A New Standard of Care for Crisis Incidents

Public health and medical personnel are often put in the position of preparing for and responding to various emergency situations – both naturally occurring such as pandemics, as well as manmade incidents and events. However, sometimes the incident is too large for local authorities to manage effectively and/or simply overwhelms the current healthcare system of the jurisdiction(s) immediately involved – e.g., the 2011 tornado that devastated Joplin, Missouri, the 2011 earthquakes that rocked both New Zealand and Japan, or even the 2009-2010 H1N1 pandemic that affected the entire nation. Nonetheless, even in extreme circumstances, numerous decisions must be made to ensure that available resources reach the patients who will benefit the most.

In 2009, at the request of the U.S. Department of Health and Human Services (HHS), the Institute of Medicine (IOM – an independent nonprofit organization that advises the federal government on health matters) formed a committee of subject-matter experts in the fields of emergency management, public health, emergency medical services (EMS), medicine, and bioethics. The committee developed the guidance needed to help state and local health officials establish and implement standards of care during and in the aftermath of major disasters.

In its first report – Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, published in September 2009 – the committee defined a crisis standard of care (CSC) as “a state of being that indicates a substantial change in health care operations and the level of care that can be delivered in a public health emergency, justified by specific circumstances.” The committee also noted that there is no single national set of guidelines for states that could be generalized to fit all crisis events. The report concluded with six clear recommendations for the nation’s medical/public health community to embrace regarding these standards of care:

  • Develop consistent state crisis standards-of-care protocols with five key elements;
  • Seek community and provider engagement;
  • Adhere to ethical norms during crises related to the standards of care;
  • Provide legal protections needed for healthcare practitioners and institutions charged with implementing the crisis standards of care;
  • Ensure consistency in crisis standards-of-care implementation; and
  • Ensure intrastate and interstate consistency among neighboring jurisdictions.

Recent Updates and Standard Templates

In its follow-up report – Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response, released in March 2012 – the committee examined the effect of its 2009 report and developed templates to guide the efforts of professionals and organizations responsible for CSC planning and implementation. Integrated planning for a coordinated response by state and local governments, emergency medical services (EMS), healthcare organizations, and healthcare providers in the community all are critical to mounting successful responses to disasters. To that end, the report provides a foundation of underlying principles, the steps needed to achieve implementation, and various pillars of the emergency response system – each of which is separate, but together are essential for upholding the jurisdictions that have overarching authority for ensuring the effectiveness of CSC planning and responses.

The aforementioned templates make up the bulk of the document; each one is specific to a distinct discipline – e.g., EMS, hospitals, state and local governments – with significant responsibilities during a catastrophic event. But at the same time the document is clear that integrated planning is the most critical element in mounting a successful response to sudden disasters.

Public Health Specifics – On Two Functional Templates

There are two templates specific to public health: (a) one outlines the core functions of state and local governments in the development of CSC plans; and (b) one outlines the core functions essential for implementing CSC plans in individual states during CSC incidents. Both templates show the amount of time and attention that went into: (a) ensuring that all stakeholder interests had been taken into serious consideration; and (b) realistic expectations had been outlined.

The first template, which is specific to state- and local-level public health organizations, is grouped by various functions including: (a) establishing a CSC planning committee; (b) drafting a workable plan; (c) introducing the plan to various stakeholders as well as to the general public; (d) adopting and disseminating the plan; and (e) maintaining and updating the plan.

The second template is deeper and more specific: focusing on the actual implementation of the CSC plans and the various roles and responsibilities assigned to both state and local public health organizations. Among the various functions identified in this template are the following: (a) alerting and activating all applicable partners in accordance with the triggers identified in the plan; (b) notifying partners, and the media, and ensuring that redundant communications system are in place ahead of time; (c) also ensuring that command and control, communications, and coordination requirements will be met; (d) providing public information capabilities; (e) understanding overall operations – specifically including those related to conventional, contingency, and crisis operations; (f) managing logistics, including staffing, supplies, and space; and (g) planning for termination, demobilization, recovery, and evaluation.

An Integrated Effort & Continuing Cooperation

Because the vast majority of public health agencies at U.S. state and local levels already have been an element in emergency planning, and significant effort between and among various stakeholders may have already occurred, the IOM report also: (a) includes a number of milestones designed to guide the integration of CSC into existing disaster plans; and (b) suggests that appropriate agencies and organizations be assigned to lead each stage of the effort (click to see table on Crisis Standard of Care Milestones and Proposed Lead Agencies). Here it is worth noting that the need for interagency cooperation is frequently emphasized, particularly at the state level.

Key Points to Remember: Cooperation & Advance Planning

The “take-home” point of this well-developed document is the recognition that, in the face of a major catastrophic event, no single agency or organization can “do it alone.” Even with this understanding, it is important to understand that, in one sense, all disasters truly are “local.” Understanding the capabilities of the local system, and surrounding systems, as well as the hazards and potential threats that also could occur during such events – examples include the possibility that hospitals and EMS bases may be without power; staff and/or volunteers may not be quickly available; medicines, supplies, and hospital beds could be in short supply; and medical attention may have to be delivered to alternate care facilities – cooperation, on a continuing basis, is of paramount importance in all planning and implementation efforts.

Taking the time now, before an incident, to assure that the lead state health department is making the necessary adjustments to the scope of the practice, treatment, and transport protocols needed, and that ambulance staffing and call-center responses also figure into crisis response plans. Among other duties, state public health authorities, working in conjunction with their state EMS agencies, will take the lead in establishing the triggers and thresholds that will signal the shift from conventional care … to contingency care … and, finally, to crisis care.

For additional information on: IOM’s Report “Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response,” visit https://pubmed.ncbi.nlm.nih.gov/24830057/

Raphael Barishansky

Raphael M. Barishansky, DrPH, is a public health and emergency medical services (EMS) leader with more than 30 years of experience in a variety of systems and agencies in positions of increasing responsibility. Currently, he is a consultant providing his unique perspective and multi-faceted public health and EMS expertise to various organizations. His most recent position prior to this was as the Deputy Secretary for Health Preparedness and Community Protection at the Pennsylvania Department of Health, a role he recently left after several years. Mr. Barishansky recently completed a Doctorate in Public Health (DrPH) at the Fairbanks School of Public Health at Indiana University. He holds a Bachelor of Arts degree from Touro College, a Master of Public Health degree from New York Medical College, and a Master of Science in Homeland Security Studies from Long Island University. His publications have appeared in various trade and academic journals, and he is a frequent presenter at various state, national, and international conferences.

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