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STANDARDS OF CARE IN MASS CASUALTY
EVENTS
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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
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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
3
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
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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 5
ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report;
Phillips/Andress
Crisis Standards of Care Protocol Development
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Who makes the plan? Nurses Physician assistants Physicians Pharmacists Administrators Morticians Academia Government Many others
ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report;
Phillips/Andress
Conventional Capacity – Spaces, staff and supplies are consistent with daily practices within the institution
Contingency Capacity – Spaces, staff and supplies used are not consistent with daily practices but maintain or have minimal impact on usual patient care practices.
Crisis Capacity – Adaptive spaces, staff, and supplies are not consistent with usual standards of care.
Space Usual patient care space or area are fully utilized
Patient care areas repurposed (ex. PACU or monitored units for ICU-level care)
Facility damaged/ unsafe or non-patient care areas (ex. classrooms, etc.) used for patient care
Staff Usual staff called in and utilizedStaff extension (ex. brief deferrals of non-emergent service, supervision of broader group of patients, change in responsibilities, documentation, etc.)
Trained staff unavailable or unable to adequately care for volume of patients even with extension techniques
Supplies Cached and usual supplies used Conservation, adaptation, and substitution of supplies with occasional reuse of select supplies
Critical supplies lacking. Possible reallocation of life-sustaining resources .
Standard of Care Usual Care Functionally equivalent care Crisis standards of care
Usual Operating Conditions Austere Operating Conditions
Capacity Continuum of Care
7
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
8
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
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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
10
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
11
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
12
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
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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
14
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
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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
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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
17
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
18
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
19
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
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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
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ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report;
Phillips/Andress
Resource Availability and Distribution
Identifying resources Resource acquisition
22
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
23
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
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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.
25
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
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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?
27
ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report;
Phillips/Andress
Thank you!
Sally Phillips, RN, PhDDirector, Public Health PreparednessAgency for Health Research and QualityRockville, [email protected]
Knox Andress, RN, FAENDesignated Regional CoordinatorLouisiana Region 7 Hospital PreparednessDepartment of Emergency MedicineLSU Health Sciences Center – ShreveportLouisiana Poison [email protected]
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ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report;
Phillips/Andress
