Crisis Standards of Care A Systems Framework for Catastrophic Disaster Response: Volume 1: Introduction and CSC Framework (2012) / Chapter Skim
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Volume 1--Introduction and CSC Framework
Volume 1--Introduction and CSC Framework
Pages 1-97
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asked the Institute of Medicine (IOM) to convene a committee of experts to develop national guidance for use by state and local public health officials and health-sector agencies and institutions in establishing and implementing standards of care that should apply in disaster situations -- both naturally occurring and manmade -- under conditions of scarce resources.
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and the ethical, palliative care, and mental health issues (Chapter 4) that agencies and organizations at each level of a disaster response should address.
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Conceptualizing a Systems Approach to Disaster Response This section broadly outlines a systems framework for disaster response of which CSC is only one, albeit a critical, aspect. However, the development and implementation of CSC plans are the means to mount a response to an incident that far exceeds the usual health and medical capacity and capabilities.
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Milestones to Guide CSC Planning To ensure that this systems coordination and integration occur, the committee offers specific milestones, enumerated in Box S-1. This systems approach to CSC, and disaster response more generally, provides the context for this report.
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7. Ensure that local and state CSC plans include clear provisions that permit adap tation of EMS systems under disaster response conditions.
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Community engagement in the assessment of ethical values that underlie such decisions can help ensure that the decisions are aligned with community values and that those values are integrated by agencies responsible for developing CSC plans where appropriate. The key elements in plan 2 The surge capacity following a mass casualty incident falls into three basic categories, depending on the magnitude of the incident: con ventional, contingency, and crisis.
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Incorporating into CSC planning the capabilities necessary to provide palliative care assures the public that even when curative acute care cannot be provided, every attempt to offer pain management and comfort care to disaster victims will be made, even if comfort care may mean nonpharmaceutical interventions such as holding a hand or offering words of comfort. Mental Health The social consequences of a disaster and the need to implement CSC will certainly impact the mental health of patients, their families, health care providers, and the general public.
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At some point, the state CSC plan will need to be incorporated into or adapted for local planning efforts (e.g., development of the health and medical annex of the local emergency operations plan) and will help guide local activities during the response to a catastrophic disaster response.
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These limitations should be addressed through the incorporation of EMS-specific disaster response and CSC plans into relevant disaster preparedness grant guidance. In this context, an important factor in operationalizing the CSC framework set forth in the committee's 2009 letter report and reiterated in Chapter 2 of this report is specific enumeration of EMS roles, responsibilities, and actions in CSC plans.
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Consistent with the Hospital Preparedness Program and Public Health Emergency Preparedness cooperative agreements, disaster response plans should delineate protocols for a shift from the conventional standard of care to ensure that essential health care services will be sustained during the response. CSC plans will be implemented under conditions in which the usual safeguards may not be possible and when resources will be insufficient to allow for the delivery of care under usual operating conditions.
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Both have a joint responsibility for and distinct but equally necessary roles in efforts to advance outpatient CSC planning to ensure that the health care goals of catastrophic disaster response can be accomplished through coordinated efforts. PUBLIC ENGAGEMENT The committee's 2009 letter report highlighted meaningful public engagement as one of the five key elements of CSC planning.
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• Federal disaster preparedness and response grants, contracts, and programs in the Department of Health and Human Services, the Department of Homeland Security, the Department of Defense, the Department of Transportation, and the Department of Veterans Affairs -- such as the Hospital Preparedness Program, Public Health Emergency Preparedness Program, Met ropolitan Medical Response System, Community Environmental Monitoring Program, and Urban Areas Security Initiative -- should integrate relevant crisis standards of care functions.
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2009. Emergency management principles and practices for health care systems: Unit 5: Appendices.
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asked the Institute of Medicine (IOM) to convene a committee of experts to develop national guidance for use by state and local public health officials and health-sector agencies and institutions in establishing and implementing standards of care that should apply in catastrophic disaster situations -- both naturally occurring and manmade -- under conditions of scarce resources.
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, hospitals and acute care facilities, and out-of-hospital and alternate care systems. Additionally, a key component of CSC planning, as recommended in the 2009 letter report, is public engagement.
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2009 LETTER REPORT: KEY ELEMENTS AND RECOMMENDATIONS The committee's 2009 letter report identified five key elements of CSC planning and implementation and offered six recommendations.
