READY OR NOT? |
Knox Andress, BA, RN, AD, FAEN
Crisis Standards of Care:
A Duty to Plan There are two viable pandemic patients, both requiring a ventilator, but only one ventilator available: Who gets the available vent? In a catastrophic disaster, which patients receive the available medical resources? What are the operational, ethical, legal and other significant considerations? Who is responsible for planning and Crisis Standards of Care implementation? What CSC planning templates for emergency departments and hospitals are available?
Latest Guidance In March, the National Academy of Science, Institute of Medicine released a new resource for federal, state and local health providers and stakeholders in planning for CSC at www.iom. edu/Reports/2012/Crisis-Standards-of-CareA-Systems-Framework-for-CatastrophicDisaster-Response.aspx. This six-volume resource provides the considerations and coordinated strategy for a multijurisdictional approach for CSC development and implementation. Volumes contained within the publication include the following: 1. Introduction and CSC framework; 2. State and local government; 3. EMS; 4. Hospital; 5. Alternate care system; 6. Public engagement; and 7. Appendixes. The volumes serve as implementation toolkits or guides. Common to each volume or system are defined roles and responsibilities, operational considerations and planning templates to guide development implementation.
Recent Incidents—Triaging Scarce Medical Resources September 2005 brought Hurricane Katrina, its flooding and devastation to the infrastructures of metropolitan New Orleans, including health systems and multiple hospitals. Many caregivers and patients were trapped in hospitals without communications, water or electrical power and had minimal medical resources for treatment. In this scenario, which patient(s) should have received the remaining medical resources? Which patients got the priority hospital evacuation triage?
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Approximately 230,000 deaths were reported one year after the catastrophic Haitian earthquake of Jan. 12, 2010. Medical resources were scarce, and patients reportedly were given the best care possible in often primitive conditions. ENA member Rose Johnson, RN, reported having to create a spirometer for her patients. Immediately after the F5 tornado plowed through Joplin, Mo., May 22, 2011, residents suddenly found themselves with one hospital with an emergency department instead of the usual two. The scene was set for scarce medical resources. St John’s Regional Medical Center took a direct hit and was itself a casualty of the tornadic weather. Of 161 reported fatalities, five were ICU patients and one was a hospital visitor. Patients were evacuated to the remaining health care facilities and alternate care sites that had care-delivery capability. EMS and medical resource needs skyrocketed, and several non-traditional methods were employed. Because of a limited number of available EMS transport units coupled with the urgent need, ‘‘vehicles of opportunity’’ were used for patient movement to hospitals.
Today—Scarce Medical Resources A growing medical resource shortage includes more than 250 drugs, mostly generics and injectables, but including several ‘‘first line’’ medications, anesthetics and chemotherapeutics. Shortages affecting prehospital and hospital providers have been reported and have included magnesium sulfate, propofol, succinylcholine and epinephrine, among many others. Occasionally patients receiving chemotherapy have had to delay treatment or even forgo their preferred therapeutic. While some pharmaceuticals can be substituted, others cannot, and patient care suffers. On April 12, Emory University hosted a conference on the ethics of the current drug shortage, discussing multiple related topics including distribution and equitable allocation of this scarce medical resource.
IOM—A Letter Report At the request of the Assistant Secretary for Preparedness and Response within the Department of Health and Human Services, the Institute of Medicine’s Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations wrote and released a report
in 2009, providing key elements of planning and initial recommendations to state and local public health departments in establishing and implementing crisis standards of care for scarce resource environments subsequent to disaster scenarios www.iom.edu/Reports/2009/ DisasterCareStandards.aspx. Final recommendations in the IOM’s 2009 report included the following: 1. Develop consistent state crisis standards of care protocols with five key elements. 2. Seek community and provider engagement. 3. Adhere to ethical norms during crisis standards of care. 4. Ensure consistency in implementation of crisis standards of care. 5. Ensure intrastate and interstate consistency among neighboring jurisdictions. The March 2012 ‘‘Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response’’ follows the intent and guidance and develops the recommendations of the 2009 report.
Volume 4—Hospitals and Acute Care facilities As the hospital’s front door in disaster response, emergency departments play a significant role in the disaster surge response, incident management and response planning. CSC: A Systems Framework, Vol. 4, ‘‘Hospitals and Acute Care Facilities,’’ begins with “Hospitals and acute care facilities providing acute medical care to the community have a ‘duty to plan’ for mass casualty incidents, including planning for expansion of clinical operations, commonly referred to as surge capacity post-Hurricane Katrina.” Of the six volumes, Vol. 4 provides multiple resources, including a template for hospital crisis standards of care planning and implementation as responses are demonstrated across the surge continuum of conventional care, contingency care, and crisis care environments. Besides templates for hospitals and acute care facilities, the framework includes sections and specific templates for state and local government; EMS; alternate care system; and tools for public engagement.
Don’t Forget Spread the word about ENA’s emergency preparedness resources with the following activities:
June/July 2012