Barriers to Integrating Crisis Standards of Care Principles into International Disaster Response Plans Workshop Summary (2012) / Chapter Skim
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Workshop Summary
Workshop Summary
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. An IOM consensus committee is currently updating the preliminary guidance issued in the 2009 letter report, and is expected to issue a full report in 2012.1 Building on these activities, the IOM Forum on Medical and Public Health Preparedness for Catastrophic Events sponsored a session at the 17th World Congress on Disaster and Emergency Medicine (WCDEM)
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Expert panelists discussed: The challenges of providing fair and equitable care in mass casualty incidents A potential framework for the equitable delivery of care in situations of scarce resources, and strategies for operationalizing crisis standards of care in austere environments Strategies for integrating crisis standards of care principles into disaster response plans The impact of international disaster response on changing the standard of care in the "host" country This report summarizes the presentations and commentary by the invited panelists. SURGE CAPACITY PLANNING AND CRISIS STANDARDS OF CARE In the United States, catastrophic disasters have been relatively infrequent events.
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released two reports, Altered Standards of Care in Mass Casualty Events (2005) and Providing Mass Medical Care with Scarce Resources: A Community Planning Guide (2007)
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The reports note that along the spectrum of care, there will be some patients who are "too well" to receive care, and some who are too sick to survive, but all will need to receive some level of health care consideration. Building on the AHRQ reports, Hanfling highlighted several publications describing the augmentation of scarce resources in a hospital critical care setting (Rubinson et al., 2005, 2008)
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. As discussed in the 2009 IOM report, the surge capacity following a mass casualty incident falls into three basic categories, depending on the magnitude of the event: conventional, contingency, and crisis surge capacity (Hick et al., 2009)
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extension techniques Supplies Cached and Conservation, adaptation, and substitution Critical supplies lacking, usual supplies of supplies with occasional reuse of possible reallocation of used select supplies life-sustaining resources a Standard Usual care Functionally equivalent care Crisis standards of care of care Usual operating Austere operating conditions conditions Indicator: potential Trigger: crisis for crisis standardsb standards of carec FIGURE 2 Continuum of incident care and implications for standards of care. a Unless temporary, requires state empowerment, clinical guidance, and protection for triage decisions and authorization for alternate care sites/techniques.
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o Proportionality -- public and individual requirements must be commensurate with the scale of the emergency and degree of scarce resources o Accountability -- of individuals deciding and implementing standards, and of governments for ensuring appropriate pro tections and just allocation of available resources Community and provider engagement, education, and communication -- active collaboration with the public and stake holders for their input is essential through formalized processes The rule of law o Authority -- to empower necessary and appropriate actions and interventions in response to emergencies
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The five key elements that should be included in crisis standards of care protocols, along with associated components, are summarized in Table 1. TABLE 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 Community stakeholder identification engagement, education, with delineation of roles and involvement and communication with attention to vulnerable populations Community trust and assurance of fairness and transparency in processes developed Community cultural values and boundaries Continuum of community education and trust building Crisis risk communication strategies and situational awareness Continuum of resilience building and mental health triage Palliative care education for stakeholders
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Statutory, regulatory, and common-law liability protections Indicators and triggers Indicators for assessment and potential management Situational awareness (local/regional, state, national) Event specific o Illness and injury -- incidence and severity o Disruption of social and community functioning o Resource availability Triggers for action Critical infrastructure disruption Failure of "contingency" surge capacity (resource-sparing strategies over whelmed)
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10 CRISIS STANDARDS OF CARE: INTERNATIONAL DISASTER PLANS Key Elements of Crisis Standards of Care Protocols Components o Human resource/staffing availability o Material resource availability o Patient care space availability Clinical process and Local/regional and state government process operations es to include State-level "disaster medical advisory committee" and local "clinical care committees" and "triage teams" Resource-sparing strategies Incident management (NIMS/HICS) principles Intrastate and interstate regional consist encies in the application of crisis standards of care Coordination of resource management Specific attention to vulnerable popula tions and those with medical special needs Communications strategies Coordination extends through all elements of the health system, including public health, emergency medical services, long-term care, primary care, and home care Clinical operations based on crisis surge response plan: Decision support tool to triage life sustaining interventions Palliative care principles Mental health needs and promotion of resilience While the crisis standards of care principles discussed at the workshop and this summary are derived from a national (U.S.)
