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Workshop Summary
Pages 1-64

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From page 1...
... Many states and healthcare organizations have developed preparedness plans that include enhancing surge capacity to increase and maximize available resources and to manage demand for healthcare services in response to a mass casualty event. During a wide-reaching catastrophic public health emergency or disaster, however, these surge capacity plans may not be sufficient to enable healthcare providers to continue to adhere to normal treatment procedures and follow usual standards of care.
From page 2...
... Lastly, many states have not yet substantially begun to develop policies and protocols for crisis standards of care during a mass casualty event. These issues prompted the Institute of Medicine's (IOM's)
From page 3...
... Finally, meeting participants were asked to help identify and discuss what resources they needed from federal, state, and regional authorities in order to advance and accelerate the establishment of coordinated and consistent crisis standards of care protocols. This workshop summary aims to highlight the extensive work that has already been done on this topic across the nation and to raise awareness of current barriers and promising directions for future work.
From page 4...
... Unlike this workshop summary, the letter report offers a series of consensus committee recommendations. The report concludes that "[i]
From page 5...
... The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protec tions for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternate care facility operations. This definition was developed by the committee that authored the letter report after the workshops took place, and no formal definition was used for the purposes of the workshop.
From page 6...
... The result of that meeting was a critical document, Altered Standards of Care in a Mass Casualty Event, which served as a foundational document for communities approaching the issues of critical care (AHRQ, 2005)
From page 7...
... . At the meeting in Orlando, Kenn Beeman, a senior physician in the Office of Emergency Planning and Response for the Mississippi State Department of Health, discussed significant barriers in his state that have, to date, prohibited the development of crisis standards of care protocols and the engagement of providers in this issue.
From page 8...
... Drawing on the experiences of states already significantly advanced in the process of developing crisis standards of care protocols, the 2009 IOM letter report laid out a five-step process that states could follow to develop such protocols (Appendix B; IOM, 2009)
From page 9...
... "We want 911 and other call centers, emergency medical services, emergency departments, hospital administrators, public health, primary care providers, urgent care and other outpatient clinics, long-term care and skilled nursing facilities, hospice and palliative care, home health organizations, pharmacists, emergency management, local government such as mayors, and VA [Veterans Administration] and DoD [Department of Defense]
From page 10...
... BOX 2 Who Should Participate in Planning for Crisis Standards of Care? A Partial List • • Large local employers Physicians • • Faith-based organizations Physician assistants • • Civic organizations Nurses • • Academia Nurse practitioners • • Charities and nonprofits EMTs/paramedics and dis patchers • Government • • Pharmacists Insurance companies • Hospital administrators • Reinsurance companies • • State and local public health of- Hospitals and hospital associations ficials • Nursing facilities • Emergency management • Health system alliances • Fire departments • Veterans Affairs hospitals • Police departments • Department of Defense facilities • Ethicists • Community health centers • Lawyers • Urgent care facilities • Morticians • Hospice and palliative care facilities • Funeral directors • Long-term care facilities • Citizens • Home health organizations • Elected officials • Dialysis centers • Media • Hospital licensing agencies • Bloggers • Regulatory agencies • Teachers
From page 11...
... The 2009 IOM letter report outlines a five-step process that state public health authorities can use to develop crisis standards of care protocols (IOM, 2009)
From page 12...
... . "Conventional capacity is really about providing patient care without any change in daily practice," said Hick.
From page 13...
... These spaces and practices are used during a major mass casualty incident that triggers activation of the facility emergency operations plan. Contingency capacity: The spaces, staff, and supplies used are not consistent with daily practices, but maintain or have minimal impact on usual patient care practices.
From page 14...
... Stages of Care in the North Dakota Plan Officials in the state of North Dakota have also outlined incremental changes to standards of care. During the Chicago workshop, Tim Wiedrich, chief of emergency preparedness and response for the North Dakota Department of Health, presented their work on outlining levels of care (Box 4)
From page 15...
... CLINICAL OPERATIONS The decision to implement crisis standards of care is a significant event -- it changes how hospitals and caregivers operate, it changes the legal environment, and it changes citizen expectations. A significant portion of the workshops was devoted to how and when that decision would be made, and how hospitals should implement crisis standards of care.
From page 16...
