Crisis Standards of Care Summary of a Workshop Series (2010) / Chapter Skim
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Appendix B: Summary of *Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report*
Appendix B: Summary of *Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report*
Pages 69-94
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From page 69... ...
Based on a review of the currently available state standards of care protocols, published literature, and testimony provided at its workshop, the committee concluded that there is an urgent and clear need for a single national set of guidance for states with crisis standards of care that can be generalized to all crisis events and is not specific to a certain event. However, the committee recognizes that within such a single general framework, individual disaster scenarios may require specific considerations, such as differences between no-notice events and slowonset events, while the key elements and components remain the same.
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From page 70... ...
The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and pro tections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternate care facility operations. The committee emphasized that, in an important ethical sense, entering a crisis standard of care mode is not optional -- it is a forced choice, based on the emerging situation.
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From page 71... ...
The committee's intent was to provide a framework that allows consistency in establishing the key components required of any effort focused on crisis standards of care in a disaster situation. It also hoped that by suggesting a uniform approach, consistency will develop across geographic and political boundaries so that the guidance will be useful in contributing to a single, national framework for responding to crises in a fair, equitable, and transparent manner.
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From page 72... ...
TABLE B-1 Five Key Elements of Crisis Standards of Care Protocols and Associated Components Key Elements of Crisis Standards of Care Protocols Components • Ethical considerations Fairness • Duty to care • Duty to steward resources • Transparency • Consistency • Proportionality • Accountability • Community and provider en- Community stakeholder identification with gagement, education, and delineation of roles and involvement with at communication tention to vulnerable populations • Community trust and assurance of fairness and transparency in processes developed
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From page 73... ...
• Statutory, regulatory, and common-law liabil ity protections Indicators and triggers Indicators for assessment and potential manage ment • Situational awareness (local/regional, state, national) • Event specific o Illness and injury -- incidence and sever ity o Disruption of social and community functioning o Resource availability Triggers for action • Critical infrastructure disruption • Failure of "contingency" surge capacity (re source-sparing strategies overwhelmed)
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From page 74... ...
2. Review Legal Authority for Implementation of Crisis Standards of Care: Review existing legal authority for the implementation of crisis standards of care and address legal issues related to the successful implementation of these standards, such as liability
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From page 75... ...
3. Develop Guidance for Provision of Medical Care Under State Crisis Standards of Care: Establish an "Advisory Committee" that will find a comprehensive set of materials to inform its de liberations in the "Indicators and Triggers" and "Clinical Process and Operations" sections of the report.
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From page 76... ...
The letter report discusses considerations for engaging with community and provider stakeholders prior to the event, during the event, and after the event. The report also notes that although there are likely to be substantive population-level mental health risks from a mass casualty public health emergency that requires crisis standards of care, there is also an opportunity to promote resilience at the individual and population levels to mitigate these risks.
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From page 77... ...
The law should clarify prevailing standards of care and create incentives for actors to respond to protect the public's health and respect individual rights. Recommendation: Provide Necessary Legal Protections for Healthcare Practitioners and Institutions Imple menting Crisis Standards of Care In disaster situations, tribal or state governments should authorize appropriate agencies to institute crisis standards of care in affected areas, adjust scopes of
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From page 78... ...
The delivery of care in the setting of contingency surge response seeks to provide patient care that remains functionally equivalent to conventional care. Contingency care adapts available patient care spaces, staff, and supplies as part of the response to a surge in demand for services.
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From page 79... ...
used for patient care Usual staff Staff extension (brief deferrals of Trained staff unavailable or Staff called in and non-emergent service, supervision of unable to adequately care for utilized broader group of patients, change in volume of patients even with responsibilities, documentation, etc.) extension techniques Cached and Conservation, adaptation, and substitution Critical supplies lacking, Supplies usual supplies of supplies with occasional reuse of possible reallocation of select supplies used life-sustaining resources Crisis standards of carea Usual care Functionally equivalent care Standard of care Usual operating Austere operating conditions conditions Indicator: potential Trigger: crisis for crisis standardsb standards of carec FIGURE B-1 Continuum of incident care and implications for standards of care.
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From page 80... ...
Agencies to Address Resource Shortages EMS Agency Crisis: Implement Resources Contingency Changes Contingency Changes Plus Dispatch Assign single agency Assign EMS only to life-threatening calls by responses, use medical predetermined criteria, no response to cardio priority dispatch to pulmonary resuscitation-in-progress calls, decline services to se- questions may be altered to receive limited lect calls critical information from caller Staffing Adjust shift length and One medical provider per unit plus driver staffing patterns Response "Batch" calls (multiple No resuscitation on cardiac arrest calls, patients transported) , decline service to noncritical, nonvulnerable closest hospital destina- patients and to critical patients with little to tion no chance of survival
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From page 81... ...
