Crisis Standards of Care Protocols

Publication Details

In the past few years, several states have developed policies and protocols for allocation of scarce resources and crisis standards of care. However, these efforts have largely been taking place independently. In fact, many workshop participants expressed surprise at learning how much work had already been done on this topic in states across the nation.

Many panelists and other participants at the workshops were integrally involved in developing those policies and protocols and shared their documents and experiences at the workshops. Among the states that have publicly available protocols are California, Colorado, Massachusetts, Minnesota, New York, Utah, Virginia, and Washington (California Department of Public Health, 2008; Colorado Department of Public Health and Environment, 2009; Levin et al., 2009; Minnesota Department of Health, 2008; Powell et al., 2008; The Commonwealth of Massachusetts Department of Public Health, 2007; The Utah Hospitals and Health Systems Association, 2009; Virginia Department of Health, 2008; Washington State Department of Health’s Altered Standards of Care Workgroup, 2008). In Canada, the province of Ontario has also developed crisis standards of care protocols, including particular considerations for patients with cancer or chronic renal disease/acute renal injury, and for blood services and long-term care (Ontario Ministry of Health and Long-term Care, 2008). At the federal level, the Veterans Health Administration (VHA) has developed a protocol for allocation of scarce life-saving resources in VHA during an influenza pandemic (VHA, 2008a, 2009a).

Despite the ongoing work in pockets around the country, it was also clear that most state and local governments and healthcare facilities were in very early stages of developing such policies and protocols or had yet to begin. Among participants who completed the feedback survey after the workshops, just less than half responded that the organization they represented had developed or begun to develop crisis standards of care policies (see Appendix D for the complete set of responses).

At the meeting in Orlando, Kenn Beeman, a senior physician in the Office of Emergency Planning and Response for the Mississippi State Department of Health, discussed significant barriers in his state that have, to date, prohibited the development of crisis standards of care protocols and the engagement of providers in this issue. Among them, “The vast number of Medicare, no-care, no-pay patients [in Mississippi, Arkansas, and West Virginia] places a burden on us from the standpoint of reimbursement,” he said. “Philosophically, [many providers] believe that they are already practicing potentially in somewhat of an altered standard of care.”

Developing Crisis Standards of Care Protocols

Many participants at the workshops described efforts under way in their states to begin the discussion about crisis standards of care. In many cases this involved convening a committee or panel of experts to begin to lay the groundwork. For example, in Louisiana the Department of Health and Hospitals organized a Pandemic Influenza Clinical Forum, which was designed to engage a wide variety of healthcare participants to provide guidance to the state as it develops policy and procedural guidelines for crisis standards of care (Box 1). The goal of the group is to use the clinical expertise and knowledge of its members to help develop decision-making steps or matrixes for the ethical distribution of scarce medical resources.

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Louisiana Pandemic Influenza Clinical Forum Priorities. Researching existing data/resources Planning/collaborating with other states

Drawing on the experiences of states already significantly advanced in the process of developing crisis standards of care protocols, the 2009 IOM letter report laid out a five-step process that states could follow to develop such protocols (Appendix B; IOM, 2009). This process, together with the adoption of key elements and components that the committee identified, offers an opportunity to develop a consistent national framework for crisis standards of care.

“The challenge is not to wait for every community in the country to have a disaster befall [its] own citizens, but to figure out how can we proactively move this conversation forward,” said Edward Gabriel, the director of global crisis management and business continuity at The Walt Disney Corporation.

Several workshop participants emphasized that careful advance planning to avoid or mitigate the effects of scarce resources, along with other aspects of effective surge capacity planning, would in fact decrease or delay the need to implement crisis standards of care.

Who Makes the Plan?

One of the topics discussed in detail at each regional meeting was who should be brought to the table to ensure that the protocols developed are fair and equitable. One of the first steps toward building consensus on fair and ethical crisis standards of care is to bring in all of the parties who have a stake in the discussion. It is not enough, clearly, for a single hospital to have an established plan for how it will handle resource shortages. Those plans must be shared and coordinated across regional lines to prevent the kind of “hospital shopping” that could cause chaos and further overwhelm the system. Participants discussed the importance of bringing political and community leaders and members of the media into the fold and encouraging them to reach out to their communities to educate, inform, and, if necessary, guide appropriate behavior. Many participants also stressed that the community must be engaged, emergency medical experts consulted, and external providers such as pharmacists and insurance providers enlisted in the cause.

However, one lesson that emerged from the workshops is that the list of groups that should be involved and engaged in the planning process is much bigger even than this (Box 2). Deborah Levy, chief of health preparedness for the Centers for Disease Control and Prevention (CDC), described a program in which the CDC works with a community to develop a model for healthcare delivery during a public health crisis. Communities are selected based on a set of criteria, one of which is the level of collaboration between public health and the various components of the healthcare sector. “We want 911 and other call centers, emergency medical services, emergency departments, hospital administrators, public health, primary care providers, urgent care and other outpatient clinics, long-term care and skilled nursing facilities, hospice and palliative care, home health organizations, pharmacists, emergency management, local government such as mayors, and VA [Veterans Administration] and DoD [Department of Defense] facilities if they happen to be in your community,” said Levy. “We usually require at least three representatives from each of those sectors to be at the table and over a 2½-day time period … to think through how they’d deliver care.”

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Who Should Participate in Planning for Crisis Standards of Care? A Partial List. Physicians Physician assistants

Others added further to that list, including groups traditionally considered completely outside the healthcare field, such as funeral directors and morticians.

The reason for including all these different participants in planning goes deeper than the simple practicality of integrating care.

“If you’re doing this kind of emergency planning … every institution needs to be represented,” said Gabriel of The Walt Disney Corporation. “Otherwise they will sit back after you are done and say that they had no involvement.” Gabriel noted that the lack of participation paves the way for outsiders to criticize the difficult decisions when the time comes. That makes it particularly critical to capture the buy-in of both hospital leadership and politicians.

In order to facilitate this broad involvement in Utah, the Governor’s Public Health Emergency Preparedness Advisory Council convenes partners from government, health care, and the private sector in the governor’s executive boardroom. Members of the council are appointed by the governor. “People have a hard time saying they won’t come when they know they’re in his own executive boardroom, and that makes it very effective for us,” said Paul Patrick, director of the Bureau of EMS and Preparedness in the Utah Department of Health.

Even while stressing the importance of engaging a wide range of stakeholders, several workshop participants also emphasized the importance of leadership and the use of effective procedures to ensure that the planning process does not become unwieldy. The 2009 IOM letter report outlines a five-step process that state public health authorities can use to develop crisis standards of care protocols (IOM, 2009). The process uses a series of working groups and committees to outline ethical considerations, review legal authority, and draft guidance. This is followed by a broad public stakeholder engagement process, after which the ethical elements and crisis standards of care can be finalized, incorporating changes raised during the engagement process, as appropriate. The final step of the process is the establishment of a Medical Disaster Advisory Committee that will provide ongoing advice to the state authority regarding changes to the situation and potential corresponding changes in the implementation of crisis standards of care. In this way, the process incorporates both broad stakeholder and public engagement as well as smaller groups that can function effectively to draft, refine, and provide real-time advice about implementation.