Standards of care in mass casualty events
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Standards of Care in Mass Casualty Events. A Series of Regional Workshops. Introduction – Framing the Problem. Consider the scenarios Pandemic Bioterrorism Natural disaster/catastrophes Regional IOM workshop descriptions Participants Locations Agenda Goals Outcomes.

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Standards of Care in Mass Casualty Events

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Standards of Care in Mass Casualty Events

A Series of Regional Workshops

ENA Leadership 2010 – Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Introduction – Framing the Problem

  • Consider the scenarios

    • Pandemic

    • Bioterrorism

    • Natural disaster/catastrophes

  • Regional IOM workshop descriptions

    • Participants

    • Locations

    • Agenda

    • Goals

    • Outcomes

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Workshop Summary Report

  • Addresses –

    • Related work on standards of care

    • Crisis standards of care protocol development

    • The surge capacity continuum of care

    • Clinical operations

    • Provider involvement and engagement

    • Public engagement and education

    • Developing intra and interstate cooperation and consistency

    • Role of the Federal government and national leadership

    • Ethical considerations

    • Legal issues for crisis standards of care

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Related Work on Standards of Care

  • Agency for Health Resource and Quality (AHRQ)

    • Altered Standards of Care in Mass Casualty Events

    • Mass Casualty Care with Scare Resources – A Community Planning Guide

  • Institute of Medicine (IOM)

    • Guidance for Establishing Crisis Standards of Care in Disaster – A Letter Report

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


“Mass Medical Care with Scarce Resources: A Community Planning Guide”

Collaboration between AHRQ and ASPR

  • Ethical Considerations in Community Disaster Planning

  • Assessing the Legal Environment

  • Prehospital Care

  • Hospital/Acute Care

  • Alternative Care Sites

  • Palliative Care

  • Avian Influenza Pandemic Case Study

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Who makes the plan?

Nurses

Physician assistants

Physicians

Pharmacists

Administrators

Morticians

Academia

Government

Many others

Crisis Standards of Care Protocol Development

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Capacity Continuum of Care

Usual Operating Conditions Austere Operating Conditions

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Surge Capacity - The Continuum of Care

North Dakota’s example:

  • Stage 1: Small Outcome Impact

  • Stage 2: Moderate Outcome Impact

  • Stage 3: Severe Outcome Impact

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Stakeholder - Provider Involvement and Engagement

  • Those with a critical roles include

    • EMS

    • Physicians

    • Hospital officials

    • Nurses

  • Engagement challenges cited

    • Time

    • Funding

    • Culture - resistant to crisis standards concepts

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Public Engagement and Education

  • Engagement challenges

    • Public is generally uneducated

    • History of distrust

  • Changing the Culture of preparedness

    • Use awareness from recent disaster events

    • Include in educational curriculum

  • Elected officials and media as allies

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Developing Intra and Interstate Cooperation and Consistency

  • Reasons for consistency

  • Approaches by states

    • Massachusetts

    • Virginia

  • Regional applications

    • FEMA Region 4

    • Capital region’s “All-hazards” consortium

    • Interstate Disaster Medical Cooperative

    • Village-to-Village Communication

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Role of the Federal Government and National Leadership

  • Guide and facilitate

    • AHRQ/ASPR

      • “Altered Standards of Care in Mass Casualty Events” (AHRQ, 2004)

      • “Mass Medical Care with Scarce Resources: A Community Planning Guide” (AHRQ, 2005)

      • “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations” (IOM, 2009)

    • VHA

    • DOD

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Ethical Considerations

  • Requirements for ethical crisis standards of care planning and development

    • Fairness

    • Duty to care

    • Duty to steward resources

    • Transparency

    • Proportionality

    • Accountability

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Legal Issues for Crisis Standards of Care

  • Liability

    • Addressing the problem

      • Deputizing physicians

      • Enacting liability protections

    • Credentialing

    • Scope-of-practice

    • EMTALA and HIPPA

    • Legal triage

    • Education and training

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Clinical Operations - Components

  • Indicators

  • Triggers

  • Triage

  • Alternate care facilities

  • EMS, community health & other components

  • Resource availability and distribution

  • Pediatrics and other “at risk” populations

  • Palliative care

  • Mental health

  • Training

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Who Gets the Resources?

Hospital outside

In a Warehouse

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


“Crisis Standards” Indicators

  • Actual or impending resource shortfalls:

    • Ventilators

    • Oxygen and delivery devices

    • ICU beds

    • Healthcare providers

    • Hospitals

    • Pharmaceuticals

    • Other

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Triggers

  • Should be:

    • Consistent

    • Based on disaster declaration

    • Driven by front-line providers

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Triage

  • Triage and the Sequential Organ Failure Analysis (SOFA) score.

    • Cardiovascular

    • Coagulation

    • Hepatic

    • Neurological

    • Renal

    • Respiratory

  • Triage across the health system

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Alternate Care Facilities

  • Creating surge capacity outside the hospital

  • Planning by:

    • North Dakota

      • Facility capabilities

      • Staffed by volunteers

    • Delaware

      • Modular medical expansion

      • NEHCs – act as gateways

      • Legislation enacted

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


EMS, Community Health and Other Components

  • Considerations for:

    • EMS

    • Community Health

    • The private sector

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Resource Availability and Distribution

  • Identifying resources

  • Resource acquisition

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Pediatric and other “At Risk” Populations

Populations

  • Children

  • Elderly

  • Mental health patients

  • Others

  • Challenges – matching resources to needs

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Palliative Care

  • Expected Need

    • Despite the best efforts…

    • Concern for lack of palliative care protocols and standards

    • Reluctance to discuss

  • Planning for care

    • No one left to die

    • Care is never withdrawn

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Mental Health

  • The need for grief management

    • Consider

      • Ceasing pediatric resuscitations

      • Discontinuing (DC’ing) vent assistance

      • Running out of life-sustaining medications or oxygen

    • Impact on

      • Care-givers

      • Family and individuals

    • Planning –

      • Missouri School of Medicine –

        • Center for Health Ethics - just-in-time, Pandemic Grief Training course.

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Training

  • Need for effective training and relationship building across organizational boundaries.

  • Forums include

    • Exercises

    • Actual event responses

      • 2009 Presidential inauguration

        • Maryland and District of Columbia

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Conclusions

  • Four Regional Workshops

  • Highlighted work ongoing around the nation

  • More work needed for:

    • Palliative care planning

    • Mental/behavioral health

    • Vulnerable populations

    • Public and provider engagement

    • Consistency

  • How far do we go?

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


Thank you!

Sally Phillips, RN, PhD

Director, Public Health Preparedness

Agency for Health Research and Quality

Rockville, Maryland

[email protected]

Knox Andress, RN, FAEN

Designated Regional Coordinator

Louisiana Region 7 Hospital Preparedness

Department of Emergency Medicine

LSU Health Sciences Center – Shreveport

Louisiana Poison Center

[email protected]

ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress


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