D
Participant Feedback Survey Responses

Feedback surveys were sent to all registered attendees at the workshops. The questions and responses are shown below. The total number of responses for each question was 53, unless otherwise indicated.

  1. Which workshop did you attend?

 

Count

Percentage

Irvine, CA–March 12

8

15%

Orlando, FL–April 14

20

38%

New York, NY–April 27

10

19%

Chicago, IL–May 8

15

28%

  1. Which stakeholder group(s) do you represent? (Please choose all that apply)

 

Count

Percentage

Healthcare provider

24

45%

Emergency medical services

10

19%

Emergency management

9

17%

Hospital administration

9

17%

First responder

6

11%

Local health official

5

9%

State health official

5

9%

Professional association

4

8%

Private sector

3

6%



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D Participant Feedback Survey Responses Feedback surveys were sent to all registered attendees at the workshops. The questions and responses are shown below. The total number of re- sponses for each question was 53, unless otherwise indicated. 1. Which workshop did you attend? Count Percentage Irvine, CA–March 12 8 15% Orlando, FL–April 14 20 38% New York, NY–April 27 10 19% Chicago, IL–May 8 15 28% 2. Which stakeholder group(s) do you represent? (Please choose all that apply) Count Percentage Healthcare provider 24 45% Emergency medical services 10 19% Emergency management 9 17% Hospital administration 9 17% First responder 6 11% Local health official 5 9% State health official 5 9% Professional association 4 8% Private sector 3 6% 105

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106 CRISIS STANDARDS OF CARE Count Percentage Emergency communications dispatch services 2 4% Academic 1 2% Academic medicine; project for NYC Department of Health and Mental Hygiene 1 2% Community health center 1 2% Community health nurse 1 2% Federal agency representative 1 2% Illinois Department of Public Health Emergency Response Coordinator 1 2% Local municipality 1 2% Metropolitan Medical Response System 1 2% M.P.A. student 1 2% Medical Reserve Corps (MRC) 1 2% National Library of Medicine project; hospital medical library 1 2% University professor 1 2% World network private sector/first responder 1 2% NOTE: Percentages add to greater than 100 because some participants checked multiple groups. 3. Does the organization you represent have policies in place for “standards of care during a mass casualty event”? 30% 25% 20% 15% 10% 5% 0% Not I am unsure No, the The The Yes, the applicable if my organization organization organization organization organization has not already has is currently has started is working policies in developing to talk about taken any on steps to developing policies place developing develop policies policies policies

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107 APPENDIX D 4. Prior to the workshop, how familiar were you with the issues re- lated to “standards of care during a mass casualty event” and with the work that has been done on this topic? 40% 35% 30% 25% 20% 15% 10% 5% 0% Extremely Very familiar Somewhat Not very Not at all familiar familiar familiar familiar 5. How much work have you done developing or implementing poli- cies related to the topic of “standards of care during a mass casualty event”? 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% I have done a I have done I plan to begin I have thought I had not significant some work on work on this about this topic thought about amount of work this topic topic in the but do not this topic very on this topic near future foresee taking much specific actions in the near future

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108 CRISIS STANDARDS OF CARE 6. Overall, how useful did you find the workshop in raising aware- ness of issues related to the topic of “standards of care during a mass casualty event”? 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Extremely useful Very useful Somewhat useful Not very useful (Optional) Comments • A lot of useful information was brought up at the workshop, but it seemed as though attendance beyond people who sat on panels was quite limited. It would be useful to encourage attendance by stakeholders who are not a part of the formal presentations. • We’re preaching to the choir. We need to be explaining these is- sues to the general public. • I found the most valuable portion of the workshop, for me, to be the beginning, when the focus was still on altered standards of care. When that focus was later lost, the workshop became less valuable for me. • It was great at raising awareness, but not at answering the problems. • Good questions posed by audience participants. • I think the answer to this question is very dependent upon indi- vidual exposure. • Lots of info, many propositions, even more questions left unan- swered. Policies are new to all! • All participants were well versed in the matter and provided out- standing insights to build upon.