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Crisis Standards of Care as Part of the Overall Surge Capacity Planning Framework Hanfling reiterated that standard of care is a continuum that ranges from conventional and contingency to crisis care. He suggested that standard of care is part of an overall framework for response, incorporating planning, substituting, adapting, reusing, and reallocating resources.
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Hanfling highlighted several key components that may serve to help develop uniform crisis standards of care: Incorporate a crisis response framework at the very outset of the acute phase of response efforts Monitor use of resources to attain achievable and desirable outcomes Establish consistency of health care delivery strategies: o Respect the sovereignty of the "host nation" o Develop consistent use of foreign medical teams (based on an opt-in classification approach) o Set goals for long-term recovery early in the response; emphasize transition of services o Understand role of palliative care in planned clinical response Jean Luc Poncelet, area manager in Emergency Preparedness and Disaster Relief for Latin America and the Caribbean, Pan American Health Organization/World Health Organization (WHO)
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Experiences from Latin America and the Caribbean Poncelet explained that following a succession of major disasters in Peru in 1970, Nicaragua in 1972, and Guatemala in 1976, the Minister of Health for the region called for a common approach to disaster response, and thus began casualty management in Latin America and the Caribbean. The main goal was to optimize available resources to save lives, while respecting national health practice and criteria.
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The fatality rate in Haiti was extreme and it became impossible, he said, to fully adhere to guidelines that had been established before the earthquake for the management of dead bodies. Barriers and Challenges to Operationalizing Crisis Standards of Care The health community has been working on mass casualty management for many years, Poncelet said, so what is stopping us from making progress?
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A disconnect was also noted between the international humanitarian community and national authorities. The international community makes rules, regulations, and standards for itself that are not necessarily comparable to or compatible with what is being done by the national authorities (if anything is being done at the national level)
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and the effect these had on long-term impacts, and discouraged practitioners from offering complex medical treatments or surgical interventions that could not be sustained in Haiti after the end of the international disaster relief effort (Etienne et al., 2010)
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Disaster medicine needs to solve communitylevel issues, Burkle agreed, and added that we have to find ways to make it more attractive to work at the community level. Hanfling and Burkle stressed the importance vetting crisis triage processes at the community level during the planning stages, and Hanfling noted that the IOM committee is exploring the issue of community engagement in some detail as part of its current task.
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The treaty obligates WHO to obtain expert advice on any declared public health emergency of international concern, and provide that advice to nation-states. The treaty also encourages countries to provide each other with technical and logistical support for capacity building.
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(Burkle noted that one of the reasons cited for not completing the survey discussed above is that countries were embarrassed that they did not yet have the required capacity.) However, the nationstates signed the Treaty, and there is an awareness that this is something larger than any individual country.
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found that pandemic responders were in place in 72 percent of the countries when H1N1 appeared; there was timely detection of the outbreak through the Global Influenza Surveillance network; and there was effective partnering, interagency coordination, and rapid field deployment of teams of experts that had been trained by WHO prior to the pandemic. Nations provided samples of live influenza virus to laboratories in the developed world.
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This leads to the question of whether such a model for global standards of care could be applied to other large-scale disasters. (Burkle noted that the IHR covers nuclear and chemical health incidents, but have only been tested thus far in pandemics.)
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Through this workshop, and subsequent workshop summary, the hope was expressed that a broader dialog would be initiated to stimulate additional efforts and Crisis Standards of Care concept development within the individual nation and larger international community. For example, while these issues were not discussed in detail at the workshop, it is important to address these moving forward: Is there a need for classification, criteria and standards for medical teams who arrive at the scene?
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