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Active engagement should contribute, as appropriate, to developing and refining CSC protocols, developing communication and educational messages/tools for the public and health care practitioners, developing and implementing strategies for community resilience, and improving future CSC responses. Legal Authority and Environment Establishing and implementing CSC plans requires careful consideration of the substantial legal challenges involved, including potential liability.
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• Statutory, regulatory, and common-law liability protections Indicators and triggers Indicators for assessment and potential management • Situational awareness (local/regional, state, national) • Incident specific o Illness and injury -- incidence and severity o Disruption of social and community functioning o Resource availability Triggers for action • Critical infrastructure disruption • Failure of "contingency" surge capacity (resource-sparing strategies overwhelmed)
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In its phase two deliberations, the committee reviewed the six recommendations presented in the letter report (Box 1-2) and reaffirmed their fundamental validity and relevance to ongoing planning for catastrophic disaster response.
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The inclusion of CSC as a priority in both the Hospital Preparedness Program (HPP) and Public Health Emergency Preparedness cooperative agreements opens up a potential source of federal funding for states and local jurisdictions to develop CSC plans (ASPR, 2011)
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Recommendation: Seek Community and Provider Engagement State, local, and tribal governments should partner with and work to ensure strong public engagement of community and provider stakeholders, with particular attention given to the needs of vulnerable populations and those with medical special needs, in • developing and refining crisis standards of care protocols and implementation guidance; • creating and disseminating educational tools and messages to both the public and health professionals; • developing and implementing crisis communication strategies; • developing and implementing community resilience strategies; and • learning from and improving crisis standards of care response situations. Recommendation: Adhere to Ethical Norms During Crisis Standards of Care When crisis standards of care prevail, as when ordinary standards are in effect, health care practitioners must adhere to ethical norms.
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These efforts should include • Using "clinical care committees," "triage teams," and a state-level "disaster medi cal advisory committee" that will evaluate evidence-based, peer-reviewed critical care and other decision tools and recommend and implement decision-making algorithms to be used when specific life-sustaining resources become scarce; • Providing palliative care services for all patients, including the provision of comfort, compassion, and maintenance of dignity; • Mobilizing mental health resources to help communities -- and providers themselves -- to manage the effects of crisis standards of care by following a concept of opera tions developed for disasters; • Developing specific response measures for vulnerable populations and those with medical special needs, including pediatrics, geriatrics, and persons with disabilities; and • Implementing robust situational awareness capabilities to allow for real-time in formation sharing across affected communities and with the "disaster medical advisory committee." Recommendation: Ensure Intrastate and Interstate Consistency Among Neighboring Jurisdictions States, in partnership with the federal government, tribes, and localities, should initiate communications and develop processes to ensure intrastate and interstate consistency in the implementation of crisis standards of care. Specific efforts are needed to ensure that the Department of Defense, Veterans Health Administration, and Indian Health Ser vices medical facilities are integrated into planning and response efforts.
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was designed to educate these groups on how to develop systematic and comprehensive protocols for allocating scarce resources during a disaster. The toolkit was offered to practitioners as one of HHS's primary resources on the subject, to be coupled with simultaneous working group efforts on strategic planning for emergency department, outpatient, and inpatient management of the 2009 H1N1 pandemic.
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State Impact With the 2009 H1N1 influenza pandemic as a major driver, several states have initiated CSC planning efforts as part of broadening their overall surge capacity plans. Examples of plans that specifically reference the letter report's framework demonstrate its impact.
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The plan provides specific guidance to relevant stakeholders, including EMS and health care facilities, and on broader issues such as the legal considerations associated with allocating scarce resources. The ethical principles on which the Michigan plan is founded closely resemble those laid out in the letter report while expanding on them to reflect a more specific sense of the values in the state.
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One of the greatest impediments to involving private-sector providers in CSC planning is related to the general disconnect that exists between private practitioners and the formal emergency response system at the local, regional, state, and federal levels. At a July 2011 provider workshop in Seattle–King County -- where the public health department has made substantial progress in developing CSC plans, has conducted public engagement sessions on CSC, and has worked with a coalition of private-sector providers to leverage community resources -- participants who INTRODUCTION 1-27
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. The text of the chapters defines the roles and responsibilities of these stakeholders, describes operational considerations associated with their development and implementation of CSC plans, and provides brief descriptions of templates that outline the specific functions and tasks for each stakeholder when allocating scarce resources in response to a disaster.