... The 2009 IOM report listed the following resources as likely to be scarce in a crisis care environment and possibly justifying specific planning and tracking: • Ventilators and components • Oxygen and oxygen delivery devices • Vascular access devices • Intensive care unit beds • Healthcare providers, particularly critical care, burn, and surgi cal/anesthesia staff (nurses and physicians) and respiratory thera pists • Hospitals (due to infrastructure damage or compromise)
From page 17...
... However, as the 2009 IOM report concluded, working through a framework that begins at the institutional and local levels, the authority to institute crisis standards of care lies with the state. In most states, the state department of health holds this responsibility.
From page 18...
... Under this triage process, both patients who score too high and too low on the SOFA assessment are not given critical care resources during an emergency: patients who score too high because they will not likely benefit from medical care, and patients who score too low because they will likely survive without substantial care. Many workshop participants also emphasized that the use of SOFA scores is far from the perfect solution.
From page 19...
... If triage of mechanical ventilation/critical care becomes necessary assess existing critical care patients according to: • SOFA score • Expected duration of mechanical ventilation • Any severe, life-limiting underlying disease states • Other disease-specific factors Order patients from most sick to least sick and reassess daily or as conditions warrant New patient requires mechanical ventilation - Assess patient SOFA score, expected duration (rough) of mechanical ventilation, and underlying disease states or other contributing data/prognosticators (as above)
From page 20...
... > 6 organ failures C Cardiac arrest i.
From page 21...
... " Training was another important factor emphasized by workshop participants, who cited the practice in some emergency departments to have "Triage Tuesdays," where all patients are run through the triage system to keep the process fresh in the minds of all practitioners involved. Alternate Care Facilities Most surge capacity plans contain some means of providing noncritical care outside of the hospital setting to free up as many hospital beds as possible for more seriously ill patients.
From page 22...
... . Rick Hong, medical director for public health preparedness in the Delaware Division of Public Health, discussed the model for alternate care facilities being used in Delaware (Box 7)
From page 23...
... Broadening the Scope: Emergency Medical Services, Community Health, and Other Components of the Health System One reality driven home by the workshops is that the forces involved in disaster preparedness are almost, by definition, top-heavy. While the regional workshops brought together a wide array of professions -- public health officers, physicians, hospital administrators, researchers, nurses, and emergency medical technicians (EMTs)
From page 24...
... Emergency Medical Services One recurring theme throughout the workshops was the critical role that the emergency medical services play in directing emergency response, and the limited extent to which they have been incorporated into planning for crisis standards of care. During day-to-day operations, EMS systems have a mandate to transport individual patients to the closest available hospital, while providing stabilizing care along the way.
From page 25...
... But the need to coordinate their care with hospital settings to ensure a single, unified approach to standards is critical. Kevin McCulley, emergency preparedness coordinator at the Association for Utah Community Health, emphasized that these community health centers represent a largely untapped resource for planners, and could be called on in a pinch to provide critical care space on a shortterm basis.
From page 26...
... "It's incumbent on every state and community and planning group to know what your resources are so you can figure out how you're going to fill and meet that gap," said Knebel of HHS. Davis Tornabene of Sarasota Memorial Hospital, FL, described what she learned in the planning process.
From page 27...
... The challenges of basic triage multiply in these populations for a variety of reasons. There is less available research on which to base decisions, and the care required may be more specialized so even during non-disaster times there are fewer trained healthcare providers and appropriate resources.
From page 28...
... Palliative Care Ultimately, despite surge capacity, despite stretching resources, and despite best efforts, the implementation of crisis standards of care in a mass casualty event may mean that some patients will not have access to critical care resources. Workshop participants widely believed that no patient, regardless of the circumstance, should simply be "left to die." Participants stressed that care is never withdrawn.
From page 29...
... So much energy is spent worrying about resource allocation for those patients who do receive critical care resources that almost none is left over for those who don't. "It's distressing after this many years that there's still a reluctance to talk about palliative care," said Knebel from the HHS.
From page 30...
... are likely to respond," said Jack Herrmann, senior advisor for public health preparedness at the National Association of County and City Health Officials. "We plan for how we want them to respond, and less for how they do respond." The long-term fallout on practitioners and patients will also be great, and multiple participants voiced the need to prepare ahead of time to assist patients and caregivers coping with post-event stress.
From page 31...
... Hanfling noted that the 2009 presidential inauguration provided an opportunity for representatives from Maryland, Virginia, and the District of Columbia to sit together in an emergency operations center ready to manage an emergency response. This enabled them to provide information in real time from their respective jurisdictions, and in turn to communicate information back from the emergency operations center.
From page 32...
