Crisis Standards of Care IOM held public meetings in May & July - PDF document

8/14/2013 Acknowledgements Arizona Department of Health Services • Andrew Lawless, MBA,PMP • Wendy Lyons, RN,BSN, MSL Peter Kelly, MD, Infectious Disease Specialist • Frank G. Walter, MD Public Health Emergency Preparedness • Deborah Roepke, MPA • Staff of ADHS, Bureau of Public Health Arizona Crisis Standards of Care (CSC) Workshop Planning Meetings Emergency Preparedness azdhs.gov azdhs.gov He alth and We llne ss for all Ar izonans He alth and We llne ss for all Ar izonans 1 2 Crisis Standards of Care Planning in AZ Resource Materials • 2008 ‐ 2009 Partners from Arizona Hospital and Healthcare Association, Arizona Medical Association, ADHS, and numerous other partners developed Disaster Triage Protocol Recommendations State of Arizona Crisis Standards of Care Web Page http://1.usa.gov/148dOtS • Spring 2009, H1N1 appears, ASPR asks IOM to develop guidance URL is case sensitive • Later in 2009, IOM defines term “Crisis Standards of Care” in the “letter report” • Jan. 2011, ADHS conducts Disaster Triage Protocol Workshop with nearly 100 attendees in Phoenix. After Action Report is developed along with recommendations azdhs.gov azdhs.gov He alth and We llne ss for all Ar izonans He alth and We llne ss for all Ar izonans 3 4 Crisis Standards of Care Planning in AZ Crisis Standards of Care • IOM held public meetings in May & July 2011 to inform CSC A Systems Framework for Catastrophic guidance Disaster Response • March 2012, IOM releases 7 volumes of guidance VOLUME 1: Introduction and CSC Framework • Jan. 24, 2013 – Initial Planning Workshop for AZ CSC Plan VOLUME 2: State and Local Government VOLUME 3: EMS • June 27, 2013 – Mid Planning workshop for AZ CSC Plan VOLUME 4: Hospital VOLUME 5: Alternate Care Site Facilities • Today – First Workgroup meetings for Clinical and Legal/Ethical VOLUME 6: Public Engagement Workgroups • GOAL – Feb 2014 – Plan Developed, Implemented, and Tested azdhs.gov azdhs.gov He alth and We llne ss for all Ar izonans He alth and We llne ss for all Ar izonans 5 6 1

8/14/2013 Catastrophic Disaster Defined 1) Most or all of the community’s infrastructure is impacted. What are Crisis Standards of Care? 2) Local officials are unable to perform their usual roles for a period of time extending well beyond the initial aftermath of the incident 3) Most or all routine community functions are immediately and simultaneously disrupted 4) Surrounding communities are similarly affected, and thus there are no regional resources (IOM, Introduction and CSC Framework 1 ‐ 15) azdhs.gov azdhs.gov He alth and We llne ss for all Ar izonans He alth and We llne ss for all Ar izonans 7 8 CSC Assumptions Examples for catastrophic disaster response conditions: • 1918 pandemic influenza • Resources are unavailable or undeliverable to HC facilities • Similar strategies being invoked by other healthcare delivery – ~500 million infected systems – 50 ‐ 100 million fatalities • Patient transfer not possible – 3 ‐ 5% of world population • Access to medical countermeasures (vaccine, meds, • Hiroshima and Nagasaki bombings antidotes, blood) likely to be limited • Available local, regional, state, federal resource caches – 140,000 to 246,000 fatalities (equip, supplies, meds) have been distributed ‐ no short term – Two cities destroyed resupply (IOM, Crisis Standards of Care , 1 ‐ 10) • In both cases recovery occurred azdhs.gov azdhs.gov He alth and We llne ss for all Ar izonans He alth and We llne ss for all Ar izonans 9 Principles of CSC Five Key Elements for all CSC Plans (Crisis Standards of care, 7 ‐ 1,7 ‐ 2) • A strong ethical grounding… based transparency, consistency, proportionality, and accountability • Prioritize population health • Integrated and ongoing community and provider • Respect ethical principles engagement, education, and communication • Liability protection for health care • The necessary legal authority and legal environment in practitioners and institutions which CSC can be ethically and optimally implemented • Triage models for allocation of scarce • Clear indicators, triggers, and lines of responsibility resources • Evidence ‐ based clinical processes and operations • Formal recognition of catastrophic disaster enables specific legal authority azdhs.gov azdhs.gov He alth and We llne ss for all Ar izonans He alth and We llne ss for all Ar izonans 11 2