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2012. Allocation of scarce resources during Mass Casualty Events (MCEs)
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2012. Ethical guidelines for allocation of scarce medical resources and services during public health emergencies in Michigan.
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As a result, in its renewed deliberations on developing and implementing CSC, the committee recognized the demand for a rigorous systems approach. CONCEPTUALIZING A SYSTEMS APPROACH TO DISASTER RESPONSE This section broadly outlines a framework for disaster response of which CSC is only one, albeit a critical, aspect.
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FIGURE 2-1 The foundation for CSC planning comprises ethical considerations and legal authority and environment, located on either side of the steps leading up to the structure. The steps represent elements needed to implement disaster response; education and information sharing are the means for ensuring that performance improvement processes drive the development of disaster response plans.
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Individuals who may not meet criteria for intensive curative measures should still receive compassionate palliative care. The legal authority and legal environment within which CSC plans are developed are the other cornerstone of the framework's foundation.
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The Impact of Situational Awareness on Decision Making During a Disaster The equitable, just, and effective delivery of care under disaster response conditions begins with the need to establish good situational awareness, with a common operating picture shared by all components of the disaster response system. At the outset of any disaster incident, particularly one in which there is a no-notice impact, decision making about resource allocation will necessarily be based on reactive choices.
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. In the MSCC framework, as in emergency response systems in general, much of the planning effort is focused on mass casualty and disaster incidents, including the expansion of clinical CATASTROPHIC DISASTER RESPONSE 1-35
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. Surge capacity can be envisioned as occurring along a continuum based on resource availability and demand for health care services (see Box 2-4)
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Resource availability influences the supply side of the health care delivery balance. Resources in the acute care sector include not just hospi CATASTROPHIC DISASTER RESPONSE 1-37
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In addition, health care providers can take specific steps to steward available medical resources, making them last longer during an incident in which those resources may be in short supply or the means to replace them compromised. The 2009 letter report described the resource-sparing strategies that can be implemented when an incident occurs (Hick et al., 2009)
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Indeed, negative influences on supply and demand, such as poor risk communication strategies, decreased availability of medical providers, and a lack of preparedness efforts, may place CATASTROPHIC DISASTER RESPONSE 1-39
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These spaces and practices are used during a major mass casualty incident that triggers activation of the facility emergency operations plan. Contingency Capacity: The spaces, staff, and supplies used are not consistent with daily practices but provide care that is functionally equivalent to usual patient care.
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GUIDANCE FOR DISASTER RESPONSE STAKEHOLDERS Following is a brief overview of the roles and responsibilities of each pillar of the disaster response framework -- federal, state, and local governments; EMS agencies; hospital and acute care facilities; and outof-hospital and alternate care systems -- in developing and implementing CSC plans. A detailed discussion of the functions and tasks of each stakeholder can be found in Chapters 5-8, respectively.
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) will continue to lead efforts to support and encourage the development of CSC plans for use in catastrophic disaster situations, primarily through continued emphasis on the importance of coordinating such planning within the larger context of surge capacity planning as part of a disaster response framework.
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. In Figure 2-5, this framework is adapted to include some of the specific functional elements described in the 2009 letter report, including the creation of state and regional disaster medical advisory committees and the role of triage teams, clinical care committees, and palliative care teams.
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Emergency Medical Services Because of their critical role in linking patients in the outpatient environment to hospitals and the delivery of care, EMS agencies should play a major part in the development and implementation of CSC plans. Adjustments to scopes of practice, treatment modalities, ambulance staffing, and call response will figure significantly in state, local, and EMS-specific disaster response plans.
