Tip:
Highlight text to annotate it
X
Operator: Ladies and gentlemen, thank you for standing by. Welcome to the Institute
of Medicineís Crisis Standards of Care Webinar. During the presentation all participants will
be in a listen-only mode. Afterwards we will conduct a question-and-answer session. At
that time if you have a question, please press the one followed by the four on your telephone.
If you need to reach an operator at any time, please press star zero. As a reminder, this
conference is being recorded, Friday, September 7, 2012. I would now like to turn the conference
over to Jim Blumenstock, Chief Program Officer for Public Health Practice at the Association
of State and Territorial Health Officials. Please go ahead, sir.
Presenter: Thank you, Cerci. Good day, everyone, and welcome to todayís webinar. ASTHO in
cooperation with the Department of Health and Human Services Office of the Assistant
Secretary for Preparedness and Response, ASPR, and the Institute of Medicine is hosting this
webinar to help you navigate the recently released Institute of Medicineís Crisis Standards
of Care, A Systems Framework for Catastrophic Disaster Response.
As all of you who are planners, responders and clinicians can clearly appreciate, the
ability to rapidly and effectively transition from a conventional to a crisis situation
is of paramount importance when it comes to human life preservation and safety. The IOM,
which youíll hear over the next hour or so, has worked very hard to create sort of a second
generation document that would guide us in this process of providing a wealth of information
and serving as an outstanding resource to us. So it is our objective today to sort of
give you the highlights and those salient points of this guidance document that will
basically advise you and empower you to use it more effectively and efficiently.
What Iíd like to do now is just briefly walk you through the agenda for the afternoon.
We are so pleased to have such an outstanding faculty assembled today, who Iíll introduce
in a few moments and give you a sense of what theyíll be talking about. With everyoneís
patience, what weíd like to do is allow the four presenters to actually share with you
their prepared remarks, and then as Cerci has said, weíll go into an open dialog format
where participants can pose questions and the panel members themselves could react and
respond accordingly.
I know the individuals who are on todayís faculty are no strangers to most of us on
the call today. Clearly we have four listed, but there are actually five faculty members
who are outstanding individuals, highly respected and are doing such an outstanding job in really
advancing and improving the nationís state of readiness and preparedness. So allow me
to introduce them to you and give you a sense of exactly what they will be talking about.
First we have Dan Hanfling. Dr. Hanfling is the Special Advisor to the Inova Health System
in Falls Church, Virginia, on matters related to emergency preparedness and disaster response.
Dr. Hanfling will then be followed by John Hecht. Dr. Hecht is a faculty emergency physician
at Hennepin County Medical Center and an associate professor of emergency medicine at the University
of Minnesota. Next we will have Mr. James Hodge, who is the Lincoln professor of health
law and ethics at the Sandra Day OíConnor College of Law and the Director of Public
Health Law and Policy Program and a fellow at the Center for the Study of Law, Science
and Technology at Arizona State University. And then we will close the formal faculty
presentation with Omair Shah. Dr. Shah serves as the Deputy Director and Director of Disease
Control and Clinical Prevention at Harris County Public Health and Environmental Health
Services.
Also allow me to introduce to you Dr. Bruce Altovote from the Institute of Medicine. Bruce,
along with the four other faculty members, have done such an outstanding job in developing
this framework, so Bruce has graciously agreed to sort of be fifth man on the team, if you
will, to support the presenters but also to assist us in answering the questions and having
a very fruitful dialog with you all when we get to that point in the program.
So with that, it is now my pleasure to turn the program over to Dr. Hanfling, who will
begin this session by covering the introduction of the IOMís Crisis Standards of Care. Dr.
Hanfling?
Presenter: Great, Jim. Thanks very much and thanks to ASTHO for the opportunity to participate
with you on this webinar, and hello to everybody out there in cyberspace. Thanks for joining
us this afternoon.
So Iím gonna kick things off by essentially focusing on the overview of some of the background
leading to the development of crisis standards of care and then highlight for you the salient
points that we developed in writing the 2009 report and then most recently this 2012 report
that was released in the end of March. And then Iíll close out my brief remarks by highlighting
the direct link between crisis standards of care and now what we see as a language in
the PHEP and HPP capabilities grant guidance so Ö and Iím sure some of you have sat through
these lectures at the various meetings throughout the country and so welcome back. And for those
of you who havenít seen these presentations before, I hope that youíll find them useful.
So let me start by borrowing part of an old slide from our colleague Eric Ofterheid and
adding to it some updated information. And essentially what you have before you is a
very arbitrary, somewhat selective listing of catastrophic disaster events of the United
States in this case for the purpose of this slide defining the catastrophic event as one
in which 1,000 casualties were generated by a single event. And the point that I want
to bring to your attention is that from the mid-1800s through the early 1900s, there were
a number of events ñ either large-scale transportation accidents like the Mississippi River steamship
that went down or the General Slocum, which went down in the East River in New York City
ñ or Mother Nature like the forest fire in Peshtigo, Wisconsin, and the floods and hurricanes
that are listed, all of which generated large numbers of casualties.
And then mysteriously, luckily for the United States, between 1928 and 2001 ñ the attacks
in New York City and Washington ñ there were no events in the continental United States
in which there were large numbers of deaths and injuries. And soon after the New York
City and Washington, DC, attacks we had Hurricane Katrina, so we saw not just terrorism but
Mother Nature as a terrorist, if you will, wreaking havoc and causing large numbers of
death and injuries. And I think that this is an important context to put these remarks
into place because essentially weíve done a lot of work collectively all of us, you
and us, over the last decade focusing on a lot of important issues like surge capacity
and capability and public health preparedness planning and all of the things that weíve
been engaged in. But the fact is is that for generations we were lucky, and we didnít
have to contemplate these sorts of catastrophic events. And I think that it in part explains
why we had so much work to do in this short period of time in the past decade.
Now, thereís no question that Hurricane Katrina was really, I think, the galvanizing force
that really took our interest in looking at standards of care in disaster, really allowed
us to begin to move this conversation from the back hallways and the water cooler to
the back of the room when we used to present in the big conference rooms now to the fact
that weíre presenting this as a sanctioned event across the country talking about changes
of standards of care in disaster events.
And I think that within the Katrina event itself there were a number of things that
happened. First of all, the fact that some of our great healthcare institutions were
laid to waste as a result of the flood was really a remarkable and shocking outcome.
This is a picture of the Charity Hospital in New Orleans, the place of so many births
and deaths and lifecycle events for the citizens of New Orleans, forever behind a chain link
fence. And I havenít been down there recently, but I would guess that it is going to be dismantled
if it hasnít come down already.
And in addition to the fact that we lost infrastructure, we also really lost ñ we lost confidence
in the ability to deliver care and be certain as healthcare providers that we werenít going
to be second-guessed and, as we know in the case of Anna Powell and her colleagues at
the Memorial Hospital, be pulled up in front of a jury of peers, in her case being accused
of criminal intent with regards to decisions that were taken in the worst of worst case
scenarios. So I think Katrina really drove home the point that we have work to do around
assuring that these sorts of events donít happen to us again. I certainly donít want
to have it happen to me or my colleagues, and I think you would say the same.
So what has transpired? Well, going back to the 2007-2008 timeframe, the federal government,
the Department of Health and Human Services specifically, began to look at how we might
address this issue of standards of care and disaster. And on the left-hand side of the
screen a depiction of the AHRQ report on altered standards of care and, by the way, Iíll remind
you that weíve gone through quite a number of name changes over the past many years in
looking at this issue of standards of care. And I always thought that altered standards
of care was the way that care was delivered at Woodstock, but regardless, weíve gone
from altered standards of care now to what we call crisis standards of care. At the right-hand
side of the screen a June 2008 GAO report focusing on medical surge but recognizing
that allocation of scarce medical resources still requires attention.
So in the academic community and in the professional community there were other efforts that were
forthcoming. This, a series of papers that was sponsored by the American College of Chest
Physicians, and a number of us on this call were participant in putting these monographs
together. And so there really was the beginnings of a recognition that conditions would change
in catastrophic disaster and that the means by which care would be delivered would really
have to undergo some sort of shift. And so this was all well and good, and we were considering
all of this, a lot of it in the context of planning for H5N1 and the bird flu.