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109 APPENDIX D • I was able to bring the technology issue into the debate, where it was not previously rated as important enough to be listed as a workgroup topic. • It is important to hear other perspectives on the topic. Good to know others are struggling with similar issues. • I think the topic of communication among agencies and commu- nities would be a great topic for [a] workshop in the future. Total responses to this question: 11 7. What information presented or discussed during the workshop did you find most helpful? [Sorted by response to Question 4: Prior knowledge] Prior knowledge: Extremely or very familiar with issues • Overviews of various organizations and their interactions, espe- cially the Florida planning. • The idea of the continuum of standards to crisis care. • “Rationing” and setting standards versus keeping one standard and identifying the shortcomings. • “Lessons learned” discussions from panelists plus the Q and A. • Policies and procedures developed by other states as noted in the resource files. • “Disaster ethics”/bioethics discussion(s). • That we are all struggling to apply ethical principles of fairness and justice within standards that we are developing across the United States. • Medical ethics. • The enlightenment of the subject being taboo at all levels. • The importance of message during a mass casualty event, the importance of interjurisdictional license suspensions, and liabil- ity indemnification. • So many it would be unfair to choose. • Controversies surrounding rationing. • Too many to identify them all. Developing the ethic platform for a state standard. Implementing altered standards of care through

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110 CRISIS STANDARDS OF CARE emergency operations centers (EOCs) versus not (ND model). • Views from all over the region. • Surge capacity breakdown into three categories; rationing of scarce resources. • Ethics issues. • The need to educate the docs in the trenches. • The discussions regarding the altered standards of care systems and to learn my local health department is not at the table. I un- derstand the role the state health department plays; however, I feel that the LPHA has much more experience working with and within the local community than the state does. Total responses to this question: 18 Prior knowledge: Somewhat or not very familiar with issues • The diversity of issues and approaches. • Triage process. • How expectations for care, along with the way we define good standards of care, must change in response to a mass casualty event. • Discussion [of] the questions/issues that need to be addressed on the local level—and strategies for creating regional/national guidelines. • Specifically what will be done, how, and by whom . . . protocol of hierarchy still needs more definition . . . and specific info as to resources and mass prophylaxis or actions. • Ethics of group selection, the standards proposed by the VA. • The concept of “rationing” equipment, care, and access. • The information about getting state to state recognition as an EMT. The [H1N1] flu information was a touch-and-go subject that I thought I would love to get more information or education about. • Interstate and neighboring community cooperation. • Local and state standards. • Discussions among presenters and attendees, and discussions with individuals during the break.

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111 APPENDIX D • Ethical principles and their application to mass casualty events. How individual facilities and regions are handling this issue. • I was only able to attend the afternoon sessions . . . Session IV was outstanding . . . particularly Tim Conley, who related di- rectly to municipality planning. • That everyone is facing the same problem and that there is no “one” solution to the question. It will depend on local resources. • The presentation on the need for coordination [among] various communities and sectors. • SOFA + criteria for vents, who will be seen/admitted to the hos- pital during a pandemic. I was most impressed by the work of some of the state and regional groups. • The overall discussion/definition of the topic was beneficial. The difficulties involved and general ideas of where the topic is headed were all helpful in determining how to help my organiza- tion respond. • Discussion of surge capacity classification and Tia Powell’s comments on the ethics of ventilator triage. Total responses to this question: 18 8. How will you use that information? [Sorted by response to Question 4: Prior knowledge] Prior knowledge: Extremely or very familiar with issues • Will use the notes from the workshop to start focus group discus- sions in many forums around the state to formulate the process for our state. • Discuss with key hospital staff who will be involved with estab- lishing altered standards of care and community emergency op- erations staff. Much of the info gathered from this conference will be included on hospital disaster preparedness webpage. • Will adapt those to our Medical Reserve Corps component in Marion County, FL. • Qualify current policy and procedures. • Presentation to intradisaster response team to stimulate discus- sion on a topic that—perhaps—has been treated too incidentally.