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to establish State Health Department plans and guidelines • Provides situational awareness to state EOC and regional medical coordination center (RMCC) and hospitals • Requests declarations and regulatory relief from governor's office and manages requests to the federally controlled Strategic National Stockpile • Oversees and ensures regional consistency in the execution of disaster response plans • Makes declaration of emergency (e.g., disaster, health emergency, or public health emergency)
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It is assumed that under disaster response conditions, resources -- including state, regional, and federal caches; access to medical countermeasures; and the ability to transfer patients -- are unavailable elsewhere in the region or state and will not be resupplied in the short term. MILESTONES FOR CRISIS STANDARDS OF CARE PLANNING AND IMPLEMENTATION Listed below are critical milestones that can be used to assess the progress of CSC planning, along with the proposed lead agency responsible for facilitating discussion, plan development, and implementation for each milestone.
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. • Develop a process for continuous assessment of disaster response capabilities based on existing information and knowledge management platforms, and create a mechanism for ensuring that these CSC planning milestones are being achieved (governor's office, state health department and emergency management agency)
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In all cases, the response and any strategies should be Analyzed at regular intervals as part of the disaster response planning cycle, and the elements repeated until the incident concludes. The terms in this figure can be further described as follows: Awareness • Incident commander recognizes current or anticipated resource shortfall(s)
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A triage team is appointed if required for scarce critical care interventions, consisting of at least two specialists practicing and ex continued CATASTROPHIC DISASTER RESPONSE 1-49
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RECOMMENDATION To enhance and elaborate on the recommendations from its 2009 letter report, which it still fully supports, the committee developed a set of templates identifying the core functions and tasks for individuals and organizations involved in CSC planning and implementation. In developing these resources, the committee emphasized the use of a systems approach that integrates CSC planning into the larger context of overall surge capacity planning.
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To facilitate the implementation of this framework, the committee specifically recommends that: • Each level of government should ensure coordination and consistency in the active engagement of all partners in the emergency response system, including emergency management, public health, emergency medical services, public and private health care providers and entities, and public safety. • Each level of government should integrate crisis standards of care into surge capacity and capa bility planning and exercises.
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2007. Medical surge capacity and capability: A management system for integrating medical and health resources during large-scale emergencies.
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. These issues cut across nearly all levels of the public and private sectors involved in coordinating and providing emergency care during disaster response.
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endorsed states' consideration of the provisions of the Uniform Volunteer Emergency Health Practitioners Act for potential enactment, specifically including provisions that protect volunteer health care practitioners from liability claims grounded in negligence (AMA, 2008) .6 In 2005, the AMA 1 Note that medical standards of care should not be confused with a health care provider's scope of practice or associated privileges (Curie and Crouch, 2008; Pegalis, 2009)
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Nonetheless, all levels of government provide limited legal liability protections for many practitioners and entities responding during emergencies to offer assurances and incentives for their participation in emergency response efforts (as detailed later in the chapter)
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. These "licensure reciprocity" provisions allow for the interstate sharing of out-of-state health care personnel whose licenses are viewed as in-state licenses for the duration of the declared emergency (although providers may still be subject to liability risks if they exceed their scope of practice in their home jurisdiction during their emergency response efforts)
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• Is the entity prepared to screen and potentially divert excess numbers of patients during an emergency consistent with the Emergency Medical Treatment and Active Labor Act (EMTALA) , absent its waiver during a declared emergency?
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Against this backdrop, the potential arises for legal action resulting from perceived or actual denial or limitation of health care services during a crisis. High-profile cases involving health care practitioners responding during Hurricane Katrina, for example, have garnered national attention.11 Potential liability claims can result from alleged civil, criminal, and constitutional violations by health care practitioners, volunteers, and government or private entities (Hodge et al., 2009)
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. In developing additional guidance for the implementation of CSC, the committee heard directly from numerous state and local public health and emergency management representatives about their concerns regarding how liability risks may impact the willingness of practitioners and volunteers to participate in emergency response efforts.
