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Barriers to Integrating
Crisis Standards of Care Principles
into International Disaster
Response Plans

Workshop Summary

Bruce M. Altevogt, Clare Stroud, and Theresa Wizemann,
Rapporteurs

Forum on Medical and Public Health Preparedness
for Catastrophic Events

Board on Health Sciences Policy

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

www.nap.edu



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Barriers to Integrating Crisis Standards of Care Principles into International Disaster Response Plans Workshop Summary   Bruce M. Altevogt, Clare Stroud, and Theresa Wizemann, Rapporteurs Forum on Medical and Public Health Preparedness for Catastrophic Events Board on Health Sciences Policy

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THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, NW • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This project was supported by contracts between the National Academy of Sciences and the American College of Emergency Physicians; the American Hospital Association; the Ameri- can Medical Association; the American Nurses Association; the Association of State and Ter- ritorial Health Officials; the Centers for Disease Control and Prevention (Contract No. 200- 2005-13434 TO #6); the Department of the Army (Contract No. W81XWH-08-P-0934); the Department of Health and Human Services’ National Institutes of Health (Contract No. N01- OD-4-2139 TO #198 and TO #244); the Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (Contract Nos. HHSP233200900680P, HHS P23320042509X1); the Department of Homeland Security’s Office of Health Affairs (Contract No. HSHQDC-07-C-00097); the Department of Homeland Security’s Federal Emer- gency Management Agency (Contract No. HSFEHQ-08-P-1800); the Department of Transpor- tation’s National Highway Traffic Safety Administration (Contract No. DTNH22-10-H- 00287); the Department of Veterans Affairs (Contract No. V101(93)P-2136 TO #10); the Emergency Nurses Association; the National Association of Chain Drug Stores; the National Association of County and City Health Officials; the National Association of Emergency Med- ical Technicians; the Pharmaceutical Research and Manufacturers of America; the Robert Wood Johnson Foundation; and the United Health Foundation. The views presented in this publication are those of the editors and attributing authors and do not necessarily reflect the views of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-22178-8 International Standard Book Number-10: 0-309-22178-1 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. Barriers to integrating crisis standards of care principles into international disaster response plans: Workshop summary. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal gov- ernment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of out- standing engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the sci- entific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Re- search Council. www.national-academies.org

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Workshop Planning Committee* FREDERICK BURKLE, Harvard School of Public Health DAN HANFLING, Inova Health System, Falls Church, VA IOM Staff BRUCE ALTEVOGT, Preparedness Forum Director CLARE STROUD, Program Officer ANDREW M. POPE, Director, Board on Health Sciences Policy ALEX REPACE, Senior Program Assistant ________________________  Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. v

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Forum on Medical and Public Health Preparedness for Catastrophic Events* ROBERT KADLEC (Cochair), PRTM Management Consultants, Washington, DC LYNNE KIDDER (Cochair), Center for Excellence in Disaster Management and Humanitarian Assistance, Tripler AMC, Honolulu, Hawaii (from September 2010) ALEX ADAMS, National Association of Chain Drug Stores Foundation, Alexandria, VA DAMON ARNOLD, Association of State and Territorial Health Officials, Arlington, VA GEORGES BENJAMIN, American Public Health Association, Washington, DC D. W. CHEN, Office of Assistant Secretary of Defense for Health Affairs, Department of Defense, Washington, DC VICTORIA DAVEY, Department of Veterans Affairs, Washington, DC JEFFREY DUCHIN, Seattle & King County and University of Washington, Seattle ALEXANDER GARZA, Department of Homeland Security, Washington, DC JULIE GERBERDING, Merck Vaccines, West Point, PA (since September 2010) LEWIS GOLDFRANK, New York University Medical Center, New York LYNN GOLDMAN, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (until September 2010) DAN HANFLING, Inova Health System, Falls Church, VA JACK HERRMANN, National Association of County and City Health Officials, Washington, DC JAMES JAMES, American Medical Association, Chicago, IL JERRY JOHNSTON, National Association of Emergency Medical Technicians, Mt. Pleasant, IA BRIAN KAMOIE, The White House, Washington, DC ________________________ * Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution. vii

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LISA KAPLOWITZ, HHS Office of the Assistant Secretary for Preparedness and Response, Washington, DC ALI KHAN, Centers for Disease Control and Prevention, Atlanta, GA MICHAEL KURILLA, National Institute of Allergy and Infectious Diseases, Bethesda, MD JAYNE LUX, National Business Group on Health, Washington, DC ANTHONY MACINTYRE, American College of Emergency Physicians, Washington, DC ANGELA MCGOWAN, Robert Wood Johnson Foundation, Princeton, NJ MARGARET MCMAHON, Emergency Nurses Association, Williamstown, NJ MATTHEW MINSON, Texas A&M University, College Station, TX ERIN MULLEN, Pharmaceutical Research and Manufacturers of America, Washington, DC CHERYL PETERSON, American Nurses Association, Silver Spring, MD STEVEN PHILLIPS, National Library of Medicine, Bethesda, MD ROSLYNE SCHULMAN, American Hospital Association, Washington, DC RICHARD SERINO, Federal Emergency Management Agency, Washington, DC SHARON STANLEY, American Red Cross, Washington, DC ERIC TONER, University of Pittsburgh Medical Center, Pittsburgh, PA REED TUCKSON, UnitedHealth Group, Minneapolis, MN MARGARET VANAMRINGE, The Joint Commission, Washington, DC GAMUNU WIEJETUNGE, National Highway Traffic Safety Administration, Washington, DC IOM Staff BRUCE ALTEVOGT, Project Director CLARE STROUD, Program Officer ANDREW M. POPE, Director, Board on Health Sciences Policy KRISTIN VISWANATHAN, Research Associate ALEX REPACE, Senior Program Assistant viii

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its pub- lished report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report: Michael Allswede, Oklahoma State University Knox Andress, Louisiana Poison Center John Coleman, South Island Shared Service Agency Limited Kobi Peleg, Israeli National Center for Trauma and Emergency Medicine Research Although the reviewers listed above have provided many construc- tive comments and suggestions, they did not see the final draft of the re- port before its release. The review of this report was overseen by Georges C. Benjamin, American Public Health Association. Appointed by the Institute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were careful- ly considered. Responsibility for the final content of this report rests en- tirely with the authoring committee and the institution. ix

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  Contents INTRODUCTION 1 SURGE CAPACITY PLANNING AND CRISIS STANDARDS OF CARE 2 Defining Crisis Standards of Care, 3 Developing National/Regional Crisis Standards of Care: The Duty to Plan, 11 Operationalizing Crisis Standards of Care in Diverse International Settings, 13 Ethical Framework, 15 Community and Stakeholder Engagement and Education, 16 THE INTERNATIONAL HEALTH REGULATIONS TREATY 18 The IHR in Practice: The 2009 H1N1 Influenza Pandemic, 20 The IHR as a Potential Framework for International Surge Planning and Crisis Standards of Care, 21 CLOSING COMMENTS 22 APPENDIXES A References 23 B Agenda 27 xi

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