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112 CRISIS STANDARDS OF CARE • Serves as the foundation for further work at the local level. • Will bring into our discussion locally. • I will incorporate the information into telemedicine and apply it to the possible pandemic. The current reaction to the prepan- demic is clearly a warning about preparedness for a pandemic event. • Working with state agencies. • Take topic to local and state committees dealing with pediatrics. • I will report to the Oklahoma state committee on Altered Stan- dards of Care much of what I absorbed. • To take a second look at a couple of areas in our guidance. Ap- peals, triage officer. • To begin discussion and development of policies to address these issues and to lobby the state Department of Public Health to do the same. • Will activate in our Hospital Incident Command System (HICS) structure and proactively work with our ethics officer to help them prepare for disasters. • Enhance our education program. • If the goal is to be consistent, transparent, and fair, the local pub- lic health authority (LPHA) needs to be a part of the planning that is currently taking place if LPHAs are expected to assist in some sort of capacity. Total responses to this question: 16 Prior knowledge: Somewhat or not very familiar with issues • Initiate further discussion in our region. • Will educate providers on possible roles and decisions required during a disaster. • I have raised the issue at our management discussions, and will continue to encourage that we do more practicing to prepare our response to a catastrophic event. • My hospital needs to work on this—and we need to work on it as a region with other hospitals. Not sure that we will have much state input. • I hope to use the information in a project on the legal aspects of

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113 APPENDIX D altered standards of care. • To tell all my coworkers, friends, and family . . . send out an alert for the need to prepare for any catastrophic event. • Discuss this with our county planning committee. • Will use triage guidelines in our walk-in clinic/urgent care set- ting, and telephone triage guidelines for call-in questions. • To continue my education and to assist others in other states in disasters as well as . . . our own state of New York. • Bring ideas to my organization. • Hope to follow up with individuals. • Will work to develop policies with the American College of Sur- geons and with our local community. • It always reinvigorates me to attend anything on preparedness . . . I wish I would have been able to attend the morning sessions. I will take back to our regional group info. I received as well as shared it with our over 100 MRC members. • To help initiate additional communication in the planning proc- ess for emergencies. • I plan to start dialogue with our municipal fire department on is- sues heard at the workshop and attempt to [have a] dialogue with the supervisor and trustee of the township regarding the same. • Keep my organization involved in the decision-making process with our regulating agencies. • As a framework for further discussions. Total responses to this question: 17

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114 CRISIS STANDARDS OF CARE 9. Overall, how useful did you find the workshop in identifying prac- tical solutions to some of the challenges you are facing in developing and implementing policies for “standards of care during a mass casualty event”? 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Extremely useful Very useful Somew hat useful Not very useful (Optional) Comments • Really are no “practical solutions” yet, really new untalked-about topic. • Essentially, there are no answers anyone can give right now— but this brought to light all the important issues that need to be addressed. • Format was excellent! Facilitated exchange of a large amount of information. • [It did not provide many practical solutions . . .] but, it was ex- cellent in raising the issues that need to be solved. • We need to get more “in the weeds” and discuss things like dis- aster charting, contingency planning, etc. • Policies in place are still in their draft stage; until a more perma- nent issuance occurs it is difficult to take action of any kind, meanwhile examples of other states’ drafts help! • I wish there was a protocol course that was mandatory for all EMTs and above to take for hands-on tactics or at least directed in the right direction for such. There should also be refresher courses for something such as disasters here and in other states.

