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Alternative Standards OfCare In Disasters
Satellite Conference and Live WebcastThursday, March 26, 2009
12:00-1:30 p.m. (Central Time)
Produced by the Alabama Department of Public HealthVideo Communications and Distance Learning Division
Faculty
Joseph J. Contiguglia, MD, MPH, TM MBAClinical Professor of Public Health
Tulane UniversitySchool of Public Healthand Tropical Medicine
New Orlens, LA
Objectives• Explain the systemized optimization
of alternatives and compromisesduring disaster as well aspreparation of a resilient andsustainable infrastructure
Objectives• Describe how operational models are
used as a tool to clearly articulatethe best combination of currenttechnology and available resourcescapable of a robust and reliableoutcome
Objectives• Discuss alternative standards of care
as “fall-back” positions preserving arational process with acceptedoutcomes
• Describe alternative standards ofcare in the context of the fivephases/venues where such treatmentis sought and provided
Objectives• Explain the process of evaluation in
defining the shortfall of necessaryfunctional capabilities for outcome,efficiency and coordination duringdisaster response
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Disaster The Leopard
“If we want everything to stay thesame, it is necessary for everything tochange.”
– Fabrizio Tomasi, Prince of Salina
Fall Back• Change process to maintain
standards of outcome
• Deliberate decisions by authorizedleadership
Fall Back• Coordinated pullback to maintain
new standards
– Carefully planned
– Capable of support
– Personnel trained & equipped
• Optimize outcome under evolvingconditions
Overview• Introduction
• Metrics
• Model
• Alternative standards
• Phases & venues
• Evaluation
Introduction• Disaster forces a population at large,
some of whose members constitutethe disaster specific population atrisk, to adapt to changedcircumstances and environmentalchallenges in a rational and effectivefashion if the goal, consistent withnational standards, is tomaximize the saving of life
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Guidelines & Standards• Guidelines & standards are needed
to define measurable, acceptable andapproved pathways & outcomes forindividuals and agencies to pursueduring a time of scarce resources
Guidelines & Standards• They permit
– The systemized optimization ofalternatives and compromises
– Within an ethical context
– Upon which public morale and thepreservation of civil orderdepends, as well as
– Preparing a resilient andsustainable infrastructure
Outcome• To optimize outcome,
all available resources need to bepreserved, coordinated and focusedso as to optimize communityresponse in dealing with
– The normal ongoing needs of thestricken and spared populations
Outcome• To optimize outcome,
all available resources need to bepreserved, coordinated and focusedso as to optimize communityresponse in dealing with
– The special disaster-related needsof the population at risk
Outcome• To optimize outcome,
all available resources need to bepreserved, coordinated and focusedso as to optimize communityresponse in dealing with
– The special needs encountered bypopulations with specialvulnerability
Adaptability• Emergency events and disasters
require the affected population toadapt to rapidly changingcircumstances
• These may include an often abruptlylimited scope of public healthservices
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Challenges
• Analyze the capacity to address theneeds of vulnerable populations inemergency response and recovery
• Develop testable models foralternative standards of care
Challenges• Determine metrics to guide the
integration of alternative standardsinto the public health system as acomponent of preparedness
• Identify facilitators of suchintegration through pilottesting
Hierarchy Of Needs• Safety
• Water
• Food
• Shelter/heat
• Clothing
• Medical Care
• Employment
Hierarchy Of Needs• Companionship
• Family environment
• Stability
• Social status & advancement
• Child development
• Care of elders
• Mid & long term plans
Hierarchy Of Needs
Kibeho refugee camp, Ruwanda, 1994
Hierarchy Of Needs
JTF safe haven, Panama 1995
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Hierarchy Of Needs
Kosovo school art
Hierarchy Of Needs
Meeting hut, Empire Range, JTF safe haven
Elements: Personnel• Numbers
• Sources
• Roles
• Competencies
• Training
• Evaluation
• Remuneration
Elements: Logistics• Equipment
– In place
– Transported
• Supplies
– Timely
– Reliable
– Coordinated
Elements: CommunicationsInfrastructure
• Hardware
• Process
• Availability
• Standardization
• Technical currency
• Maintenance
• Evaluation & standards
Elements:Risk Communications
• Content
• Audience
– Senior leadership
– Population at large
– Population at risk
– Responders
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Elements:Risk Communications
• Purpose
• Timing
• Feedback
Metrics• Parameters of
– Preparation
– Process
– Outcome
Metrics• Metrics are the core ingredient in
providing guidelines & standardsneeded to define measurable,acceptable and approved pathways& outcomes for individuals andagencies to pursue during a time ofscarce resources.