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Specific federal declarations provide targeted liability protections and authorize the emergency use of medical countermeasures needed for a response. For example, the federal Public Readiness and Emergency Preparedness (PREP)
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related to the response to the public health emergency unless such damages result from providing, or failing to provide, medical care or treatment under circumstances demonstrating a reckless disregard for the consequences so as to affect the life or health of the patient."a Uniform Emergency Volunteer health Alternative A: VHPs are not liable for their actions Volunteer Health practitioners (VHPs) or omissions while providing services during an Practitioners Act (UEVHPA)
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(c) During a state of public health emergency, any health care providers shall not be civilly liable for causing the death of, or, injury to, any person or damage to any property except in the event of gross negligence or willful misconduct."h Maryland State Torts Claims State personnel (including Provides state personnel immunity for acts or omissions within the scope of their duties.j Act unpaid individuals performing state functions)
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Although lacking consistency across all emergency responders and entities, the existing patchwork of liability protections can facilitate emergency planning and response efforts by providing assurances of liability protection against negligence claims during and after declared emergencies. These laws collectively provide an umbrella of protections covering hundreds of thousands of practitioners, volunteers, and entities that 21 P roject Bioshield Act of 2004, Public Law 108-276, § 564(a)
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, follow government disaster plans or protocols, or act specifically under government authority.25,26 Liability protections for volunteers do not similarly immunize health care employees working alongside them (some of whom may be covered by medical malpractice insurance subject to insurers' exceptions) , although some states also immunize compensated workers.27,28 Liability protections for health care entities, including hospitals, clinics, pharmacies, and others, are more limited than individual protections.29 Health care practitioners may also be concerned about whether malpractice and other forms of insurance will cover unintentional errors or care given outside a provider's scope of practice under CSC.
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During a public health emergency, health professionals will have to make difficult decisions to allocate scarce medical resources (O'Callaghan, 2008) .31 It is unclear whether a decision to withdraw or withhold certain treatment during an emergency would trigger due process protection.
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This may include instituting reforms to provide enhanced liability protection for health care workers, volunteers, and entities working to implement CSC, depending on the policy objectives and preferences within their jurisdictions.
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2005. Hurricane Katrina response: Legal protections for intermittent disaster response per sonnel under a Federal Declaration of Public Health Emergency.
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2008. Emergency preparedness: States are planning for medical surge, but could ben efit from shared guidance for allocating scarce medical resources.
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The second section of this chapter, therefore, addresses the importance of providing palliative care when curative care is unavailable and describes ways to strengthen this aspect of disaster response planning and implementation. The third section addresses the issue of mental health, which, like palliative care, must be incorporated into CSC plans and affects their implementation at all levels of a disaster response.
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Key Features The ethical framework set forth in the letter report includes substantive and process features and should support ethical behavior for those at every level of disaster response, from government planners to individual providers. Its key features are as follows: • fairness, • the duty to care, • the duty to steward resources, • transparency, • consistency, • proportionality, and • accountability.
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Different communities may have different priorities for allocating scarce resources in a catastrophic disaster. Through appropriate public engagement processes (Chapter 9)
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. The outcome of these events was productive identification and subsequent discussion of the community's underlying values in allocating scarce resources during a disaster such as pandemic influenza.
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The ethics framework's greatest potential for impact is during the development of CSC plans. Personnel with the responsibility for ensuring that CSC plans incorporate such ethical principles benefit the process best when they themselves are well versed in the specific issues affecting and affected by CSC plans and their implementation.
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Use of a lottery with no reference to prognostic factors in the allocation of scarce medical resources would result in excess mortality since some patients would receive treatment despite having a high probability of mortality with or without treatment, while others who might have survived would die without it. For specific cohorts for whom differences in morbidity and mortality are particularly difficult to predict and no validated scoring system exists, as is the case with critically ill children, some authors believe use of a lottery may be justified (Pediatric Emergency Mass Critical Care Task Force, 2012)
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The lack of family can be as life-threatening a scarcity as the lack of access to medical resources, and there is no public consensus on how to address the various consequences of social isolation. This problem arises with the question of using bag-valve ventilation as a supplement when critical care resources are in short supply.
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should include a holistic and humane approach to public health and health care services during such an incident, and should be considered in the development of community plans for disaster response. The provision of palliative care in the context of a disaster with scarce resources can be considered a moral imperative of a humane society.
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Meeting these challenges will require training nonprofessional caregivers in basic comfort measures and ensuring broad-based coordination among EMS, hospitals, hospice and palliative care professional organizations, home care agencies, long-term care facilities, and state and local public health authorities. The emerging role of health care coalitions will also be instrumental in the successful integration of palliative care planning and implementation into regional protocols for disaster response.