And then in the Spring of 2009 H1N1 happened, and this a shot from Mexico City with this
statue covered by ill-fitting masks. I would daresay those masks probably wouldnít provide
too much protection. And in fact the Institute of Medicine had been asked by the ASPR to
conduct a series of workshops around the country to begin to test the waters and see just what
sort of work was being done, if any, around crisis standards of care or the recognition
of standards of care in disaster situations. And we were actually in New York City at the
fourth of four regional meetings when H1N1 started.
And so soon thereafter, ASPR requested formally of the IOM to put a committee together, and
I was privileged to be asked to be the vice-chair and to work with an outstanding group of colleagues.
And in a very short period of time, in fact no more than about two and a half weeks, we
convened in Washington in the first week of September 2009, and by the 24th of September
we issued a 120-page letter report to Dr. Laurie. And it was focused on guidance for
establishing crisis standards of care for use in disaster situations. And in touching
on the salient features of the report start with the ethical foundation, which was really
focused on what we highlighted and emphasized as the duty to plan, the fact that as planners
itís really ultimately our responsibility to plan for these sorts of situations so that
ad hoc, post-hoc decisions like those that were taken by Dr. Powell and her colleagues
should never happen without some degree of forethought and foreplanning.
And what we did in the 2009 report was define crisis standards of care as a substantial
change in usual healthcare operations and the level of care that itís possible to deliver.
It is something that is formally declared by state government in recognition that the
crisis operation is going to be a sustained event. In other words, itís not just busy
Saturday night in the emergency department. Itís not just your colleague wants to go
get a cup of coffee and you feel overwhelmed with the patients youíre responsible for.
Itís really a pervasive change in the way that care is delivered.
And this formal declaration enabled specific legal and regulatory powers and protections
for healthcare providers and recognizes that they will be allocating and using scarce medical
resources and may even be delivering care in the out-of-hospital environment using such
facilities such as alternate care facilities and so on.
And so this is really the formal definition, if you will, of crisis standards of care.
And the point to emphasize is that as we looked at the issue of delivering care, we really
recognize that what weíre talking about is expanding the ability to deliver surge capacity
and the capability required therein. And so John Hecht, who is going to present to you
in just a moment, really helped to help us think through the framework for looking at
surge capacity and expanding the notion of surge capacity from just sort of an arbitrary
kind of one catch-all phrase of surge response to recognizing that surge capacity extends
over a continuum, and it ranges from conventional surge to contingency surge to crisis surge.
And we looked at that and came up with the concomitant recognition that really in a conventional
surge response youíre likely to be practicing under conventional standards of care. And
in a crisis surge response youíre likely to be responding under crisis standards of
care, and thatís really where the name came from and thatís how we settled upon that
notion.
But the important to emphasize on this slide is that as you shift from conventional to
contingency ultimately to crisis care, you are shifting from a patient focus to population
focus. And this point was really driven home in January of 2010 with the Port-au-Prince
earthquake, and thatís actually yours truly on the right-hand side of the screen tending
to one of four patients who we pulled out of a collapsed university in Port-au-Prince
in the immediate aftermath of the earthquake. And Iíll tell you, it was humbling as the
author of the report, as one of the co-editors of the report but also as a practitioner in
disaster situations in austere environments to recognize just how difficult it is to transition
from patient-based focus to population-based focus. It is not an easy issue.
But the point to make here is that on the tail end of the 2009 report, ASPR recognized
that there really needed to be further elucidation of some of the principles and points that
we highlighted in that report of September 2009. So the IOM was asked to bring the band
back together and to reconvene the committee to look at crisis standards of care from a
much more thorough perspective. And so we did and spent the better part of 2011 crafting
the report that was written and released in March of this year, March 2012. And let me
remind you that this is available to you for free download from the IOM website. You can
Google IOM crisis standards of care. Youíll have access to both reports. And it is really
intended to be user friendly as we will now demonstrate to you over the course of the
remaining part of this presentation.
So the report is divided into specific volumes. We have an introduction that crosscuts and
describes the overarching framework and legal issues. We address ethics and palliative care
and mental health issues. And then we have four discipline-specific volumes that focus
on the state and local government responsibilities, EMS, healthcare facilities and out-of-hospital
care. And I should mention Iím remiss in not mentioning to this point that Iíve mentioned
that ASPR convened ñ reconvened the committee. It was ASPR in conjunction with Department
of Transportation, NHTSA, National Highway Transportation Safety Administration and the
Veterans Health Administration. So it was actually all three who contributed to bringing
us together again to look at this work. And then finally thereís a section in the 2012
report that focuses on public engagement, including a public engagement toolkit.
Let me conclude my remarks by just highlighting for you the framework that we put together
and the focus that we really wanted to emphasize, which is that crisis standards of care really
occurs ñ has to be thought of as a systems framework and that weíre really talking about
a system for catastrophic disaster response. And so what you see before you on this slide
is ñ if it looks like the Lincoln Memorial, then youíd be mostly correct. It sort of
does look like the Lincoln Memorial. And what it is intended to demonstrate is a foundation
built upon ethical considerations and the legal authority environment in which these
decisions are taken that really are the foundational elements for development of crisis standards
of care.
And then in the middle of the diagram you see steps that take you towards execution
of those efforts. Provider engagement is critically important. All of you who are participating
with us on the call today, you need to understand and buy into this before we can effect this
in the community. Community engagement, we have to include the citizen who we serve as
willing and equal partners in discussions around these very, very vexing and difficult
decisions. We have indicators and triggers that are critically important and clinical
processes and operations. And I will highlight for you that all of this has to occur in the
context of education, which you see on the left-hand side of the diagram, and information
sharing, which really are a part of performance improvement.
And a case in point. You know, performance improvement really suggests that thereís
a research element and that weíre constantly trying to look at what weíre doing and improve
upon what weíre doing. And the case in point relating to that has to do with, for example,
all of the work that has gone into looking at ventilator triage and the work that a number
of us have participated in looking at, for example, the use of SOFA scoring, sequential
organ failure assessment scoring, which had it been applied strictly to patients who presented
with acute lung injury during H1N1 probably wouldíve killed more patients than we were
able to support. So performance improvement is critically important.
And then you see the columns that represent each of the emergency response disciplines.
Any one of these columns alone canít do this. It really is a collective effort of the hospitals,
public health, the out-of-hospital, private sector, EMS and emergency management and public
safety bounded all under the umbrella or roof of local and state government and ultimately
the federal government. So here in one slide really is our system framework, if you will.
And as I said, what we have recommended is really an integration and coordination across
all of the emergency response system, and so on this slide and the next slide, you see
the recommendation that we put in place within the report.
Let me conclude by highlighting for you the fact that these efforts really have found
their way into the grant guidance, into the grant language. And I think that much like
the way that surge capacity and capability planning has sort of framed a lot of the discussions
of the last ten years or so, my sense is that the expansion of surge capability and capacity
planning in the context of crisis standards of care may help to frame the next ten years.
And so here from the FEP capability released in 2011 the recognition that there really
need to be written plans that look at the coordination and transition of conventional,
contingency and crisis standards of care and how this will be done. And in the HPP guidance
released earlier this year very specific recommendations under the medical surge planning area focused
on guidance and indicators, legal protections, implementation and training around these issues.
So with that said, I know this represents a lot of work and a lot of attention in the
context of everything that weíre doing. I could leave you with an optimistic note that
hey, you know what? It may never happen and that would be great. I wish I could say that
were the case, but going back to that first slide that I showed you of catastrophic events
in the United States, the fact that weíve been as busy as we have been over the last
decade makes the fellow who wears this T-shirt probably a minority opinion, not likely to
be the fact.
So with that I will stop and turn it over to my colleague, Dr. Hecht.
