Chapter 4 OPERATIONAL INFRASTRUCTURE [ENTER FACILITATOR’S NAME AND CONTACT INFORMATION] Developed by Troutman Sanders LLP Developed for the Virginia Department of Health Funded by Centers for Disease Control and Prevention

2Operational Infrastructure

3 Toolkit Presentations Instructions for Use  Toolkit Presentations are intended to be a companion to the Hospital Implementation Guide and should not be used in isolation.  The Presentations are intended to serve as a starting point for the facilitator. The facilitator should thoroughly review the Presentation prior to use in Implementation Team, CRAG or Subcommittee meetings and customize the Presentation to meet the unique needs of the meeting participants.  Pay particular to attention to the information provided in brackets ([ ]), which must be completed by the facilitator prior to use.  Included in the “Notes” section of each slide are the following types of information: Slide Type, which indicates whether the slide is for information or discussion, serves as a placeholder, or is some combination thereof Planning Guide Section(s), which will direct the facilitator to the corresponding sections of the Planning Guide and Hospital Implementation Guide for further information Special Instructions, which provides directions for the facilitator to customize the slide for the intended audience Speaker’s Notes, which provides more detailed information to supplement the material on the slide  Refer to the Hospital Implementation Guide for further guidance and helpful hints on effectively completing the process described in the Planning Guide.

4Operational Infrastructure CRAG Members  [Enter names and departments of each CRAG member]

5Operational Infrastructure  Add slides from Altered Standards Overview and/or Chapter 1 presentation, as needed, to re-introduce the CRAG to the concept of altered standards and critical resource shortage response planning, especially if new members are involved.

6Operational Infrastructure Introduction

7Operational Infrastructure Why do we need an Operational Infrastructure?  Many hospitals already have an emergency response infrastructure  Most hospitals do NOT have the type of infrastructure that will be needed to respond to a critical resource shortage event  An overall operational infrastructure will provide consistency to Protocol development, implementation, and operationalization

8Operational Infrastructure Chapter Overview  Determine process for activation and termination of the CRSRP  Determine process for activation and termination of each Protocol  Develop structure for making resource allocation decisions  Develop infrastructure for reviewing and revising CRSRP during a CRSE  Define “essential documentation”

9Operational Infrastructure Chapter Overview cont.  Develop process for responding to non- compliance  Identify resources for psychological and emotional support  Develop a communication plan  Develop strategy for providing palliative care during a critical resource shortage event Determine goal Develop standard definition Identify mechanisms for providing palliative care

10Operational Infrastructure Review of Ethical Framework

11Operational Infrastructure Strong Foundation Ethical Framework Operational Infrastructure Education & Communication Building the CRSRP Protocol Ad Hoc

12Operational Infrastructure [HIGH PRIORITY ETHICAL VALUE] [HIGH PRIORITY ETHICAL VALUE] [HIGH PRIORITY ETHICAL VALUE] [HIGH PRIORITY ETHICAL VALUE] [MEDIUM PRIORITY ETHICAL VALUE] [MEDIUM PRIORITY ETHICAL VALUE] [MEDIUM PRIORITY ETHICAL VALUE] [MEDIUM PRIORITY ETHICAL VALUE] [MEDIUM PRIORITY ETHICAL VALUE] [LOW PRIORITY ETHICAL VALUE] [LOW PRIORITY ETHICAL VALUE] [LOW PRIORITY ETHICAL VALUE] [LOW PRIORITY ETHICAL VALUE] [LOW PRIORITY ETHICAL VALUE] [Withdrawal/Withholding] of Resources [Exclusion Criteria] [INSERT GOAL DEVELOPED IN SECTION 3.2] Ethical Framework Operational Infrastructure Ethical Framework

13Operational Infrastructure What’s Next? Ethical Framework Operational Infrastructure Development of the operational infrastructure

14Operational Infrastructure

15Operational Infrastructure CRSRP Process Termination Maintenance Implementation Activation

16Operational Infrastructure CRSRP ACTIVATION AND TERMINATION

17Operational Infrastructure Activation of CRSRP Demand for the Resource Supply of Critical Resources

18Operational Infrastructure Activation Flow Chart Event Occurs Identify Critical Resource Shortage Event Report Critical Resource Shortage Event Declare Critical Resource Shortage Event Activate CRSRP Who is responsible for each step in the activation process? Resource levels begin to diminish & demand increases

19Operational Infrastructure Hospital Incident Command Structure

20Operational Infrastructure Identifying a Critical Resource Shortage Event STATUS Does demand exceed supply? FORECAST When will demand exceed supply if it doesn’t already? DURATION For how long will demand exceed supply? MAGNITUDE To what extent does or will demand exceed supply? MITIGATION Options for obtaining additional supplies of the resource.