... "Most of the time they have to be chased to a meeting or have their arms bent to sit on a committee." Several participants also expressed concern over the lack of involvement of emergency medical services (EMS) providers in the planning process.
From page 33...
... report titled Closing the Seams. The report found that although $8 billion was spent on disaster preparedness since September 11, 2001, only 20 percent of the primary care providers surveyed believed they knew how to respond in a mass casualty situation (PricewaterhouseCoopers, 2007)
From page 34...
... " A second issue is simply culture. Many workshop participants worried that physicians and nurses will resist the very concept of crisis standards of care, and will tend to push off the idea and assume that the resources will eventually be there.
From page 35...
... Shawn Rogers, director of EMS for the Oklahoma State Department of Health and the President-Elect of the National Association of State EMS Officials, spoke of the experience of the Oklahoma City hospital groups, and how it took not one -- but two -- disasters to force executives to confront the need for a coordinated response:
From page 36...
... If the public is not engaged in developing crisis standards of care, if it is not involved in evaluating the harsh choices that must be made, if it does not understand and agree with the ethics and logic surrounding those choices, even the best laid plans will fail. "If you are going to alter how you deliver care, your public has to be on board," said the CDC's Levy.
From page 37...
... "You're going to have a couple of people who are really distressed in a not particularly productive way, and it can really derail that kind of meeting." Powell recommended holding smaller focus group meetings, perhaps relying on community groups or faith-based organizations as a centralizing mechanism. Given how critical the public role could be in directing an emergency response, however, workshop participants explored two approaches, discussed in more detail below.
From page 38...
... Similarly, having an informed public that understands that crisis standards of care are uniform across regional boundaries would discourage the inefficiencies and potential chaos that go along with "hospital shopping." Most importantly, an informed public should be better able to accept the sacrifices required in a mass casualty event, including understanding that resources may not exist to provide uninhibited care during the heart of the emergency. "People are hungry for information," said Inova's Hanfling.
From page 39...
... This is the reason that efforts must be made to engage directly with elected officials and the media before events take place. As with doctors, hospital administrators, and others, participants worried that elected leaders will blanch at the concept of implementing crisis standards of care.
From page 40...
... Without consistency, individual physicians may be exposed to increased legal liability from patients who believe they could have received better care at a different hospital down the road. Without consistent standards and interneighbor cooperation, there cannot be a fair allocation of resources among neighboring facilities or by tapping into emergency reserves of supplies.
From page 41...
... . FEMA Regions A number of workshop participants highlighted the Federal Emergency Management Agency (FEMA)
From page 42...
... "One of the things they are really trying to do is establish some consistency state to state." James Blumenstock, chief program officer for public health practice at the Association of State and Territorial Health Officials said, "There are six or seven other regional coalitions around the country that exist primarily for the same purpose.
From page 43...
... The Interstate Disaster Medical Cooperative The Interstate Disaster Medical Cooperative was created in 2007. The mission of the cooperative, as Timothy Conley, preparedness planning director at Western Springs Fire Department and Emergency Medical Services, IL, explained at the Chicago workshop, is to provide a forum to allow states to network with one another and share best practices.
From page 44...
... But the point is clear: planning cannot simply take place in the upper reaches of hospital departments, but must reach down to providers, emergency medical service providers, homecare nurses, and other critical points on the healthcare chain. Communications and Consistency Communications among stakeholders during an emergency was a critical issue that was mentioned throughout the meetings, with different groups taking different approaches.
From page 45...
... We learned about alternate standards of care for patients that were leaving an acute care facility and going to an alternate care site or going to a nursing home because they were stable and the nursing homes had beds. What we didn't have at the time is we didn't have a coordinating entity: one person or one voice that was able to get all of the information out to the hospitals to let them know what's happen ing, what the standards are right now, and who's going where, and who's going to be moving when.
From page 46...
... Many participants, however, believed some level of guidance at the federal or national level would be helpful. They saw a range of ways that federal or national leadership could facilitate the development of fair and consistent crisis standards of care policies and protocols, and could help reduce unnecessary duplication of effort.
From page 47...
... Many workshop participants praised the aforementioned work of AHRQ and ASPR to establish the outlines of a framework in their 2005 report, Altered Standards of Care in Mass Casualty Events and 2007 report, Mass Medical Care with Scarce Resources: A Community Planning Guide (AHRQ, 2005; Phillips and Knebel, 2007)
From page 48...
