Pandemic Influenza Response: Virginia’s Approach to Providing Care

1. Pandemic Influenza Response:Virginia’s Approach to Providing Care Karen Remley, M.D., M.B.A. Virginia State Health Commissioner Steven D. Gravely, J.D., M.H.A. Partner, Healthcare Practice Group Troutman Sanders LLP

2. Virginia’s Preparedness Efforts • 2004 – Rewrite Virginia’s Quarantine and Isolation statutes • 2005 – Create immunity for MRCs and CERTs • 2006 – HIPAA and EMTALA legal analysis • 2006 – Initiate altered standards of care planning project • 2007 – Develop HR Consensus Policy Statements and Report • 2008 – Statute granting immunity for healthcare providers providing care during emergency goes into effect • 2008 – Continuity of operations and financial sustainability initiative • 2008 – Development of alternate care site planning tool • 2009 – Implementation of alternate care site planning tool

3. Altered Standards of Care: The Context • Healthcare system is under significant stress • Staff shortages currently exist • “Just in time” model is prevalent Introduce a significant event into this environment and substantial disruptions to the delivery of care are inevitable.

4. What is an “altered” standard of care? • “Altered standards of care” is somewhat misleading • Confusion between the “medical” standard of care and the “legal” standard of care • Focus should be allocation of scarce critical resources • Health care providers must plan now for allocating scarce resources in disasters • This is difficult to do in a legal vacuum

5. “Ideally, hospitals should be able to follow guidance and decision support tools to make resource allocation decisions that are sanctioned and approved at the Federal level and distributed by the State. Even with the support of these tools or policies, however, it is the hospital that will have to take on the role of implementing them…If no guidance exists, it will be incumbent on the hospital to have a plan or strategy for bringing together the appropriate personnel who can make the best decisions possible and reevaluate the situation during each planning cycle.” Source: AHRQ Providing Mass Medical Care with Scarce Resources: A Community Planning Guide (November 2006)

6. Virginia’s Response • Healthcare providers are essential to any disaster response and recovery scenario • Healthcare providers need assurance that they will not be unfairly singled out after a disaster for liability

7. Altered Standards of Care Work Group Convened by VHHA in 2006 Diverse representation from across the state Hospitals Providers Emergency Planners Health Department General Assembly

8. Providing care with limited resources Two possible deliverables from Work Group: Detailed standards and algorithms for determining treatment Detailed process that hospitals can use to develop facility specific algorithms Work Group chose process Consensus that VDH should not prescribe how to provide care and allocate scarce resources No “one size fits all” algorithm Consistency in process is the goal rather than consistency in result Work Group developed a comprehensive planning guide for dealing with shortages of critical resources Initial version 2006 Updated June 2008

9. Planning Guide Framework Pre-Event/Preparedness Establish critical resource planning committee Conduct critical resource vulnerability analysis Establish baseline ethical principles to guide responses to a shortage Address operational issues Develop critical resource response plans Shortage of material resources Shortage of physical space Critical personnel shortage Create triage protocols Create mechanisms to operationalize intra-event ad hoc response plan development Modify EOP and ICS Educate staff Exercise/drill

10. Planning Guide Framework Intra-Event/Response Report critical resource shortage Determine whether there is an existing critical resource response plan Develop ad hoc critical resource response plans, if needed Implement plan Modify plan as needed Terminate critical resource response plans Post-Event/Recovery Provide psychological support services to employees, staff and MDs Evaluate critical resource response plans Modify plans as needed Provide support services to patients and their families

11. For questions, please contactKaren Remleykaren.remley@vdh.virginia.gov(804) 864-7005orSteve Gravelysteve.gravely@troutmansanders.com(804) 697 - 1308