Presenter: Thatís been Dan Hanfling coming to you live from the Pentagon Briefing Room,
actually coming to you live today from the Swine Barn at the Minnesota State Fair. So
what Iím gonna try to do is just in the next 15 minutes give you a quick 10,000-foot view
of some of the issues relating to health systems and crisis care in regards to public health.
I want to thank you all for taking some time on your Friday afternoon to be with us and
listen to this and have an interest in this issue. I know that we may be all that is standing
between you and Happy Hour right now, so weíll try to give you some valuable information
here.
When we talk about crisis standards of care, there is an issue between public health and
healthcare that public health really is a government function. There is a lot more accountability
there and, quite honestly, a lot more authority to act during health emergencies than hospitals
and healthcare have. There also are mass care responsibilities, which carry significant
implications for the provision of crisis care and crisis medical care. Hospitals are private.
Theyíre not directly accountable to government. Sometimes there isnít any responsibility
for them to act directly together during an incident, and so public health often is in
a role to play the convener in these situations and for these conversations.
Thereís a number of intersections we need to think about and, in particular, about public
health really stands at the center with the Emergency Operations Center and the other
information sources available to it as the definitive source of information for the public
as well as for healthcare facilities about the situation, the epidemiology of whatever
it is thatís going on, providing the risk communication and public information that
allows people to know when to seek care, where to seek care and, hopefully, provide some
balance so that hospitals and clinics are not overwhelmed with people that do not need
to be there. They also can provide a significant amount of leverage to help care systems coordinate
to be that focal point for emergency service function during a crisis.
And as far as provision of clinical care, even though this isnít a primary role of
public health, there is definitely a coordination function that public health can play between
assuring a degree of medical care from the level of shelters all the way up to the level
of ICU care and also coordinating and helping provide the population-based interventions
that may prevent people from becoming sick in the first place.
There may be a gatekeeper role as far as resource management and resource allocations, whether
thatís antivirals, N95 masks or other resources. And there may be a role for policy development
or regulatory authority or regulatory rollback for EMS, hospitals, clinics, telephone triage
and prescribing and other things that may need to come into play during one of these
crises. So we donít expect that everyoneís gonna sit down with the whole volume here
and read cover to cover, but we do think that by taking a look at the templates, which are
housed at the end of each section and do provide an overview for the functions that need to
occur within each area, this one being the hospitals alerting and notification first
page.
But if you run through these functions and youíre comfortable that that those are accounted
for within your community, then youíre well on your way to have completed some of the
planning that needs to be done to make this go easily when something like Hurricane Katrina
hits. And itís really that combination of volume and especially loss of healthcare workforce
and infrastructure that can combine to put us in a crisis situation.
As Dan mentioned, weíre operating all the time on that continuum of care that we may
be providing conventional care. Contingency care I just want to say I think importantly
is the provision of functionally equivalent care that we are maintaining the standards
of care. Weíre just doing it in a little bit different way. So the patients who normally
might be cared for in a hospital room might be cared for in a same-day surgery environment,
that sort of thing. But once we get to the crisis situation, weíre not able to provide
that functional equivalent care. We need to start shifting to population-based focus,
and we may have to make some pretty difficult decisions. Thatís where coordination with
other healthcare facilities really comes into play.
So as we move up and some of you are very familiar with these tiers of response, as
were originally expressed by Barbera and McIntyre, but healthcare facilities need to coordinate
with one another, whether thatís of their own doing or with public health leverage.
That integration then between the healthcare facilities and public health and other agencies
needs to occur at the jurisdictional level so that there is resource and patient balancing
across the system so that theyíre not sort of islands of overwhelmed hospitals or facilities
that are within the community where others have adequate resources.
And a lot of this comes down to what is accomplished in the incident management framework, and
having a good incident management framework and an understood mechanism for coordinating
these things at the facility level as well as the community level. Those of you who are
familiar with incident management may recognize a lot of similarities between this diagram
and the planning P, and thatís definitely intentional. We want to make sure that everyone
has thought through, whether itís an agency or an institution, how they will go through
this process and make the appropriate adaptations that they need to make for the situation because
if we donít, the default when we have care normally provided in home environments, in
clinics if those areas of patient care are not coordinated and/or we donít do a good
job with population-based interventions, the pressure always falls back on the hospitals,
and that wonít work during a major incident in a crisis situation. We then just wind up
further degrading their opportunity to provide appropriate care for those that they have
the resources to so making sure we have release valves for that. Weíre doing a good job with
risk communication.
We have the potential to set up alternate care sites, flu centers, other means to decompress
the hospitals, thatís very important. And coordinating that really revolves around the
mechanisms that public health must be involved with on the jurisdictional level to figure
out what the interface is in your community between the hospitals and the clinic systems,
emergency management, emergency medical services, and a lot of times thatís a specific multiagency
coordination function, a regional coordination center function. This is how it happens to
be set up in our region, but thereís a number of different models that work. Itís just
a matter of understanding them and practicing them before an event happens.
Within that construct, really the goals are to increase system capacity whether thatís
hospital outpatient to reduce non-emergent care, keep the patients that donít need to
be in a hospital environment away from the hospital and provide screening, interventions
and early treatment at centers before patients get sick. So really that multiagency coordination
is just about getting patients to the right place at the right time, and by doing that
youíre managing and balancing resources to assure as consistent regional care as you
can.
And the foundations of that really come back to understanding common ethical frameworks,
understanding the legal and liability protections for providers that are out there that James
will speak to, understanding and defining state roles and the mechanism for regional
coordination, the hospital role within that framework. And whatever your mechanisms are
for planning, make sure the operational framework is defined so that when something happens
at 2:00 in the morning ñ youíre short a ventilator, thereís a decision about triaging
several patients who are candidates for ECMO ñ how will those decisions get made, by what
process. Who do the notifications go out to and then what are the support tools, the decision
tools that can be used in those situations?
At the hospital level, thereís a number of challenges, so integrating the crisis standards
of care into incident management and how that fits within usual the HCS system, recognizing
a resource shortfall, what actions get taken, knowing your subject matter experts at the
facility and the community that can be brought into advise, understanding how a triage team
would work whether thatís at the facility level or the regional level and what tools
they might use and how those tools are modified to fit the incident and thatís critical.
As Dan mentioned, a simple SOFA score would not have been an appropriate tool to use for
those suffering from isolated respiratory failure from H1N1. Thereís a lot of other
considerations from security to behavioral health that go into this and need to be addressed
within the institution and then making sure that there is that process improvement, that
evaluation of decisions, evaluation of the situation and then coordination with the outside
agency such as public health. Thatís all just part of that planning P process and making
sure that youíre in a rhythm of reassessing and acting and trying to do the best you can
based on what happens to be the challenge that day.
Thereís a number of strategies out there. The chest articles that Dan had mentioned
in one of his slides are certainly a nice resource. Thereís another one that Minnesota
Department of Health has worked hard to put together. If you Google MDH scarce resource,
youíll be guided to that card set that provides some overall guidance as well as some specific
guidance for ventilator triage, for adapting to shortages of oxygen, medications, intravenous
fluids and other things. So you may find that as well as others to be a helpful resource
as far as extending the resources that you have as well as making decisions about resources
that are in shortage.
On the EMS level, again, EMS is provided differently in many different jurisdictions. Sometimes
itís a private system. Sometimes itís a public system, and thereís implications for
public health for both. But there are a number of things that need to be done on an EMS agency
level to plan for mass casualty situations and particularly what happens in crisis situations.
So in a conventional disaster there may be a need to, say, auto answer dispatch calls,
auto answer 911 calls that are coming in. By the time you get to crisis, you may be
actually declining to send ambulances to certain calls and the same thing for response and
assessment. Instead of shifting in a conventional framework who you ask to respond, for instance
in a car accident maybe the default is to just send fire until injuries are confirmed.
And once you get over to crisis, youíre dealing with non-ambulance responses and even once
you get there deciding that the patient does not need transport to a medical facility,
declining to transport. That obviously brings up a lot of liability and other issues that
need to be addressed before an event like this occurs. So planning with EMS is very,
very important both from the private as well as the public sector.
