5

Implementing Crisis Standards of Care Across Sectors

To encourage more detailed conversation within various disciplines, participants spent a portion of the workshop in groups divided by sector, consisting of emergency medical services (EMS), state and local public health, health care, vendors, subspecialties, and legal entities. The focus for their initial convening was simply on highlighting challenges and opportunities for crisis standards of care (CSC) planning, given everyone’s experience in the past decade. The second focus of each sector’s discussion was charting a potential path forward for future CSC planning. Within this context, participants were asked to consider the importance of systems and processes over a prescriptive plan, building from the bottom up to drive regulatory and administrative supports, and how technology can assist in the allocation of resources, real-time triage, and information sharing. This chapter summarizes the highlights across the six sectors, as well as some common areas that emerged across the system that can guide the forum and relevant stakeholders in future planning.

EMERGENCY MEDICAL SERVICES

Challenges and Opportunities

Ira Nemeth, associate medical director for EMS and LifeFlight at UMass Memorial Hospital, reported out from the EMS group on challenges and opportunities for CSC. There were very few examples of implementation in the EMS world that the participants could come up with, he noted. It is fundamental for EMS providers to follow protocol, he said, so stray-

ing from that and explaining the concept of adjusting protocol in certain scenarios is a challenge for their workforce and will require a different mindset. As an opportunity, he said many of the participants discussed how there is a need to find better ways to engage the EMS community—whether through health care coalitions or using financial leverage. Nemeth highlighted examples from Texas, where they involved their EMS community in planning after many experienced financial losses during a previous event. They found they were more likely to participate the next time there was an opportunity. Overall, Nemeth said it is important to have EMS systems as a whole at the table because they can be extremely variable depending on location and infrastructure.

Exploring the Way Forward

Regarding potential actions and new ideas guiding CSC for EMS over the next 18–24 months, Nemeth said that engagement was a big topic that came up during their discussions. There are all these different players, he said, but how do we find ways to get them engaged? He suggested “give something to get something”—first identifying what needs they have as a sector and how this type of planning and partnership can be mutually beneficial. He also suggested making CSC planning an opportunity for leadership, saying it could be a way to bring people up at the provider level. Leaders in CSC planning have also not done a good job of presenting and disseminating this information at national EMS conferences, he added.

Other areas for improvement described by several participants include working within a region to ensure that the EMS office, which is usually housed within the public health department at the state level, is connected to those in public health working on CSC, as well as the other critical first responders such as police, firefighters, emergency managers, and those who run the dispatch center. These are all important players, he said, but they often are not engaged on this topic and do not participate. Nemeth also identified the lack of penetration of CSC into the health care community, saying we need a more practical way to get some of these concepts into the hands of practitioners. There is a wealth of information being developed in plans, but it is not making it down to the level where the action happens. There are also likely lots of events where providers are implementing CSC—whether they know to call it that or have a written plan, Nemeth said. For example, the 2017 mass shooting in Las Vegas resulted in mass casualties and overwhelmed area hospitals, so naturally, health care providers innately implemented a type of triage or scarce resource allocation. But we want to capture that more formally and advance the lessons, and pair them with the years of planning experience we have accumulated for others who may find themselves in similar situations, Nemeth concluded.

Fink added an important point during the discussion related to the prehospital response following Hurricane Harvey in 2017. She said 911 dispatch completely stopped triaging calls once they became overwhelmed, so even the ability to implement standards that might be appropriate in that situation was impossible, and they had to stop receiving calls. She said the county had set up their criteria for the allocation of first-response resources in a mass emergency, which was described as a life-threatening situation such as high waters or a medical emergency. But she noted that the way the system was set up did not allow for this altered allocation to be executed. There were so many steps along the way that if one broke, she said, the standard of care could not be completed as intended. She also agreed with Nemeth’s point about emphasizing the importance of EMS to the whole system, saying that if they are not included and accounted for, the patient may not even make it to the hospital.