Measurable Standards• Currently, few measurable standards
exist to guide an effective andsystems-based approach toproviding the best public healthservices under emergencysituations.
Measurable Standards• Of specific importance is the lack of
data to inform decision makingregarding addressing the needs ofvulnerable populations by apotentially severely strapped publichealth system
Metrics
• Permit the systemized optimizationof alternatives and compromiseswithin an ethical context upon whichpublic morale and the preservationof civil order depends
• Prepare a resilient and sustainableinfrastructure
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Metrics• Ability of local command and control
agencies to prepare, muster andemploy personnel
– Time
– Numbers
– Roles
– Competencies
– Training
Metrics• Ability of local command and control
agencies to prepare, muster andexecute required logistics
– Standing infrastructure
– Locally warehoused
Metrics• Ability of local command and control
agencies to prepare, muster andexecute required logistics
– Newly required equipment & supplies
• Timely
• Proper
• Reliable
• Coordinated
Metrics• Ability of local command and control
agencies to develop prepare, andemploy an effective and supportablecommunications Infrastructure
– Hardware
– Process
Metrics• Ability of local command and control
agencies to develop, prepare, andemploy
• Risk Communications
– Content
– Purpose
– Timing
– Audience
Metrics• Risk Communications
– Audience
• Senior leadership
• Population at large
• Population at risk
• Responders
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Metrics• Ability of local command and control
agencies to achieve population-wideaction including
– Information
– Motivation
– Facilitation
– Enforcement
• Capability of addressing victims’hierarchy of needs includingstandards of
– Access
– Venue
– Security
– Safety
Metrics
– Information
– Privacy
– Disability
– Cultural needs
• Drive Operational Models
– Adequate for existing perils
– Consistent with availableresources
– Capable of optimal consequencemanagement
Metrics Operational Model• Achieving the best results for
vulnerable communities involves
– Identifying reasonably foreseeableperils
– Developing effective doctrinesupporting an operational model
Operational Model• The operational model clearly
articulates the best amalgam ofcurrent technology and availableresources capable of a robust andreliable outcome
• The Operational Model defines howthe operational elements will be bestintegrated for a community’sresponse to peril
Operational Model
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EVACUATIONSITE
STAGING AREA
HOSPITAL
RESPONSE TO AN EXPLOSIVEATTACK WITH PERSISTANT
NERVE AGENT RELEASE
WIND
ATTACKSITE
TRIAGEAREA
HOTZONE
HOSPITALSINGLE POINT ENTRY
DECONTAMINATION
IDENTIFICATION SCREENINGEDUCATION
SUPPORT NERVE
Testable Models• In developing testable models for
alternative standards of care, allavailable resources have to bepreserved, coordinated and focusedto optimize community response indealing with the disaster-relatedneeds of general populations andthose with special vulnerability.
Government Consultation• Consultation with state & local
governments is needed to
– Develop models consistent withthe perils and intrinsic needs ofcommunities
– Drive acceptable and achievableoutcomes in community responseto significant perils
• Incorporate guidelines of process &standards of outcome intocommunity planning
• Reinforce resilient design so as tooptimized the support or evacuationof vulnerable populations
• Operate within a systematic ethical &rational process
Government Consultation
Scenarios• Scenarios employed should be based
on likely perils which have beenidentified as significant by competentauthorities and will drive operationalmodels to
• Employ alternative standards of care tobest coordinate/employ all potentialresources
• Identify shortfalls & create alternatives
Testable Models• The models should incorporate
guidelines of process & standards ofoutcome with appropriate metrics tooptimize the support of general &vulnerable populations
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• Evaluate community capability by
– Identifying what capability exists
– Examining its elements & scope ofaction
– Determining if it worksthrough
Testable Models
• Application of metrics
Testable Models
• Evaluation of historical data
Testable Models
• Survey of health workers andsupport agencies
Testable Models
• Proposing and assisting appropriatetrial of capabilities and plans incarefully designed & evaluatedexercises
Testable Models Facilitators Of Integration• Facilitators of integration must be
identified to assist in accomplishingtesting to address questions andissues such as
– Are the metrics correct?
– Examine if existing process andinfrastructure can work?
• If not, why?