And Iíll just mention quickly the issue of alternate care sites. Alternate care systems
may play a very broad range in helping meet the needs of a catastrophic incident, whether
that is medical care thatís provided in shelter environments, whether that is flu centers
for early treatment, whether that is hospital overflow. All of those things have a little
bit different requirements as far as staffing and configuration and equipment. This is a
picture of a federal medical station, which are prepackaged essentially hospital overflow
or sort of higher intensity outpatient medical treatment. This are predeployed into shelters
of opportunity, and the ability to integrate assets such as these into your community response
is very important.
Alternate care really occurs across a spectrum, and on the left side many, many patients benefit
from very small interventions such as web-based or telephone triage care all the way over
to the right side where if youíre missing very specific surgical or intensive care resources,
you can bring those in in portable or other fashions to benefit a very small number of
patients. And in the middle we have more the federal medical stations and shelter medical
care and, again, each one of these requires a little bit different approach to planning,
which is why this can be very, very challenging for public health and healthcare. There is
issues authority. Who has the authority to establish these? What are the likely sites?
How is transportation accomplished? Are there liability issues? Who provides the supplies
and the staffing? And are there reimbursement guidelines for these? Is it going to be funded
strictly by time and materials through emergency management or will the third party payers
agree to pay in these situations?
And so mapping out sometimes the roles and responsibilities for these sites can be very,
very helpful in determining who will do what because there is certainly not any one right
answer as far as what agency or entity should take the lead, and some of this is dependent
on the mission as well. So you see here a framework that could be of use, and defining
the functions first of an alternate care site and then defining primary and secondary agency
responsibilities that then can lead to a little bit more effective planning.
So weíve just scratched the surface from hospital to EMS to alternate care or outpatient
care sites. I hope youíll take time to take a look through the functions and read the
areas of the report that you feel that there are deficiencies. I hope we provided some
good guidance, and weíd be happy to continue to provide more detailed support or detailed
treatment of some of these areas as desired. And with that, Iíd like to turn it over to
Omair Shah from Harris County, who I understand has left Texas for Switzerland and is hiding
out from West Nile virus, so weíre gonna turn it over to Omair in Switzerland and thanks
again, everyone, for your time.
Presenter: Dr. Shah, are you with us?
Presenter: Hello. This is Bruce Altovote from IOM. Let me at least start the presentation
while we try to reconnect with Dr. Shah, and hopefully we can get that connection up and
running quickly.
As Dr. Hecht suggested or introduced him, Dr. Shah is the Deputy Director from Harris
County Public Health and was a member on both the committees. He Ö weíll go to the next
slide if I can and actually the third most ñ heís from Harris County, Texas, which
is the third most populous county in the nation with over 4.1 million individuals. The main
part of his presentation was gonna be looking at the role of government in crisis standards
of care planning, and we wanted to focus in on the fact that governments at all levels
play a crucial role in leading and planning ñ in CSC planning and implementation. Itís
not a state function. Itís not only a local function, but indeed, all have a role in this.
Dr. Shah, are you back on? Let me keep going. Sorry, everybody.
If we go to the next slide, we see that the state government as defined in the 2009 report
has ultimate accountability in crisis standards of care planning. They have the political
and constitutional mandate to be prepared. However, local government is also uniquely
positioned for the organizational structure, and in some cases it is important that the
state ñ that the locals take over and help in the planning efforts as we move forward.
And in the next slide, we see that ñ sorry, if we can go back one slide, we see that state
and local planning for crisis standards of care that the emergencies are unexpected,
theyíre multijurisdictional, and this is a key component of the report and one of the
main messages of the report is the multijurisdictional nature of these disasters that weíre planning
for. Therefore, coordination at the state level is critical in moving forward, both
at the intrastate and at the interstate level. It requires comprehensive planning, comprehensive
coordination at all levels: local, regional, state and federal.
And another component that was highlighted in the report is that the states also have
varied organizational structures, and the relationships with local governments also
vary.
Presenter: Hello?
Presenter: And because of this, we have to plan accordingly. Is that you, Dr. Shah?
Presenter: Yeah, thatís me.
Presenter: Great, why donít ñ you want to take over?
Presenter: Sure, where are you? Sorry, Bruce.
Presenter: Weíre at the slide with the pie chart showing the variations in state and
local ñ
Presenter: Perfect.
Presenter: Slide No. 6.
Presenter: I apologize. Yeah, thank you. Apologize, folks. As I guess Bruce mentioned, Iím dialing
in from Geneva here and had some problems with my line but thank you. Thanks, Bruce,
for tag teaming there and welcome to everybody and I apologize for having some troubles from
overseas. And the other complicating thing is that Iím having trouble with Internet
access. I actually cannot see what Iím about to talk about, but I will do my best to continue
to be mindful of moving slides forward or having the slides moved forward.
So Slide 6 really just describes what Bruce had just talked about: variations in state
and local health department relationships. And certainly there are variations that weíre
cognizant of and the colleagues that put together the IOM report for crisis standards of care.
Really, we took some additional care in really thinking about centralized structures and
decentralized structures. As many folks on the call are aware, that both in states across
the country there are variations that certainly make it quite challenging at times to actually
have a report thatís a one size fits all. Next slide.
So the role of state governments is really a critical one in that decision-making as
primarily at the state government level, and James is gonna be talking about this right
after me, but there are certainly authorities that are at the state level that are very
critical. And certainly the state plays an integral role in making sure that crisis standards
of care are both planned for accordingly but also implemented in a very consistent manner.
And so we do believe that state health departments, though, are best suited at the state level
to lead CSC planning and response efforts for a variety of reasons, which we certainly
go into in our report. States as well have a very critical role in interplay with the
federal government in both resource support, clinical care guidance, et cetera. And then
the regional coordination that I know John referred to in terms of ARM CCs, RD Max and
other hospital coalitions. Next slide.
So the role of state government, while also critical, itís also critical that the state
really works very closely with local governments, and I think all the folks on this call with
ASTHO are very aware that state and local governments work very closely together regardless
of what kind of structure. Whether centralized or decentralized, the structure is within
any individual state. The role of local government, thus, is to really be an interplay between
whatís happening at the state level in terms of planning and response but also whatís
happening within the community itself. And so local health departments are the front
line of public health agencies and the fulcrum of local CSC response. And so we really at
the state level we saw the state health department as being critical. We saw the local health
department very much integral as well. And certainly the additional interplay is really
looking at coordination and collaboration, both in the local and state juxtaposition.
So states ñ next slide ñ states are obviously at various stages in CSC planning. Some states
are more actively engaged and other states have not made as much progress, and that was
really what the 2009 report to the 2012 report some of the chronology of our review of where
states were really was an important piece to say that states that are more actively
engaged, we want to say kudos. Continue the work thatís happening at the planning stage,
which is now. And the fact is ñ and I think this is also integral in all of our presentations
is that thereís really a duty to plan. And so that duty to plan is really inherent now
in continuing the CSC work thatís already happening in a more engaged state and also
that the local role is very active in that response. And so with the local role being
active, we want to make sure that the states and locals are working very closely together.
When you move to the implementation stage, the state role is very important in ensuring
jurisdictional consistency, which Iíll mentioned in just a couple of slides. It also provides
two-way communication, situational awareness between state efforts and whatís happening
on the ground. Next slide.
However, we also know that there are states that are less actively engaged thus far in
CSC planning, and this can also be considered when you have local health departments that
are already further along the CSC spectrum into planning work. So in this case states
really need to begin CSC work now. This is not too hard to do, as one of my colleagues
has said. This is really one of those things that has to be part of planning efforts even
now. And so really itís important for states to move the process forward, but if there
is really work thatís already happening at a local or regional level, we really feel
strongly that states should augment and leverage work already started and add to whatís already
occurring. Certainly in the implementation stage, it is equally important for consistent
and coordinated response for states and locals to work closely together. Next slide.
