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

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

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

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

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

“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


Crisis standards of care protocol development

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


Standards of care in mass casualty events

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

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

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

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

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

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

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

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

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

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

“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

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

  • 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

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

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

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

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

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

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

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

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

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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