21Operational Infrastructure Declaration and Activation Demand for the Resource Supply of the Resource Who will declare the CRSE? Who will activate the CRSRP?

22Operational Infrastructure Governmental Emergency Declarations  How will federal, state or local emergency declarations be identified?  Who will find, read and summarize the declaration(s)?  What is the role of legal counsel?

23Operational Infrastructure CRSRP Termination Too soon Not soon enough

24Operational Infrastructure BREAK

25Operational Infrastructure PROTOCOL ACTIVATION AND TERMINATION

26Operational Infrastructure Activation of Protocols Demand for the Resource Supply of Critical Resources

27Operational Infrastructure Simultaneous Activation Demand for the Resource Supply of Critical Resources

28Operational Infrastructure Asynchronous Activation Demand for the Resource Supply of Critical Resources

29Operational Infrastructure Protocol Termination Options  Simultaneous  Asynchronous Who will terminate the Protocols? Will the decision vary by Protocol? What information is required?  Termination by Tier

30Operational Infrastructure BREAK

31Operational Infrastructure Allocation Infrastructure

32Operational Infrastructure Model 1 – Treating Physicians

33Operational Infrastructure Model 2 – Triage Officer

34Operational Infrastructure Model 3 – Triage Committee

35Operational Infrastructure ED Inpatients Direct Admits ELIGIBLE INELIGIBLE Model 4 Triage Officer and Triage Committee Resource #1 Resource #2 INELIGIBLE

36Operational Infrastructure Which model should we adopt?

37Operational Infrastructure Triage Officer Powers AUTHORITYYESNO Recommend resource allocation Withdraw resources from patients and re- allocate Research/monitor outcomes Situational Awareness Re-assess and modify Protocols Require physicians and staff to provide care according to Protocol Reprimand non-compliant providers Other?

38Operational Infrastructure Triage Committee Powers AUTHORITYYESNO Recommend resource allocation Withdraw resources from patients and re- allocate Research/monitor outcomes Situational Awareness Re-assess and modify Protocols Require physicians and staff to provide care according to Protocol Reprimand non-compliant providers Other?

39Operational Infrastructure BREAK

40Operational Infrastructure Re-assessment of CRSRP during the CRSE

41Operational Infrastructure R eassessment of CRSRP Implementation of CRSRP Re-assessment of situational factors Revision of CRSRP Dissemination of CRSRP

42Operational Infrastructure Documenting CRSRP Modifications Re-assessment of situational factors Revision of CRSRP

43Operational Infrastructure BREAK

44Operational Infrastructure Additional Operational Issues

45Operational Infrastructure Primary Functions of Documentation During a CRSE  Care and safety of patients  Support Protocols  Quality assessment  Obtain timely reimbursement How will you ensure the completion of “essential documentation”? Essential Documentation

46Operational Infrastructure Reasons for Non-Compliance That is outside my scope of practice. I don’t have the knowledge or skills to successfully complete this task. My patient deserves to receive the resource. The triage committee used the Protocol incorrectly. My patient, my responsibility, my decision. I won’t do that because I don’t want to get sued.

47Operational Infrastructure Non-Compliant Providers How will you respond? Ignore Terminate employment/ revoke privileges Assume control of patient Counseling/ Persuasion DirectiveRestrict/ suspend privileges

48Operational Infrastructure Psychological and Emotional Support

49Operational Infrastructure Updating Staff

50Operational Infrastructure BREAK

51Operational Infrastructure Palliative Care

52Operational Infrastructure Palliative Care “Normal” v. Disaster “Normal” Times  End-of-life care  Performed by select group of providers  Patient choice CRSE  Patients who in “normal” times would have received regular care  Providers who are not used to this type of care  Little, if any, patient choice

53Operational Infrastructure Potential Goals  To relieve pain  To manage symptoms without use of the critical resource  To ensure that patients are not abandoned or ignored  To minimize the physical/psychological suffering of those not provided the critical resource  Others?

54Operational Infrastructure Define Palliative Care  Definition is important for consistency and understanding  Will be informed by the goals established in this meeting  No existing definition really captures palliative/comfort care in the disaster context

55Operational Infrastructure Providing Palliative Care  Who will provide palliative care?  Can we partner with existing local palliative care organizations?  What training will be needed?  Can palliative care be provided in alternate care facilities?  How will psychological/emotional support be provided to palliative caregivers?

56Operational Infrastructure Questions?