So jurisdictional consistency in CSC planning and implementation is very important, and
as you can see in this diagram, what we really want to say is that as resources become decreased
in a crisis response as you walk yourself to the right of the diagram from conventional
to contingency to crisis care, what we really see is that thereís going to be some change
in care. And what we are also looking for is to make sure that care is as consistent
as possible across jurisdictions and hence the role of the state in being involved in
this so that you donít have form shopping thatís occurring between one jurisdiction
having one level or one type of care whereas another jurisdiction very close by is having
a very dissimilar level of care thatís being provided. Next slide.
But it can get complicated. As you can see from conventional and contingency into crisis,
it blows up very quickly with the number of agencies that come together very rapidly.
And so ñ next slide ñ walking through it can get quite complicated, and Iím not putting
a plug in for any private sector product here. But I guess fortunately thereís an app ñ
I mean, a template for that. Thatís supposed to be a joke. Thereís a template for that.
Next slide. And so we have a number of templates as already been described by Dan and John
in all the sections but definitely in the module for state and local government, for
planned development as you can see in template here 5.1 ñ next slide ñ as well as template
5.2 with plan implementation. Next slide. And as you can see back a little bit closer
with the round circle here that Tasks 1 and 2 in really the planning stage are really
critical, and itís very important that folks on this call really take a good look at not
just the theory of crisis standards of care but actually the practice of them, the pragmatic
approaches that you can take to really move CSC planning forward.
So Iím gonna now segue into public engagement in crisis standards of care, and really this
is a very critical piece that IOM recognizes. Dan had mentioned at the beginning of this
talk is that really itís important for us not just to be thinking about ways that we
talk to ourselves but also how do we engage both the public as well as providers. And
so in this first slide here it says from our 2009 report that we ensure strong public engagement
and community and provider stakeholders, especially looking at those that are oftentimes left
out of the planning process. Next slide.
So public engagement goes from theory to practice, and so our 2012 report for March says that
really thereís a case for public engagement on crisis standards of care and it provides
a framework defining the essential principles. And then we put together a user-friendly toolkit
that we think is really helpful for conducting public engagement activities at the state
and local level. Next slide.
Public engagement so the goals ñ what are the goals? Well, the goals are informing community
members about potential need for crisis standards of care but also for community members to
really receive information on how scarce medical resources should be allocated in CSC type
scenario. So itís really a two-way process of understanding both for the community and
the folks that are involved as participants but also for the planners to really get the
viewpoint so that ultimately it ensures CSC guidelines reflect the communityís values
and priorities. Next slide.
So public engagement really the essential principles are that policymakers seek public
input for a variety of reasons: that you want to make sure that thereís resources adequately
and theyíre available to make sure thereís the quality process; that participants represent
the diversity of the community. And this oftentimes means that stipends may need to be used in
reading underrepresented populations, et cetera. Process should also offer participants meaningful
opportunity for deliberation. In other words, this isnít really trying to achieve consensus.
This isnít also trying to rubberstamp things. This is really, really trying to get to what
are those values that are coming from the community and certainly that policymakers
are committed to considering those outputs and really can give participants response
back that how those values, those outputs that came from the public engagement side,
how they can actually be used in final policy decisions and if theyíre not gonna be used,
why theyíre not gonna be used and/or why they were not used. Next slide.
So the benefits are obviously short term and long term. In the short term thereís increase
visibility and awareness about the need for CSC guidelines and thereís also really information
thatís being shared with participants about what state and local governments may be doing
already in the area of disaster response. But in the long term itís what Iíve already
said. Itís really making sure that the community values are incorporated into the priorities
that the policymakers put forward with CSC planning and response activities.
The challenges are to ensure credibility of process. This is the next slide. Really to
ensure that thereís meaningful conversation about a difficult topic, that you really are
bringing people that reflect the diversity of the community but really that theyíre
having meaningful conversations and are not just being brought together for the purpose
of hey, well, letís bring them all in one room but really to have meaningful conversations
about difficult, challenging topics. And also, as Iíve mentioned, allowing the outputs to
be part of the policymaking but also to manage expectations around how the input will be
used, as Iíve mentioned. And then finally that there are enough resources to initiate
and sustain the process and this is done, especially as many in our state and local
governments are dealing with public health priorities in increasingly budget-constrained
environments. So itís very important that we also make sure that the resources are there.
So the toolkit ñ next slide ñ really weíve put forward a model process and a set of tools
for community conversations that are based on experiences of various jurisdictions, including
Seattle Kin County, Washington and Harris County, my health department in Texas and
Minnesota, our colleagues in Minnesota. And some of these pictures that you see here are
actually some of the public engagement processes that were used in Harris County. And so really
our public engagement toolkit really built upon some of the activities that were happening
in the various jurisdictions around the country so weíre not starting anew. But at the same
time, we also put two pilot engagement conversations in Massachusetts. And I had the privilege
to lead as the facilitator for these two and I have to be honest. These really brought
together a lot of very common themes that came through many of the different jurisdictional
activities that were happening, conversations that were happening at Seattle, Harris County
and in the state of Minnesota. So really what we think the toolkit has done is that weíve
developed it so that state and local jurisdictions then can tailor and adapt the toolkit to their
needs. Next slide.
So the toolkit ñ sorry about the busy slide here and Iím almost done ñ it includes tools
for engaging the lay public in discussions about what values should underlie the allocation
of scarce medical resources in disasters. So we have a sample agenda, content slides,
facilitator scripts and strategies, survey scenarios, data collection templates, survey
questions. And I donít want to sound like a used car salesman but ñ and much, much,
much more. So I really recommend everybody looks at the toolkit.
And the toolkit also addresses a number of important questions, which really Iím not
gonna go through these in any great detail but just to say when should we do this? How
do we engage community partners? How long should this be? How do we make the materials
helpful to participants and who should be the facilitators? What data collection mechanisms
should be used, and is this really research delivered democracy? Next slide.
And so thereís a sample scenario so here listed is our major earthquake. Thereís also
a deadly virus scenario and we have a couple of agendas, one thatís a three- to four-hour
agenda, another thatís a six- to eight-hour agenda depending on how much time a local
or state jurisdiction may have in terms of really figuring out when ñ how much time
they have to bring participants together. Next slide.
We also have sample scenario deliberations. Hereís an example of really asking some of
participants well, how do you make decisions when you actually have maybe only age as your
criteria and you also have really some very important considerations in deciding where
scarce allocation of resources, how are they gonna be approached in a crisis scenario?
Next slide.
The toolkit then has sample survey questions, as you can see here, and I think itís critical
that we actually use the audience response system, some of those clickers that youíve
seen, but there are a number of different modalities that have been used lately in other
forums, such as text messaging and also just not having any technology but just having
people raise their hands or do other things. So we recognize that there are a number of
different ways you can do this, but we do think that there are some opportunities of
really learning from what others have done. So next slide.
So the take-home message ñ and this is really not just from our Institute of Medicine but
really just the summation of what we were able to review that was out there in terms
of what jurisdictions were doing is that public engagement should be embraced and should not
be feared. I think thatís the most important thing, that the public ñ when done well,
the public is able to understand challenging concepts and is thoughtful in deliberating
despite the complexities. And public engagement can really yield some very important, very
tremendously rich and useful information.
Participants appreciate the opportunity here as well as and equally important to be heard
so to hear and be heard is very critical. And certainly we think and we believe and
we recommend that the CSC toolkit is really a reference guide that provides materials
to help facilitate successful public engagement sessions. Next slide.
This is contact information for me and certainly if I can answer any other questions about
state and local government and/or public engagement, I will. Hopefully, my line doesnít get disconnected
from Geneva. Thank you.
Presenter: Dr. Shah, thank you very much. And we will now hear from James Hodge.
Presenter: Well, thank you so much, Omair. First of all, itís great to hear your voice
from Geneva and glad to have you on board in the end. So listen, Iím at the point where
Iím gonna take a very brief opportunity for everybody on the call to try to _________
just a little bit of perspective about what the committee as we were developing this report
really found profound, which is the legal issues underlying implementation of a crisis
standard of care.