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115 APPENDIX D • I think it’s important to exchange ideas to formulate new or re- fine existing concepts. • As expected at this type of event—more questions than answers! • The Interstate Disaster Medical Cooperative (IDMC) group was one practical effort discussed that I think has the potential to im- pact every community. Total responses to this question: 10 10. If applicable, please describe any practical solutions the work- shop helped you to identify, and briefly describe the next actions you will take. [Sorted by response to Question 5: Prior work] Prior work: Have done a significant amount or some work on this topic • Don’t have to reinvent the wheel. Good contacts and references to learn from. • This workshop has validated many of the concerns shared by li- censed healthcare providers in our area (FL). However, the pol- icy makers and regulators in our state have not provided a forum for discussion and input from those in the trenches; perhaps this is something we can work on. • Use of quantifiable scoring systems to determine priorities in provision of vaccines and antivirals in a pandemic. • Policies need to pay particular attention to inclusive language, [that is,] consider population dynamics and demographics. • We need to have much more of a discussion with our communi- ties. The public cannot have expectations of a usual standard of care in an extreme event that results in such an impact on capac- ity and capabilities to provide that care. • I think the workshop is a bit too esoteric and the panel’s thought process needs to be more focused on operationalizing the basic concepts. • Would like to have seen the conference a little more policy spe- cific related to hospitals and redelegating roles to unlicensed per- sonnel, and more about how and what to do just-in-time training.

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116 CRISIS STANDARDS OF CARE The conference was very broad and not user specific enough. . . . • I will move forward on the expenditure of $3 billion in the buildout of WNIS infrastructure in NYS with anticipation of a useful outcome if the pandemic should evolve into a major mass casualty, which is unclear as yet. The area of concentration will be to extend primary care into the community and minimize the assemblage of people around one or more infectious carriers in what a local hospital calls an alternate care area; to me it is an inoculation center and should be avoided. I find it especially risky to draw in potential carriers into close contact with patients with other illnesses, which may be impairing their ability to evoke an effective immune response. The expenditure will, in the current financial condition, require the assistance of the Fed- eral Reserve to facilitate the issuance of debt directly or thru a participating primary dealer of the Federal Reserve System. The provisioning of funds will allow the purchase of empty St. John’s Hospital and Mary Immaculate Hospital in Queens, NYC, from bankruptcy court and the provisioning of those facilities for a possible increase in patient population. • Meeting with stakeholders to develop consensus. • Developing our philosophical statement, including the ethical platform. Ideas for implementing altered standards of care via governor’s Executive Order at the time of crisis and implement- ing via the state EOC versus working through the state legisla- ture to pass language. Total responses to this question: 10 Prior work: Had not done any work on this topic • Work with staff to create policies/procedures. • Further workshop, stay informed and current. . . . • I found there were people there that pointed me in the right direc- tion on how to obtain a state-to-state registry, but what I can’t understand is why does not every state acknowledge this (NREMS) and why is there yet ANOTHER charge for taking the test for the first time? • Tools with their limitations for rationing scarce resources. Tools to begin the discussion with leadership.

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117 APPENDIX D • We need to really address standards of care. I will contact our lo- cal CCDPH rep. concerning this and request guidelines that I can share with neighboring communities, as well as my own. • The effort [made by] the IDMC, spoken of by Tim Conley, is something I am going to look into to make sure my municipality is participating in. Total responses to this question: 6 11. Overall, how useful did you find the workshop in facilitating dia- logue and relationships among stakeholders? 60% 50% 40% 30% 20% 10% 0% Extremely useful Very useful Somew hat useful Not at all useful (Optional) Comments • I imagine it was more useful for the other people there who are from the same area. • I learned a great deal from the various experts. I was most disap- pointed that FL Board of Medicine and Nursing, Agency for Health Care Administration, and Emergency Management were not active participants. Lines of authority among these agencies once an emergency has been declared need to be established, espe- cially among public and private healthcare providers who may have to resort to some form of altered standards of care. At present there is little interface.

