Faculty Alternative Standards Of Care In Disastersalabamapublichealth.gov/Staging/test/alphtn/assets/... · Alternative Standards Of Care In Disasters Satellite Conference and Live

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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



– The special disaster-related needsof the population at risk



– 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


agencies to prepare, muster andexecute required logistics

– Standing infrastructure

– Locally warehoused


agencies to prepare, muster andexecute required logistics

– Newly required equipment & supplies

• Timely

• Proper

• Reliable

• Coordinated


agencies to develop prepare, andemploy an effective and supportablecommunications Infrastructure

– Hardware

– Process


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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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


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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


• Hospital Care providing diagnostics,complex or urgent therapeutics &complex support


• Urgent consultation involvingspecialist intervention for sudden orserious/complex events


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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


• How provided

– Implying variation in process


• Where provided

– Implying variation in sequence andvenue


• How overseen

– Implying variation in level ofexpertise and clinicalsophistication


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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?

Documents

Faculty Alternative Standards Of Care In Disastersalabamapublichealth.gov/Staging/test/alphtn/assets/... · Alternative Standards Of Care In Disasters Satellite Conference and Live