Now I know you all have questions in relation to what youíve heard so far. You may have
a few in relation to this topic, so Iím gonna be very brief. The slides that youíll see
here momentarily will all be made available to you and, to be sure, youíll have lots
of opportunity for questions, hopefully on this call as well and in addition outside
of it. So let me just sort of touch base on what I want to try to communicate ever so
briefly in the time that weíll take here just for a few more moments.
First of all, when you look at the crisis standard of care report, thereís a section
on the legal implications. It is, I think, quite illustrative. Itís written for the
layperson. You donít need your legal attorney to read it with you to get what weíre talking
about, and youíll see it goes into a lot of detail on some very specific issues, including
a very helpful table. I just want to drill down on three, so today letís just talk about
three critical things youíre probably already thinking about implementation issues underlying
any crisis standard of care.
Whatís this actual legal environment during emergencies? How do we kind of think this
through? What about and how do we regulate health professionals? What are the issues
related to licensure and scope of practice concerns? Then the big one, the one we heard
a lot about in relation to developing the standard: What about liability issues?
So to that front letís continue on and see just how we can break through and kind of
think about these issues from a legal perspective. One thing thatís absolutely true is how pervasive
law is in emergency responses. Laws pervade every level of government in regards to their
emergency preparedness and response efforts. They determine what constitutes a public health
or other emergency. Itís law that creates the infrastructure through which emergencies
are detected through which we can prevent them and address them. Laws authorize you
and others to do certain things or to not do certain things during emergency responses.
And they determine the extent of responsibility or liability for actual or potential harms
that arise during emergencies.
Itís this concept of law coupled with the various levels of government that come together,
especially in major catastrophes, working through a whole host of partners and a whole
bunch of different actors from public health to private healthcare workers and such that
creates this environment or this status that I like to call ìlegal triage.î Weíve been
referring to what and how we might provide medical triage in a lot of settings. Lawyers
and policymakers are working behind the scenes as well to address a whole host of legal issues.
I like to define this term legal triage in a way that gives us a little something to
grab onto and understand whatís going on behind the scenes. Itís when you have the
efforts of legal actors and others to sort of construct a favorable legal environment.
Itís critical that we can do this during emergencies. And the way we do it is weíre
prioritizing critical issues. Weíre developing solutions, and weíre trying to do the very
best we can to do like Dan Hanfling was talking about: facilitating public health responses
to a major crisis, not just looking at it from an individualized healthcare perspective.
Now towards this end, how do we do this? Well, legal actors and others ñ this is not just
the role of attorneys but others ñ weíre all working in real time during these events
to assess and monitor change in legal norms, particularly related to declared emergencies,
to identify those sort of legal issues that are facilitating or impeding public health
responses, to develop innovative and hopefully responsive legal solutions, things that work
to facilitate the response efforts. Weíve got to explain those conclusions in very simplistic
language so that people can use them and work with them. And then you do that once, itís
fine. Do it again the next day and the next day. Youíve got to consistently revisit the
utility, the efficacy and the ethicality of that type of legal guidance. Why is this so
essential? What are we doing in building this legal environment? Itís essential that we
do this through legal triage because once an emergencyís declared, the legal landscape
as we know it, it changes and it can change drastically. But that depends in part on the
type of the emergency thatís been declared, whether itís a Hurricane Katrina-like event,
the California wildfires or particularly a pandemic-like event.
As you see in this specific slide and illustration, as you probably know, every level of government
from international to federal to state to local has some capacity in many jurisdictions
to declare some type of emergency or public health emergency or disaster response. Itís
particularly at the state level that we tie the crisis standard of care, right, because
statewide control of licensure. It might be control of liability determinations. So when
the state declares that emergency as did Louisiana in response to Hurricane Isaac and also declaring
a public health emergency in response to the same event, thatís what triggers some of
what weíre talking about. But all these other emergency declarations, theyíre all working
to change how we respond in real time.
This slide gives you a little illustration of that. Depending on the type of emergency
that youíre responding to ñ be it local, state, federal or some sort of international
protocol, the public health and healthcare authorities, the powers, the liabilities you
may be subject to, your immunities to those, other critical legal issues ñ they depend
on that emergency declaration and they will vary based on that. So just one example of
this among many different types of approaches is kind of how we laid out some of these key
powers in the Emergency Health Powers Act, an act that youíll see in a moment has proliferated
across the country.
When you declare a public health emergency under this model act that was drafted and
developed in 2001 following 9/11, you really are doing some different things. Youíre bestowing
individuals with special entitlements and special protections. Youíre changing the
licensing and credentialing requirements. You can effectively waive them pursuant to
that type of declaration. Volunteers and other may be protected from civil liability. They
would not be in a non-emergency event but they would in this. Governmentís vested with
very specific expedited powers to respond. These are effective techniques all designed
to change the legal landscape so that we can effectuate crisis standard of care more bene
ñ here are just those jurisdictions, for example, the 26 that actually formally allow
for via statute declarations of public health emergency and, like I say, it was used in
Louisiana just recently this past week.
So letís just talk for a second about the critical issue of health professionals. For
example, when weíre talking about providing crisis standard of care, you will be working
with a lot of different health professionals, some of which will need to come from outside
that jurisdiction, that influx and flow of volunteer health professionals into a specific
event setting is critical if weíre going to be able to respond in real time. But you
canít pull that off legally unless you have emergency declarations doing like I say: waiving
the licensure requirements for out-of-state personnel to be able to step in and provide
care immediately. The effect of these emergency laws is to say, ìWe view your good-standing
out-of-state license as if it was issued in state for the duration of the emergency declaration.î
Thatís exactly what Louisiana did.
And then, of course, compacts like Emergency Management Systems compact _________ agreements
like the nurse licensure compact can accomplish these very same things. Just because youíve
waived licensure doesnít mean that youíve set the scope of practice, and this is quite
critical as well legally. Could you, for example, allow a nurse to perhaps exceed her scope
of practice, things that she or he may not be necessarily authorized to do in a non-emergency?
Can you change that? In a non-emergency, as you know, no itís not easy. Itís gonna be
potentially a licensure and sanction to do that. During an implementation of a crisis
standard of care in a formally declared emergency, thereís every opportunity to do that to some
degree, especially with certain volunteers. We can work with changing the scope of practice
at the state level and just so long as they provide the care consistent with how the stateís
changed that scope, itís legit. Itís legally sound.
What about liability? This is the critical one that we hear so much about. Weíre referring
here to potential responsibility that a person or an entity or an institution like a hospital
may owe for their actions or their failures to act, for that matter, that result in injury
or losses to others. Who can be liable? Anybody can be liable in an emergency response effort:
your healthcare workers, your volunteers? Sure. Healthcare entities, hospitals, clinics,
employers? Yeah, go for it. Persons or entities responsible for emergency responses, governmental
entities and such. Yeah, can they be liable? Thereís a way to find that. How do we work
that through in real-time events to mitigate some of that potential liability?
Well, the first technique is we switch to a crisis standard because for all intents
and purposes, that means that we can legally switch to a sort of different standard that
allows us to recognize these practitioners and others are not operating under standard
protocol. Theyíve switched to crisis, and thatís exactly what weíre expecting happens.
But as this slide illustrates here, weíre trying to show thereís a couple paths to
accomplishing some sort of mitigation of liability concerns because this is a major concern among
virtually every healthcare practitioner as well as volunteers especially.
Path 1 says well, letís just follow what youíve heard already. Weíll assess liability
based on whether weíre in conventional care, contingency care or whether weíve issued
an emergency declaration and thus have a crisis standard. Thatís good but it doesnít keep
you out of court. It can get you hauled in just like Dr. Anna Powell.
So the next path might be to say hey, even as liabilities risks are increasing, the use
of volunteers is increasing, the patient numbers are increasing, and weíre having decreases
in resources and employed personnel that are available as well as potential malpractice
liability coverage. Path 2 says letís do something about that statutorily. Letís create
enhanced liability protections that apply right here. Thatís exactly what youíre seeing
across the United States: federal, state, local governments providing literally an umbrella
of liability coverage meant only for the emergency, meant to apply to protect those healthcare
workers that are doing things within the scope of what theyíre there to do, certainly not
acting in a criminal way or an unlawful sort of manner. But these various protections include
strong governmental sovereign immunity that can be applied even to private healthcare
workers at times. Good Samaritan acts have limited application but in some ways, too.