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118 CRISIS STANDARDS OF CARE • Networking opportunities were tremendous. Would have liked more time to speak with other participants. • I greatly appreciated the significance of ongoing dialogues as noted above. However, my situation demands dialogues and com- munication within our institution, as well as without. I am con- cerned about these internal communications issues, as well. • I have made some important contacts and hope others have gained some insight. • I was sorry that more people were not able to attend due to H1N1 or other reasons. • Networking is always most helpful. • The dialogue that ensued was most interesting and informative, particularly hearing different viewpoints from different areas of expertise. Total responses to this question: 8 12. If applicable, please elaborate on how the workshop helped (or will help) you to develop relationships among stakeholders. • Good sound structure given for basic and advanced networking. • Listening to the panel discussions helped to raise awareness of the many different types of scenarios. • I was pleased to be able to meet others who are working in this area, and anticipate that now knowing them will be of great value to us in our anticipated project on legal issues involving altered standards of care. • I made contact with some stakeholders, and hopefully plans for networking will materialize. • It’s always interesting to hear differing opinions. Requesting clari- fication on those “differing opinions” allows us to better under- stand and therefore work more synergistically with one another should the need arise.

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119 APPENDIX D • It was great to meet other “like minds” who are interested in this topic. I liked the way there was a panel of presenters on each topic. • My actions are dictated by my position as an MRC member. • It was very informative and will help to get the information that I have learned out to others, including other EMTs and higher that I work with. • I will maintain ongoing communication during mass casualty events. • Ability to know who individuals are, more than presentation con- tent, which was quite rushed. • I became aware of experts in this area and who needs to be in- cluded in efforts to develop guidelines. • It always helps to put faces with names and begin to establish per- sonal relationships with others concerned about the same issues. • I collected business cards from those states that were developing similar frameworks to Oklahoma. • Developed contacts in Illinois that will help with crossborder is- sues. • Although I knew many of the attendees, it is always helpful to hear this discussion together. And it is helpful to give feedback to the presenters. • I will need to meet with our local hospitals (one was represented at this workshop) and learn what their particular standards of care are in an emergency. • It helped me to identify the areas where we need to work on building relationships. Two such are with residents and doctors. • The workshop offered a forum with some “familiar local faces” that I now know are involved and can partner with as well as in- troducing new organizations/individuals that I can reach out to. Total responses to this question: 19 13. Is there anything else you would like to tell the workshop plan- ning committee, for example:

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120 CRISIS STANDARDS OF CARE • About issues that you did not feel were sufficiently ad- dressed during the workshop? • About next actions you intend to take on this topic? • About the organization of the workshop? • Will use the available links and resources for additional help and info. • Bring the Trial Lawyers of America on board. • I would like to have the opportunity to work with some of those who presented in the workshop when we begin our project on legal issues related to altered standards of care. Thank you for put- ting on this workshop and for giving us the opportunity to be in- volved. • (1) There needs to be transparency/accountability for federal fund- ing; tracing the money has been impossible once it is released to the state (FL). Application/distribution/results of this funding are also a mystery. (2) Interface among county health departments, emergency management, and healthcare facilities and providers is weak. There is confusion about lead authority and roles/responsibilities. (3) Liability issues for healthcare provid- ers/facilities have not been adequately addressed. (4) Suggestion for next workshop topic: View from the Trenches. It is my belief that there is not enough exchange of info between these levels and we could be missing some important issues/lessons. Next action: We will be meeting with hospital and community leaders to frame/discuss these issues and try to engage state officials. The panelists and experts were excellent sources of information, but as I stated on previous answers, the lack of participation by profes- sional boards/regulators and public health preparedness from FL was quite troubling. Thank you for the opportunity to participate in the workshop and survey. Keep up the good work. • Minimal attention was paid to the relatively large psychological footprint of a multicasualty disaster, especially to the value of group crisis intervention when staff [are] limited. Individual psy- chological first aid would be quite impractical in large-scale inci- dents.