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Facilitators Of Integration• Facilitators of integration must be
identified to assist in accomplishingtesting to address questions andissues such as
– Testing of alternative standards
– Designing of demonstrationprojects
– Survey of appropriate communities& populations
Alternative Standards Of Care• To define personnel, logistics and
communications requirements withinwell designed doctrine
• To establish a resilient infrastructurecapable of the most effectiveconsequence management and
• To enable early, effective
& coordinated recovery
• Exercise findings can be used toenhance the capacity of public healthagencies and communities to
– Improve community resiliency
– Emergency response capabilities, for
• General population
• Most vulnerable of the population
Alternative Standards Of Care• Development of “fall-back” positions
preserving a rational process withaccepted outcomes permits
– Effective preparation for emergencyaction
– Definition of requirements
– Support of effective consequencemanagement recruitment & training
Alternative Standards Of Care
• Facilitate responder focus on thehierarchy of needs of the populationat risk
• Streamline and simplify supportduring arduous circumstances
• Establish & preserve a rationalprocess with accepted outcomes todrive resiliency into a preparation foremergency action
Alternative Standards Of Care• In developing alternative standards
of care, optimization of outcomerequires all available resources to be
– Preserved
– Coordinated
– Focused
Alternative Standards Of Care
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Integration OfAlternative Standards
• Guiding the integration of alternativestandards into the public healthsystem is an important component ofpreparedness
Phases & Venues Of Care• Standards for the alternative
provision of medical care in adisaster affected environment shouldbe examined in the fivephases/venues where such treatmentis sought and provided
• Community Care involving activity inthe pre-professional setting
Phases & Venues Of Care
• Emergency Medical Services (EMS)at the first level of regularprofessional activity
Phases & Venues Of Care
• Hospital Care providing diagnostics,complex or urgent therapeutics &complex support
Phases & Venues Of Care
• Urgent consultation involvingspecialist intervention for sudden orserious/complex events
Phases & Venues Of Care
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• Home care providing support in aresidential setting for patients who,in normal circumstances, mightrequire inpatient care in asophisticated outpatient clinic
Phases & Venues Of Care Alternative Standards Of Care
• Alternative Standards of Care implythe deliberate and planned alterationof a series of elements in the medicalcare process
• Who
– Implying variation in roles,competencies and training
Alternative Standards Of Care
• How provided
– Implying variation in process
Alternative Standards Of Care
• Where provided
– Implying variation in sequence andvenue
Alternative Standards Of Care
• How overseen
– Implying variation in level ofexpertise and clinicalsophistication
Alternative Standards Of Care
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• How evaluated
– Implying alteration in criteria ofoutcome
Alternative Standards Of Care Evaluation• Using responsible agencies &
appropriate focus groups, metricsshould be proposed and employed indefining the shortfall of functionalcapabilities for outcome, efficiencyand coordination.
• Timeliness of response and timesensitivity of outcome
Evaluation• Access for individuals within
vulnerable populations at risk
Evaluation
• Quality of medical intervention andthe employment of availabletechnology
Evaluation
• Effectiveness of diagnostic andtherapeutic actions in thepreservation of life and health
Evaluation
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Evaluation• Acceptability within the expectations
and cultural sensitivities of thecommunity
Pilot Testing The Models• Present capability should be
evaluated in the context of theexisting virtual plan which will besubject to review in the developmentof an operational model includingalternative standardsconsidered most likely tooptimize effective response.
• A Delta Analysis can be used todetermine modifications necessaryto achieve Initial OperationalCapability
– The level of performance at whichprofessionally assisted competentauthority considers outcome to besatisfactory
Pilot Testing The Models• The relative success of the Delta
Analysis at achieving its objectiveshould be examined throughexercise (tabletop, functional & fullscale)
Pilot Testing The Models
• Pilot programs can be used tointegrate & evaluate alternative caremodels
Pilot Testing The Models Expanded Studies• The pilot project should expand as
– The scope and depth of theexperimental matrix evolves
– The validity and utility of the modeldrives a broader array of playersregionally
• An expansion of the pilot processcould drive a broader and moreresilient regional infrastructure
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Prevention• Shape the battlefield
• Back to the future
“The good news to a hungryperson is bread.”
–Desmond Tutu
Summary• Introduction
• Metrics
• Model
“Plans are nothing, planningis everything.”
–General George Patton
• Alternative standards
• Phases & venues
• Evaluation
Questions?
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