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Standards of Care in Mass Casualty Events

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

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  1. 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

  2. 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

  3. 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

  4. 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

  5. “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

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. “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

  18. 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

  19. 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

  20. 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

  21. 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

  22. Resource Availability and Distribution • Identifying resources • Resource acquisition ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. Thank you! Sally Phillips, RN, PhD Director, Public Health Preparedness Agency for Health Research and Quality Rockville, Maryland Sally.phillips@ahrq.hhs.gov Knox Andress, RN, FAEN Designated Regional Coordinator Louisiana Region 7 Hospital Preparedness Department of Emergency Medicine LSU Health Sciences Center – Shreveport Louisiana Poison Center wandr1@lsuhsc.edu ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report; Phillips/Andress

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