Volunteer protection acts are in place at the federal and state level. The Prep Act
will come into play here at the federal level and can provide extensive liability protection
and even entity liability protections for hospitals and others involved. These are all
possible. Theyíre only possible because of the declared emergency in most cases, and
they apply to specific actors differently. But to be sure, this is the liability environment
that weíve chosen from a statutory and policy perspective in the United States. We will
protect workers and hospitals and others engaged in crisis standards of care when possible.
You may have other questions. I hope you do. Youíd let us know about those on the legal
front. We can handle these through our network for public health law. Contact us in the Western
Region office. Contact me directly. Special thanks to my colleagues, and I think Iíll
turn it back over now to our moderator for additional questions and thoughts. Thank you.
Presenter: Great. James, again, thank you and to Dan, John, James, Omair and Bruce,
thank you for such an outstanding informative presentation. Before we open it up for conversations
in looking at some of the notes that came in, I do want to mention to everybody that
the audio of this webinar as well as the 105-part slide deck will be made available to all participants.
It will be put up on the ASTHO website, and I also understand that it will be available
through the Institute of Medicineís website as well. So both the slide deck of the presentations
and the audio and the speakersí bios will be made available as soon as possible.
So with that, Cerci, could I ask you to open up the line for audience participation who
wants to make statements, questions and begin a conversation?
Operator: Certainly, thank you. Ladies and gentlemen, if youíd like to register for
a question, please press the 1 followed by the 4 on your telephone. You will hear a three-tone
prompt to acknowledge your request. If your question has been answered and youíd like
to withdraw your registration, please press the 1 followed by the 3. Again, to register
for a question, please press 1-4. One moment please for the first question. And there are
no questions from the phone lines at this time.
Presenter: Well, while theyíre thinking of questions, let me present one to James. In
your presentation, clearly the evolving ñ the evolution on the continuum to a crisis
seems to be sort of the dominant theme or focus point. But there is a question in my
mind and possibly others about the legal frameworks and the liability protections when youíre
in a contingency phase of the continuum. When youíre sort of transitioning from conventional
to crisis, youíre sort of in that gray zone in between when youíre not declaring a declaration
of emergency but, yet, sort of conventional standard practices are being modified out
of necessity. How does the framework and how does that fit into your presentation as far
as what legal concerns or liability protections need to be considered?
Presenter: Itís a great point, Jim, because one of the critical things you have to understand
and think through as you see back on the slide here is that our focus for the purposes of
the legal environment here is on when we actually do have a crisis standard, and thus, the emergency
declaration triggers the sorts of protections and environment that Iím discussing here.
Whatís so great to note is this contingency care as John and Dan have mentioned, you know,
things are changing already based on sort of the contingency care, the sort of lead-up
care you may have to do or the sort of things that you know youíre gonna have to anticipate.
The best thing I can say in regards to this from a legal perspective is that what youíll
see in many jurisdictions like you saw in Louisiana this past week is they will sort
of early declare a public health emergency before all of the specific critical powers
may be needed or, even if theyíre not needed, theyíll declare it in advance to kind of
prepare for that exact issue. So as a result, what you may see on this continuum is while
the emergency declaration will always kind of follow some of the initial efforts for
contingency care, it may come earlier than you think so that we can trigger all of the
typical liability protections and other things that come into play, including the licensure
reciprocity provisions. To be sure, though, you identified it as a gray zone. Itís a
very accurate response because thatís exactly what it can be for a short period while we
anticipate literally government acting to declare the emergency.
Presenter: Thank you very much. Cerci?
Operator: Thank you very much. Our first question comes from the line of Beth McKinney. Please
proceed with your question.
Audience: Hi, this is Suzette McKinney from Chicago. Hi, Jim.
Presenter: Hey, how are you?
Audience: My question is for Mr. Hodge with regards to the umbrella of protection that
you talked about, the liability protection and specifically ñ yes, this slide ñ specifically
what your thoughts are about governmental regulatory approaches to providing this coverage.
I mean, is this something ñ obviously, this is something we want to see happen nationwide,
but the planning is really going to start at the local level moving up to the state
level. So where do you see ñ which level of government I should say do you see this
liability coverage starting? I canít see it as being something that the federal government
passes that will help all of us. I see it more as a local regulation perhaps, then moving
towards state regulations. But Iím interested to hear your thoughts on that.
Presenter: Okay so thatís a great series of observations and I can assure you in some
jurisdictions with considerable home rule at the local level ñ and home rule, as you
all may know from a legal perspective, just means local governmentís got the authority
to actually enter into and to create specific provisions. In larger cities, Chicago size
and other places, you see the sort of attempt to create some sort of liability protection
within those limited circumstances. But to be perfectly honest, this is a state policy
initiative, and in most jurisdictions, thatís where youíll see almost all the work be done
is at the state level. Now the feds have done some very significant work like, for example,
in the declaration of the federal ñ or the creation of the Federal Prep Act, thatís
really good liability protection when youíre implementing countermeasures in the pandemic
response type of effort. And thereís, of course, the Federal Volunteer Protection Act.
Itís a little bit of a patchwork, Beth, but what I do want to assure you is that when
you systematically look at the liability protections for emergency responders in the healthcare
arena across this country, youíre hard pressed to not find some avenue for protecting these
persons because it has become a predominant policy approach to actually provide some type
of liability protections for these healthcare workers and hospitals and others that are
literally being scripted into an emergency response effort implementing crisis standard,
for example. So itís become a predominant policy approach. You can find it in a lot
of states. The feds have not done a systematic across-the-board liability protection act.
Youíre probably not gonna see that. Weíve seen lots of attempts. Theyíve all failed.
Thereís reasons for that. But what you do see is a very substantial patchwork that I
think constitutes a pretty strong umbrella of liability coverage.
Presenter: Suzette, thank you for that question. Next?
Presenter: Just wanted to ñ this is John Hecht. I just wanted to chime in on the tail
end of that and just mention that a lot of the decisions and a lot of the planning that
we do ahead of the necessity for these legal interventions or these legal decisions is
really what the report is all about. Itís about staying out of crisis situation. Itís
about trying to anticipate and make the decisions and manage the incidents that we donít get
to that point. And thereís no question that in, especially that reactive phase, the triage
decisions that crisis care is going to get provided before there are formal legal or
other declarations in place. Thatís just the reality of whatís gonna happen on the
ground. But itís in our best interest to make sure that there is support from governmental
standpoint ñ regulatory legal and otherwise ñ for those efforts going on in the facilities
and in the other places where care is being provided.
Presenter: Excellent point. Thank you, John. Other questions?
Operator: Okay, our next question comes from the line of Jane Cooley. Please proceed with
your question.
Audience: Hi, itís Jane Cooley from Buffalo, New York. I was wondering ñ I think you addressed
this a little bit earlier about printing the slides, but is there a website that you go
to do that or is there a cost for it or how does that work?
Presenter: Sure, the website ñ the PowerPoint presentation will be made available free of
charge, and it can be found on both the IOM and the ASTHO websites. So for ASTHO itís
www.astho.org, and, Bruce, if youíre on the line if you can share with the audience where
they can find it on the IOM website?
Presenter: Yes, itís as simple as yours. Itís www.iom.edu. The easiest would be actually
just doing a Google search for IOM and crisis standards of care, and that will get you to
the appropriate page within the IOM. We should hopefully have the slides up by Monday or
Tuesday, and certainly Iím sure Iím speaking for Jim also. Thereís no cost associated
on the IOM page. You can download the complete report, individual volumes of the report as
well as the public engagement templates and other associated materials and thatís all
free of charge.
Presenter: Thank you.
Audience: Can I ask another question about that? The toolkit? Is that a separate thing
or is that in the report because it seemed like a prudent thing to have along with the
slides.
Presenter: Yeah, this is Omair Shah.