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121 APPENDIX D • Great job presenting the issues and bringing the stakeholders to- gether. • I thought it was done overall very well. • It was time well spent. A few folks seemed to use the time to “vent,” which is fine—there is nothing wrong with expressing a real concern over an important issue or frustration; however, at times it seemed redundant. After the worries are expressed, we should concentrate on solutions. • Need a clinical workshop directed at the operational side of provi- sion of care during an extreme event. This workshop could provide guidelines for the evidence base to support contingency planning when resources are scarce. • More workshops with the experts in the field are extremely satisfying. • Future workshops should utilize speakers who are focused on the issues, not focused on their personal accomplishments or showing off their vocabulary. • Have the next event posted on listservs for American College of Physicians, American College of Emergency Physicians, and other professions. • I would like to see someone come out with a better way to bring all the states together so that certification would not be so difficult to get and not only in disasters. I feel that if we as emergency medical services give of ourselves in disasters/mass casualties and we are recognized then, we should be recognized nationally with- out having to take other exams. If we are capable at those times, is it not feasible that we are just as capable when there is not? • I think a separate committee must be established to coordinate the development of e-tel nursing medicine as a viable intervention in mass casualty events. I will chair such a committee. • I felt the presentations were hurried; I’m not sure what solutions exist to this problem other than follow-up information, notes, etc., that will be provided. • No, it was well designed, attended, and implemented.

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122 CRISIS STANDARDS OF CARE • Too much emphasis on bio events, which is understandable as the participants were mainly public health and government agency types who work in bio fields. But bio events are real outliers in the realm of disasters, being one of the least likely mass casualty sce- narios and having a prolonged time course unlike virtually all other forms of disaster. [They] give time for surge to develop and to discuss altered standards that most disasters do not, as most dis- asters occur immediately with immediate overwhelming of re- sources with no warning—there is no progression from conventional to contingency to crisis over days to weeks in most disasters—it is conventional to crisis in 15 minutes. And therefore some of the issues and challenges, especially the time constraints and chaos. are quite different. An honest effort must be made in meetings such as these to broaden the perspective and understand that as important as bio events are to prepare for, their actual level of threat is quite low—look at history and read the newspapers to see what threats face us everyday. The feds and the AMA and CDC must get themselves out of this fixation on bio while ignor- ing the more likely scenarios. Ethical and moral and medical is- sues cut across all disasters and should not be just applied to influenza pandemics. • Pediatrics always needs more emphasis, since 25 percent of the population in the United States is children; people are developing tools (Akron, OH, for example), but then “they are not applicable for children.” It was helpful to hear the debate on whether scoring tools developed for adults can be transferred to children. The or- ganization of the workshop was easy to follow and helpful to ob- tain a wide perspective. The audience participation was also useful. I only wish a number of my colleagues could have partici- pated. • I would have benefited from more discussion regarding the differ- ent states’ strategies to actually implement their altered standards of care within the political climate of their state. For example, MO has made progress, but has a new governor. If the state is relying on a governor’s Executive Order, what happens with a new gover- nor? Are any states trying to pass language within the state legislature? • We could have talked all day on this topic! Perhaps more time for just open discussion.

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123 APPENDIX D • Please find ways to engage the physician stakeholders. • Thank you! • I would have liked to hear how EMS Incident Command will in- teract. • It was a very interesting workshop. I am not sure if I will use the info, but it was reassuring to know that we are on the right track in our planning. • The organization was excellent! • Thank you to the AMA for hosting the workshop and to the IOM for making it available to those of us in the community. • Overall, I was very impressed with the workshop planning and fa- cilitation. I would like to see continued follow-up information and contact (such as this survey) to maintain channels of communica- tion. The workshops offered a method of outreach to regional, state, and local participants and I would encourage you to cultivate those contacts. • It would have been helpful to better understand the IOM’s even- tual overall goals with defining standards of care in a mass casu- alty event. Will a guideline be published as a result of these workshops? The frustrating thing is that so many efforts are hap- pening on many different levels, and I feel that there is much rein- venting the wheel going on that might be unnecessary. I was hoping this workshop would help in outlining general accepted standards to be adopted and supported everywhere. Total responses to this question: 28

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