8/14/2013 Community and Health Care Resource Use prioritize population health rather than individual outcomes Intensive care Usual hospital care Resources Outpatient care Well People azdhs.gov He alth and We llne ss for all Ar izonans 13 Legal Work Group Charter Goal of Crisis Standard of Care Plans • Distribute scarce health care resources across • Purpose : Address legal barriers for provision of optimal and ethical care the whole community in a fair and ethical • Goals: Identify legal and regulatory barriers to a health care manner so that we do the most good for the provider’s ability to provide care during a catastrophic most people. emergency • Identify specific statues and regulations that need a waiver by the Governor using an emergency proclamation or executive order • State an ethical framework for a paradigm shift from personal care to community care azdhs.gov azdhs.gov He alth and We llne ss for all Ar izonans He alth and We llne ss for all Ar izonans 15 Emergency Declarations Emergency Powers Applying Arizona Law to Public Health Emergencies; Aubrey Joy Corcoran, AZ Attorney Applying AZ Law to Public Health Emergencies, Aubrey Joy Corcoran, AZ Attorney General • Governor has complete authority over State agencies • Declared state of emergency or state of war and has the right to exercise all police powers vested emergency with occurrence of imminent in the State threat of illness • Public Health Emergency Governor in consultation • Arizona Dept. of Health Services coordinates with ADHS Director may: public health emergency response – Mandate medical examinations of exposed persons – Ration medicines and vaccines • ARS title 36, Chapter 6, Article 9 – Transport medical support personnel and ill or exposed persons – Provide for procurement of medicine and vaccines azdhs.gov azdhs.gov He alth and We llne ss for all Ar izonans He alth and We llne ss for all Ar izonans 3

8/14/2013 Expanded Scope of Practice During a State of Professional Licensure Emergency Applying AZ Law to Public Health Emergencies; Aubrey Joy Corcoran, AZ Attorney General • Person holding a professional license issued by • Persons licensed as RN, PA, NP, Pharmacists another state may render professional aid as if could provide professional services beyond the license had been issued in this state. (ARS 26 ‐ 310 ) current scope of practice • Pharmacist licensed in another state may • Specific services, additional training, dispense prescription medications during a supervision requirement, liability protection? declared emergency (ARS 32 ‐ 1910) azdhs.gov azdhs.gov He alth and We llne ss for all Ar izonans He alth and We llne ss for all Ar izonans Liability Protections Liability Protections 2 Applying AZ Law to Public Health Emergencies ; Aubrey Joy Corcoran, AZAttorney General • Public Health Emergency • State of Emergency – State and political subdivisions immune from claims based – Any person taking an action required by law is on acts of emergency workers immune from civil and criminal liability – Emergency workers responsibilities, immunities and – Action presumed to be in good faith workers compensation benefits as state or subdivision – State of emergency immunities under ARS 26 ‐ 314 agents and employees performing similar work also available • State and political subdivisions must provide liability ARS 26 ‐ 402 • coverage including legal defense of emergency workers azdhs.gov azdhs.gov He alth and We llne ss for all Ar izonans He alth and We llne ss for all Ar izonans Liability Protection 3 For Discussion Applying AZ Law to Public Health Emergencies; Aubrey Joy Corcoran, AZ Attorney • There is no protection for willful misconduct, • Liability for health care institutions gross negligence or bad faith. • Temporary waivers of health care institutions • Expanded scope of practice • Absent legislative action health care institutions cannot be insulated from liability azdhs.gov azdhs.gov He alth and We llne ss for all Ar izonans He alth and We llne ss for all Ar izonans 4

8/14/2013 Ethical Framework of CSC Key Features of Ethical Framework (Crisis Standards of Care 1 ‐ 72) (Crisis Standards of Care 1 ‐ 72 to 1 ‐ 78) • Groups at risk are most vulnerable during a • Fairness disaster. Sound planning will secure equivalent • Duty to care resources for at risk ‐ groups. • Duty to steward resources • When CSC prevail health care providers must • Transparency adhere to ethical and professional norms. • Consistency Conditions may limit autonomous choices but • Proportionality do not permit actions that violate ethical norms • Accountability azdhs.gov azdhs.gov He alth and We llne ss for all Ar izonans He alth and We llne ss for all Ar izonans 5