... Workshop participants' call for federal and national leadership to provide practical, more detailed information to advance the development of crisis standards of care protocols, and to facilitate intrastate and interstate consistency, formed the basis for the subsequent Institute of Medicine committee report entitled Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations (IOM, 2009)
From page 49...
... That leadership can come through direct purchasing power; as noted earlier, some believe that provider participation in the Medicare program should be predicated on adequate disaster preparedness and emergency management training. Or it can come from serving as a model for other regions or localities in how to develop crisis standards of care.
From page 50...
... Again, the IOM letter report called on state and local officials to coordinate with DoD facilities in the development and implementation of their standards of care protocols (IOM, 2009)
From page 51...
... As the workshops revealed, the work done on crisis standards of care focuses a great deal on achieving consistency, in part because consistency and fairness are integral to any ethical system. The 2009 IOM letter report outlines seven ethical considerations that are central to the development of ethical crisis standards of care protocols: fairness, duty to care, duty to steward resources, transparency, proportionality, and accountability (IOM, 2009)
From page 52...
... For the New York standard, Powell's group decided that access to ventilators would be based solely on medical evaluations. Rather than granting healthcare workers priority access, New York decided to do more to protect them from getting sick in the first place.
From page 53...
... LEGAL ISSUES FOR CRISIS STANDARDS OF CARE Legal concerns hover over every issue in disaster planning and crisis standards of care. "Laws absolutely pervade emergency responses at every level of the government," explained James Hodge, then executive director at Johns Hopkins' Center for Law and the Public's Health, one of several legal experts who presented at the four regional workshops.
From page 54...
... "When we willfully and knowingly withdraw or withhold life support, knowing there may be a bad outcome, we tread that line of willful misconduct," said Cheryl Starling of the California Department of Public Health. Starling and others noted that this is one of the key barriers to getting healthcare providers and facilities to come to the table to discuss crisis standards of care and disaster preparedness.
From page 55...
... Participants discussed a variety of ways in which the actual legal protections could be achieved. BOX 13 Medical and Legal Standards of Care Medical Standards of Care: The type and level of medical care required in spe cific circumstances by professional norms, accreditation or other requirements.
From page 56...
... A theme throughout the workshops was the concept of moving up the political chain of command when empowering this kind of legal liability protection, and putting the declaration of the emergency in the hands of a single powerful individual, such as a governor. Colorado, for instance, has draft executive orders that the governor can enact and that provide blanket protections for everything from license issues to who can dispense medicine.
From page 57...
... Other means of augmenting the core caregiver community were seen as critical, including expanding the types of care that certain healthcare providers can provide and supporting retired healthcare workers who are interested in volunteering during times of crisis. Participants discussed the critical importance of having sufficient, qualified personnel during an emergency.
From page 58...
... Pharmacists may be asked to administer vaccinations, nurses may be asked to function in the role of nurse practitioners, and emergency medical technicians may be asked to dispense medicine. Similarly, many states have statutes that allow retired healthcare providers to provide a limited set of services, such as palliative care.
From page 59...
... BOX 15 EMTALA and HIPAA EMTALA: The Emergency Medical Treatment and Labor Act was enacted by Congress in 1986 to "ensure public access to emergency services regardless of ability to pay." The law requires hospitals participating in the Medicare system to provide medical screening examinations to patients requesting treatment for emergency medical conditions. Hospitals must also provide stabilizing treatment for these conditions, or, if such treatment is outside the hospital's capability, provide an appropriate transfer (http://www.cms.hhs.gov/emtala/)
From page 60...
... [I] t changes instantly and it can change drastically, and depending on how it changes, based on the type of emergency that we're involved with, the legal responsibilities and liability protections and altered standards of care issues come into play." Hodge noted that since September 11, 2001, many new laws have been put into place governing emergency response and disaster preparedness.
From page 61...
... Workshop participants repeatedly observed that significant work was needed to disseminate information about legal liability protections to healthcare providers, even in those states that have tackled the problem head-on. CONCLUSION How can healthcare providers and facilities, with the support of state and local public health officials, the federal government, and their communities, provide the best care possible during a crisis?
From page 62...
... Healthcare providers will not have time during an emergency to develop programs from a standpoint of fairness and equity. There will not be time to develop laws to facilitate information sharing, dramatically increase staff, or provide legal liability.
From page 63...
... 63 WORKSHOP SUMMARY "How far do we need to get in standards? " asked Phillips, summarizing the Irvine meeting.


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