Therefore, it is necessary to use a mass casualty disaster mental health concept of operations in order to enable a crisis standard of disaster mental health care through the use of currently available, evidencebased mental health rapid triage and incident management systems. Additional details can be found in the complete letter report.
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From page 82... ...
. Crisis Standards of Care Indicators Resources that are likely to be scarce in a crisis care environment and may justify specific planning and tracking include the following: • Ventilators and components • Oxygen and oxygen delivery devices • Vascular access devices • Intensive care unit (ICU)
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From page 83... ...
. TABLE B-4 Possible Indicators for Crisis Capacitya Institution/ Indicators Agency Region State Situational awareness indicators Overall hospital bed avail- < 5% available < 5% < 5% ability or no available beds for >12 hours Intensive care unit bed None available < 5% regional < 5% state beds availability beds available available Ventilators < 5% available < 5% avail- < 5% available able Divert status On divert > 12 > 50% EDs > 50% EDs on hours on divert divert Emergency medical ser- 2 times usual vices call volume Syndromic Will exceed Will exceed Will exceed predictions capacity capacity capacity Emergency > 12 hours department (ED)
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From page 84... ...
TABLE B-5 Possible Triggers for Adjusting Standards of Care Category Trigger Space/structure Non-patient care locations used for patient care (e.g., cot based care, care in lobby areas) or specific space resources overwhelmed (operating rooms)
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From page 85... ...
Situational awareness is not available. Proactive triage involves systematic decisions made by clinical or administrative personnel to a situation requiring resource triage where situational awareness is available and the decision making is accountable to the incident management process.
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From page 86... ...
. All healthcare systems must also understand how their incident management system interacts with that of jurisdictional emergency management and any coalition hospital response partners, including the process for obtaining assistance during an emergency (Figure B-2)
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From page 87... ...
• Incident command system broader guideline group • Situational awareness of • Maintains and provides situational • Provides situational facility capability/capacity awareness of healthcare system awareness to SEOC and • Implement surge capacity • Acts as "clearinghouse" for healthcare RMCC/facilities plans issues and manages resources • Requests declarations • Recognize need for existing/ according to coalition agreements and regulatory relief possible crisis care – • In some areas, takes active role with based on event convene clinical care other agencies developing policies • Assures interstate/ committee and guidance necessary for regional regional consistency • Make resource/other response requests to RMCC • May implement regional triage State Disaster Medical and/or review processes during crisis Advisory Committee (SDMAC) Clinical Care Committee event such as a pandemic • Review resource availability • Develops guidance (pre and requests Regional Disaster event and during event)
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From page 88... ...
Usual coordination and resource requests outlined above are used to minimize healthcare service disruption and/or to provide the most consistent level of care across the affected area and the state as a whole. When prolonged or widespread crisis care is necessary, the state should issue a declaration or invoke emergency powers empowering and protecting providers and agencies to take necessary actions to provide medical care and should accompany these declarations with clinical guidance, developed by the State Disaster Medical Advisory Committee, to provide a consistent basis for life-sustaining resource allocation decisions.
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From page 89... ...
. A clinical care committee is activated by the facility incident commander when the facility is practicing contingency or crisis care due to factors that are not readily reversible.
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From page 90... ...
Unwitnessed cardiac arrest ii. Witnessed cardiac arrest, not responsive to electrical therapy (defibrillation or pacing)
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From page 91... ...
. Finally, throughout the letter report, the committee emphasized the importance of consistent implementation of crisis standards of care in a disaster situation within and among states.
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From page 92... ...
92 CRISIS STANDARDS OF CARE in response to a disaster event. These efforts should include: • Using "clinical care committees," "triage teams," and a state-level "disaster medical advisory committee" that will evaluate evi dence-based, peer-reviewed critical care and other decision tools and recommend and im plement decision-making algorithms to be used when specific life-sustaining resources become scarce; • Providing palliative care services for all pa tients, including the provision of comfort, compassion, and maintenance of dignity; • Mobilizing mental health resources to help communities -- and providers themselves -- to manage the effects of crisis standards of care by following a concept of operations devel oped for disasters; • Developing specific response measures for vulnerable populations and those with medi cal special needs, including pediatrics, geriatrics, and persons with disabilities; and • Implementing robust situational awareness capabilities to allow for real-time information sharing across affected communities and with the "disaster medical advisory committee." Recommendation: Ensure Intrastate and Interstate Consistency Among Neighboring Jurisdictions States, in partnership with the federal government, tribes, and localities, should initiate communications and develop processes to ensure intrastate and inter state consistency in the implementation of crisis standards of care.
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From page 93... ...
Despite the gaps that remain, the committee was greatly encouraged by the search for solutions taking place. In studying this issue, the committee's intent was to provide a framework that allows consistency in describing the key components required by any effort focused on standards of care in a disaster.
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