel called for better baseline systems. How can we build the capacity, she asked, to be able to absorb more when needed? For example, when an emergency does occur, how can we have that elasticity in terms of bed count, supply chain, etc.? Right now, information systems are operating in the red even just to support day-to-day needs and requirements. Agencies interested in CSC need to figure out how to fund this effort better to help drive planning and have more flexibility in resources. She added that this cannot just be from public health; because this really is one big system, there is a need for better ongoing conversations across sectors in terms of funding and planning guidance. She also called into question the lexicon of CSC and some of the terminology, asking whether the field needs better nomenclature moving forward into the next stage of CSC efforts. She advocated for using technology better and finding ways to increase elasticity overall.
Little also advocated for doing a better job of integrating the CSC continuum and concepts at the dispatch and hospital levels to make it something that is used more routinely. It should become more robust at different levels to ensure that it is not another plan sitting on a shelf. In considering a normal system slowly getting worse and worse, do leaders need authority for certain levels as situations continue to deteriorate? He said we have done a good job of the top-down approach; now we need to match it with the bottom up.
Audiences for Future Efforts
While many professionals in public health and medical preparedness circles have been introduced to the concept of CSC over the past 10 years, there are still several relevant groups that are likely less than familiar with it. Hodge saw a need for targeting the entrenched legal actors who consis-
tently “put up a shield” about what can be done within their organization because they either do not understand what resources are available or do not want to deal with the size of the challenge. It can be hard to convince legal counsels in organizations and companies to switch their thought process from “will this leave my client liable?” to “will this save lives in our community?” Patel added that there is a need to refresh what this message looks like and expand it to other areas more tangential to health, such as critical infrastructure. The principles will remain the same, but a lot has changed in the past 10 years of progress and discussion, she said, and we need to adapt the message moving forward, along with refreshing and re-socializing the concepts.
She also brought up the current public health challenge of lung injury from vaping, and the response of CDC, along with the 2019 outbreaks of measles in the United States, saying that we learned very clearly from these events that younger generations absorb information quite a bit differently than most of us in this room and in our offices. CDC’s target audience for lung injury is ages 18–35, she said, and they are not looking at CDC’s website or reading its well-written reports. To truly reach different audiences, especially younger ones, there is a real need to think through changes in communication by the public and how people access information.
Little thought it was also necessary to engage leadership at the point-of-care level, such as medical directors of clinics, executive directors, and hospital system leads. If we truly need to flip to a “crisis” standards scenario, he said, they could be potential roadblocks or valuable accelerators in getting the right pieces in place. Hick noted that providers in general are in the group that was not really directly addressed in the initial report development in 2009, and Little said the opportunity through the strengthening of health care coalitions could make it easier to integrate this difficult-to-reach population. Little elaborated that, though they will not be able to attend presentations or give up multiple afternoons, they may be interested in functional exercises and be able to participate in valuable information sharing about gaps and lessons.
Leveraging Technology
Dan Hanfling, In-Q-Tel, underscored the technology component of CSC, and how fundamental it is to thinking about these important issues. We have the tools and enabling technologies in the 21st century to give us real-time information and inputs to fine-tune many facets of our daily life. But, he asked, where are the barriers to actually implementing and using these within public health and health care? We know that companies like Amazon and FedEx are able to leverage digital tools and advancements to appeal to their customer base but why is it, Hanfling asked, that health
care is struggling to catch up technologically? Little agreed that this is an abundant area of opportunity for the future, because the current technology and legacy systems in place yield poor data that require lots of cleaning and checking for errors. “For example,” he said, “the bed board in our hospital in theory should tell me the number of open beds available, but it often misses nuances in patient status or other glitches that lead to a number that is not accurate. Because it doesn’t take other important pieces into account, it yields no useful information for me as a provider.” Hick suggested some of this may be a lack of motivation by some players, saying they have better prognostic information available in electronic health records (EHRs), but they have not dug into it yet. Hick also observed that, unless they are able to bring together stakeholders from EHRs, providers, and hospital groups to develop new questions and standards, the potential insight and wealth of data that EHRs can provide will be left unrealized.
Patel concurred with the important role of technology but saw it as three important areas to break down. First, there is the titanic component of how massive the challenge of health care technology is. Health care systems have been around for a long time and have even been built in a piecemeal fashion, so any efforts to change EHRs and make systems more usable would require a total overhaul, she said. Secondly, technology continues to change so rapidly that many sectors—especially government and health care—are not able to move fast enough to implement the upgrades and advancements. Having interoperability and integrating into older systems is a challenge that needs to be considered. Outbreaks move faster than the data, she explained, and this is no different. She even gave an example of the media curve for lung injury, which was a perfect match for CDC’s epidemiological curve—but it was published 1 week earlier. Finally, she said, there is the generational aspect of technology, which she hinted at in her previous comments. The difference between those who are using the tools and those who have the information to share is sometimes two to three generations apart. This mismatch adds to the difficulties in leveraging technology successfully to relay accurate information. In conclusion, Hodge said, technology is a tremendous tool, but it can also create its own crisis, and we have to be ready for how the nation uses technology to respond to misinformation. For example, he highlighted the anti-vaccination issues affecting several countries around the world, including the United States.