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should be identified, defined, and provided; that palliative care services should be fully incorporated into all levels of state and local disaster planning/ training guidelines, protocols, and activities; and that first responder personnel and local and regional disaster response planners (e.g., EMS; fire, police, and public health departments; community health clinics; local and regional government entities) should be involved in identifying and developing clear specifications for what levels of care are to be delivered in what settings (at the incident, in alternate care sites, in existing secondary referral sites such as nursing homes or individuals' homes)
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, the use and titration of oral and injectable narcotic analgesics for patients in pain and/or near death, symptom recognition in the case of pandemic influenza or a chemical or radiological attack, and basic psychosocial counseling and support. Disaster planning should take into account the potential benefits of stockpiling palliative care medications at accessible sites, including away from acute care hospitals (e.g., in nursing homes)
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The arguments for incorporating palliative care into disaster response -- humane treatment, diversion of dying people away from overburdened hospitals, more effective use of scarce resources, and the provision of care that patients want -- have moral weight on their own, but research should still assess their impact. In developing CSC plans, state and local public health agencies should work with hospice and other relevant partners to incorporate palliative care into disaster response plans.
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During Hurricane Katrina, absent supplies and direction, the palliative care response was erratic and inefficient. One way to ameliorate a chaotic palliative care response is to form palliative care response teams comprising psychologists, chaplains, and health care providers with knowledge of palliative care as a core component of the emergency response process.
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Summary Facing the deaths of large numbers of its members while ensuring that those deaths are as pain and symptom free as possible is a major challenge for a community. Boxes 4-1 through 4-3 summarize key considerations in incorporating palliative care into CSC planning and implementation.
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o Integrate palliative care planning into the development of alternate care systems. o Develop evacuation plans for existing and new palliative care patients.
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o Coordinate with mental health resiliency efforts to support those responders en gaged in the delivery of palliative care. Development of Triage and Treatment Decisions • Work with first responder personnel and local and regional disaster response planners (e.g., emergency medical services [EMS]
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mitigate these impacts by incorporating the social and psychological aspects of disaster response into CSC planning, as proposed in the committee's 2009 letter report (IOM, 2009)
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If not sufficiently addressed, these foreseeable mental health consequences may further degrade the functionality of the health care system and its ability to implement CSC optimally. Health care workers may bear the double burden of stress due to their professional roles and that due to seeing their families and friends requiring care within the CSC context.
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. Operational Guidance to Enhance Resilience and Manage the Mental Health Consequences of Crisis Standards of Care The 2009 letter report offered specific strategies and described several national best-practice initiatives with respect to managing the mental health consequences of mass casualty events (IOM, 2009)
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o The plans should address the full continuum of those affected, from those with pre-existing mental illness, to those directly affected by the implementation of CSC and their families, to health care workers who must implement CSC, to the general public. • Plans should address the anticipated consequences of CSC incidents through a gap analysis of the range of expected mental health impacts versus current resources.
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These programs should encompass preincident stress inoculation, development of personal resilience "plans," simple peer-to-peer psy chological first aid, self-triage, and linkage to Internet-based interventions for those at higher risk who desire further support. For Patients and Their Families In a mass casualty event involving high rates of illness, injury, and mortality, disaster mental health resources, like health care resources generally, are likely to experience significant surge demand.
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Therefore, strategies employed at the population level should utilize evidence-based rapid triage to help identify those at greatest risk for more sustained and serious consequences and allocate limited mental health resources to those at the highest level of evidence-based risk for sustained disorder and impairment. One example is the PsySTART disaster mental health rapid triage system, currently used by the American Red Cross and the Minnesota Department of Health, and available to 83 Los Angeles–area hospitals and community clinic agencies in the Los Angeles County Emergency Medical Services Agency Hospital Preparedness Program.
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Aimed at the general community, Listen, Protect, and Connect has versions for children and parents and for teachers, as well as a "neighbor-to-neighbor, family-to-family" all-ages version. These versions were recently adapted for the Los Angeles County Department of Public Health and its community disaster preparedness partners, including the medical reserve corps, community health clinics, hospitals, public health workers, schools, and first responders.1 These versions are available without cost from http://www.cdms.uci.edu/protect.pdf.
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In Gerontological palliative care nursing, edited by M Matzo, and D
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2009. Palliative care considerations for mass casualty events with scarce resources.
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. Pediatric Emergency Mass Critical Care Task Force.
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2007. Chapter VII: Palliative care.
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