[Crosstalk]
Presenter: The toolkits are the toolkits that Dr. Shah mentioned in his presentation and
are meant to help facilitate the public engagement process. And then all of those templates that
have been mentioned in the presentations today to help in the planning and implementation
part of this activity are also available for individual download through the IOM project
site.
Presenter: Thanks, Bruce. This is Omair Shah. I don't know if you can hear me. Can you hear
me?
Audience: Yes, Mr. Shah.
Presenter: Okay, great. I just wanted to real quick just say that with respect to the toolkit
definitely one of the questions that weíve gotten a lot is about the agenda and including
some of the content slides so that is, as Bruce has mentioned, is part of the toolkit.
So you can actually pull off really the sample content slides, if you will, for public engagement
and really how we put things together but also really to help some of the planners really
think about what are some of the considerations when youíre really working with the community
or with participants who come in who may not really know anything. This is really di novo
work for them for the first time, concepts that they might not be aware of. And so that
certainly is part of the toolkit as well, and those slides are as Bruce mentioned as
part of the report itself as the public engagement module.
Audience: That sounds wonderful because I think ñ Iím a regional emergency preparedness
coordinator in Buffalo, New York, and an RN, BSN, retired colonel in the Army Nurse Corps,
so it seems like a good thing to do, and we have a great local and state type of thing
in an emergency preparedness people and meetings and everythingís good. But I think weíd
like to take it to the next level about what youíre talking crisis standard of care so
that they can get involved in this because it sounds like a very good program as well.
And just as an aside to Mr. Hodge, being in a military in Desert Storm and few things,
we didnít have to worry about the legality of what we did because the government would
protect us, but I could see where itís good to look into the protection of just regular
civilian type people that help in these kind of crises.
Presenter: Yeah, thatís a good point. Not everybody enjoys the protections that federal
agents, and to be sure, thereís a lot of private healthcare workers doing a lot of
great work __________.
Audience: Yes.
Presenter: Yes, excellent points. Thank you very, very much.
Audience: Okay, thank you.
Presenter: Cerci, other questions or comments?
Operator: The last question comes from the line of Dennis Tomsik. Please proceed, sir.
Audience: Yes, thank you. Yeah, the question comes about your use of the term ìstandard
of careî and ìcrisis standards of careî. Thereís some discussion about the very fact
that the definition of the standards of care is that the reasonable practitioner does what
he would reasonably do given the circumstances. So thereís been some question about whether
this is really the appropriate word for crisis standards of care. Do you have any comment
or clarification about that?
Presenter: Yeah so this is Dan Hanfling and then Iíll ask James to follow. But weíve
heard this comment and weíve heard this sort of discussion, and frankly, to be honest with
you, I think itís a conversation that we ought to just zip up and do away with. I think
itís seen its day, and as I stated in the beginning, what really we have defined here
is an extension on a systems approach to surge capacity and capability planning and response.
And to get hung up just on the word of standard of care or crisis standard of care I think
is to miss basically the forest for the trees.
And so to take you back to the evolution of that phraseology, what we really are defining
here is a continuum of surge response that develops across the continuum and with that
response is a concomitant standard of care, if you will. Now, thereís no question it
is related to the situation at hand, but as James Hodge very eloquently described, there
are certain things that are going to occur in a catastrophic event where there are resource
limitations and staffing shortages and an extreme run on demand for healthcare services
in which the situation is so different that just to call it the situation at hand can
be done. But what we have decided is to really say we really link that to the surge response
thatís occurring. So let me ask James to add his input on this issue and then weíll
turn it back to you.
Presenter: Yes and Iíll be very brief, Dan. That was very eloquent and I think probably
consistent in how this committee worked through this particular very pivotal question. But
the one point Iíll throw into it from a legal perspective that has got to be recognized
is what Dan mentioned much earlier and the slide you see on your screen really emphasized
this. In a typical standard of care delivery of health services is focused on your individual
patients. Itís a great thing. Itís how we assess that in a legal setting. We say well,
okay, did this particular patient get what was consistent with the typical care a reasonable
practitioner would provide and all that typical language? In a crisis standard, we are switching
to a population health approach. There is simply not a recognition legally for some
of how we might do this. A formal declaration makes that possible, and legally speaking,
from a pure policy perspective it makes it clear that there are decisions being made
that might not always advance a particular patientís interest but do advance populationís
interest. These are tough critical allocation decisions. They will be made and have to be
made in these major emergencies, and the law will respect that more based on the recognition
of a crisis standard type of event.
Presenter: Dennis, this is John Hecht. Nice to hear from you. I just want to chime in
that as Dan said, this really is a half of one percent of the report and of the myriad
legal and regulatory issues that enter into these events the issue of provider liability
is one component. If providers are convinced by the arguments that they are protected under
those sort of usual terms of the application of the legal term standard of care, then thatís
really up to them in their particular state. I will say that in our regional workshops
it was loud and clear from the providers that they had substantial concerns, especially
where they were having to make structured triage decisions for which there is absolutely
no legal precedent, and therefore, they didnít take much comfort in the fact that there hadnít
been any legal precedent in those areas.
Presenter: Great, an excellent culminating conversation so thank you all for that. Unfortunately,
our time together this afternoon has come to an end. But before we adjourn, let me take
the liberty of sort of inviting or allowing our five presenters to have the final say,
if you will. If there are any final messages or points of clarification the five panelists
would like to share with us, just allow me to sort of provide that opportunity to you
right now.
Presenter: Jim, Dan Hanfling. I will say that I don't know if all of the attendees are able
to follow the chat as well. There was an excellent chat question regarding the importance of
regional coordination and not just intrastate regional but interstate regional coordination.
And I think that thatís another area that really deserves further attention and ultimately
is going to require state-to-state coordination, governor-to-governor coordination. But I just
wanted the attendees to be aware that that point had come up in the course of the chat
discussion.
Presenter: Excellent, thank you. Thank you for raising that. Any others?
Presenter: Jim, this is Omair. I just wanted to add one other thing is that as weíve been
working on both state and local government roles but also in the public engagement piece,
we really have done our best with the toolkit to move forward principles of how to engage
the lay public. One of the areas that weíre also working and perhaps have not made as
much progress thus far is really provider engagement. And so I think itís really critical
that we bring to the table and that the folks on the webinar are aware that both public
engagement can include providers, healthcare providers, but healthcare providers can also
be separate very different group of folks to really engage, and itís critical that
we actually bring our healthcare providers to the table as well so that they can also
understand the concepts but also be able to really be real champions of crisis standards
of care in the work that weíre all trying to get accomplished. So I just wanted to bring
that up. Thatís really an area that we are continuing to look for avenues on how do we
enhance those efforts.
Presenter: Great, an excellent point of sort of increasing the ability to more appropriately
inform future policy and practice decisions so, Omair, thank you very much for raising
that. Last call for comments from the panel.
Presenter: Just one quick one from me. James Hodge here in Arizona. If anybody didnít
get a question answered, let us know. Weíll look forward to addressing that furthermore.
Presenter: Thatís a commitment from all of us so, again, thank you all very much. So
for the audience, please join me in your own special way through this virtual environment
in thanking our five panelists today for providing an extremely informative and somewhat provoking
conversation on the issue of the framework for crisis standards of care. So that concludes
todayís webinar. As we mentioned earlier, we will certainly provide to you all the audio
and the PowerPoint slide deck on the two websites previously mentioned. And we also are quite
confident in the months ahead there will be other opportunities to discuss this with the
authors, the researchers, the experts and the practice community. Iím assured this
activity will be a showpiece for the upcoming preparedness summit in March of 2013, and
Iím sure there are other events that the preparedness community are planning in the
upcoming months that will give us, again, additional opportunities to learn a little
bit more about the toolkits and how best to apply it. So again, thank you all very much.
Have a safe and enjoyable weekend, and Iím sure we will be in touch. And that concludes
todayís conference. Thank you.
Operator: Ladies and gentlemen, that does conclude the webinar for today. We thank you
for your participation and ask that you please disconnect your line.
[End of Audio]