1. 1 A Series of Regional Workshops ENA Leadership 2010 – Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

2.  Consider the scenarios  Pandemic  Bioterrorism  Natural disaster/catastrophes  Regional IOM workshop descriptions  Participants  Locations  Agenda  Goals  Outcomes 2 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

3.  Addresses –  Related work on standards of care  Crisis standards of care protocol development  The surge capacity continuum of care  Clinical operations  Provider involvement and engagement  Public engagement and education  Developing intra and interstate cooperation and consistency  Role of the Federal government and national leadership  Ethical considerations  Legal issues for crisis standards of care 3 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

4.  Agency for Health Resource and Quality (AHRQ)  Altered Standards of Care in Mass Casualty Events  Mass Casualty Care with Scare Resources – A Community Planning Guide  Institute of Medicine (IOM)  Guidance for Establishing Crisis Standards of Care in Disaster – A Letter Report 4 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

5. Collaboration between AHRQ and ASPR  Ethical Considerations in Community Disaster Planning  Assessing the Legal Environment  Prehospital Care  Hospital/Acute Care  Alternative Care Sites  Palliative Care  Avian Influenza Pandemic Case Study 5 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

6. 6  Who makes the plan?  Nurses  Physician assistants  Physicians  Pharmacists  Administrators  Morticians  Academia  Government  Many others ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

7. Conventional Capacity – Spaces, staff and supplies are consistent with daily practices within the institution Contingency Capacity – Spaces, staff and supplies used are not consistent with daily practices but maintain or have minimal impact on usual patient care practices. Crisis Capacity – Adaptive spaces, staff, and supplies are not consistent with usual standards of care. Space Usual patient care space or area are fully utilized Patient care areas repurposed (ex. PACU or monitored units for ICU-level care) Facility damaged/ unsafe or non-patient care areas (ex. classrooms, etc.) used for patient care Staff Usual staff called in and utilized Staff extension (ex. brief deferrals of non-emergent service, supervision of broader group of patients, change in responsibilities, documentation, etc.) Trained staff unavailable or unable to adequately care for volume of patients even with extension techniques Supplies Cached and usual supplies used Conservation, adaptation, and substitution of supplies with occasional reuse of select supplies Critical supplies lacking. Possible reallocation of life-sustaining resources. Standard of Care Usual CareFunctionally equivalent careCrisis standards of care Usual Operating Conditions Austere Operating Conditions Capacity Continuum of Care 7 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

8. NORTH DAKOTA’S EXAMPLE:  Stage 1: Small Outcome Impact  Stage 2: Moderate Outcome Impact  Stage 3: Severe Outcome Impact 8 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

9.  Those with a critical roles include  EMS  Physicians  Hospital officials  Nurses  Engagement challenges cited  Time  Funding  Culture - resistant to crisis standards concepts 9 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

10.  Engagement challenges  Public is generally uneducated  History of distrust  Changing the Culture of preparedness  Use awareness from recent disaster events  Include in educational curriculum  Elected officials and media as allies 10 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

11.  Reasons for consistency  Approaches by states  Massachusetts  Virginia  Regional applications  FEMA Region 4  Capital region’s “All-hazards” consortium  Interstate Disaster Medical Cooperative  Village-to-Village Communication 11 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

12.  Guide and facilitate  AHRQ/ASPR  “Altered Standards of Care in Mass Casualty Events” (AHRQ, 2004)  “Mass Medical Care with Scarce Resources: A Community Planning Guide” (AHRQ, 2005)  “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations” (IOM, 2009)  VHA  DOD 12 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

13.  Requirements for ethical crisis standards of care planning and development  Fairness  Duty to care  Duty to steward resources  Transparency  Proportionality  Accountability 13 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

14.  Liability  Addressing the problem  Deputizing physicians  Enacting liability protections  Credentialing  Scope-of-practice  EMTALA and HIPPA  Legal triage  Education and training 14 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

15.  Indicators  Triggers  Triage  Alternate care facilities  EMS, community health & other components  Resource availability and distribution  Pediatrics and other “at risk” populations  Palliative care  Mental health  Training 15 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

16. HOSPITAL OUTSIDEIN A WAREHOUSE 16 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

17.  Actual or impending resource shortfalls:  Ventilators  Oxygen and delivery devices  ICU beds  Healthcare providers  Hospitals  Pharmaceuticals  Other 17 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

18.  Should be:  Consistent  Based on disaster declaration  Driven by front-line providers 18 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

19.  Triage and the Sequential Organ Failure Analysis (SOFA) score.  Cardiovascular  Coagulation  Hepatic  Neurological  Renal  Respiratory  Triage across the health system 19 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

20.  Creating surge capacity outside the hospital  Planning by:  North Dakota  Facility capabilities  Staffed by volunteers  Delaware  Modular medical expansion  NEHCs – act as gateways  Legislation enacted 20 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

21.  Considerations for:  EMS  Community Health  The private sector 21 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

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

23. POPULATIONS  Children  Elderly  Mental health patients  Others  Challenges – matching resources to needs 23 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

24.  Expected Need  Despite the best efforts…  Concern for lack of palliative care protocols and standards  Reluctance to discuss  Planning for care  No one left to die  Care is never withdrawn 24 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

25.  The need for grief management  Consider  Ceasing pediatric resuscitations  Discontinuing (DC’ing) vent assistance  Running out of life-sustaining medications or oxygen  Impact on  Care-givers  Family and individuals  Planning –  Missouri School of Medicine –  Center for Health Ethics - just-in-time, Pandemic Grief Training course. 25 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

26.  Need for effective training and relationship building across organizational boundaries.  Forums include  Exercises  Actual event responses  2009 Presidential inauguration  Maryland and District of Columbia 26 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

27.  Four Regional Workshops  Highlighted work ongoing around the nation  More work needed for:  Palliative care planning  Mental/behavioral health  Vulnerable populations  Public and provider engagement  Consistency  How far do we go? 27 ENA Leadership 2010 - Chicago Stds of Care in Mass Casualty Events - A Workshop Report ; Phillips/Andress

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