STATE AND LOCAL LEVELS

Challenges and Opportunities

Steve Huleatt, director of health at West Hartford-Bloomfield Health District in Connecticut, described the challenges and opportunities discussed by several participants in the state and local public health group. The biggest issue we saw when taking a look back over the years was engagement, he said, and getting the right people to the right places to add value to the conversations. While getting buy-in from leadership is important, he also pointed to the need to make the process meaningful for people to participate at the ground level. He also said that words matter, noting that people may struggle with the term CSC because it really is not a linear planning process. According to Huleatt, most of the process has been much more dynamic. Huleatt suggested possibly shifting the terminology to “creating a framework” instead of “developing a CSC plan” and that finding terms that work for the majority can help get more people to the table, such as through hospital partnerships. In places where hospital and public health partnerships have been active, he said, they have seen a lot of success due to this increased participation and more robust dialogue, leading to a more advanced and well understood framework in the community. A similar challenge over the years is that people have different interpretations of words. He said that how you explain CSC and build its importance among clinicians and different specialties may need to be tailored, and that communication across the board is an area that has the most room for improvement.

Another challenge Huleatt described is that communities are sometimes being asked to create environments that are beyond their reach, but the plan

should really be something that can move horizontally across sectors within a jurisdiction. For example, local health departments are often asked to secure a designated “place” as a shelter or alternate medical facility during a disaster (which is often a high school gymnasium). But they also need to ensure that the right kind of medical care can be provided there, while also meeting the needs of vulnerable populations and those with disabilities. He suggested the states take on a bigger role in this, although some home-rule states would not be able to tell localities what to do. Huleatt suggested that some groups have been afraid to fail, so they have put off even starting this planning process. Finally, he said this type of planning is really a form of continuous quality improvement, and needs to be thought of through the lens of ongoing learning. A lot of this conversation has taken place inside clinics or health department walls, so we need to bring the conversation to the community so they can help us figure out the gaps. He added a last opportunity of leveraging the breadth of public health as a strength. “We can be a liaison role to the emergency operations center,” he said, “a conduit to local emergency management, the acute hospital setting; it’s important for local health to be the connector.”

Exploring the Way Forward

“The first observation I have,” Huleatt posited, “is a theme to generate awareness of the CSC planning process, including what it is, how it is socialized, and other related campaigns.” That kept emerging during discussions, he said. His first suggestion for action was conducting a national assessment, because currently there is a lack of clarity about where various jurisdictions are in their understanding, planning, and drafting processes. He added that this was not to be critical or create more work, but understanding the progress of various entities across the country can provide a much better vision. In order to execute this well, he noted, we need standardization of terms as part of this assessment definition package. It is also necessary to better understand the different authorities at play in that assessment, at all levels, and to see which are being used in each planning process in order to see which groups have to respond and to whom. He called for a simple implementation toolkit that could act as a roadmap for CSC plans. Huleatt envisioned this toolkit to include evaluation guidelines, specific tools, and be designed for use in the institutional realm and emergency management. He saw the target audience being geared more toward the emergency management component of an institution versus the typical C-suite executive leadership. This effort could also include a “train the trainer” program to ensure the toolkit is being used correctly, and the development of communities of practice related to CSC. For those who are knee-deep in this planning process, having other people at similar levels or

other like-minded institutions at the same place to draw insight from could be really beneficial.

Reiterating his previous comments on engagement, he said they would really benefit from figuring out which levels of government need engagement for different activities. The federal level might require certain agencies to be involved, but this may be different at the state level. Finally, he expressed support for public–private partnerships (PPPs) and engagement to add value to CSC planning efforts, as demonstrated through the numerous infrastructure issues that were presented at the workshop, creating complex challenges outside of hospital walls.

HEALTH CARE SETTINGS

Challenges and Opportunities

Eric Toner, senior scholar at the Johns Hopkins Center for Health Security, presented the salient points from the discussion of challenges and opportunities among participants in the health care setting related to CSC. He noted that CSC as a whole has not been frequently exercised, saying that part of this is because it is difficult to create those types of continuum/crisis exercises. One participant said that they created a role for ethicists within their incident command system structure at their institution, which Toner said was a novel idea. Another barrier identified was political pushback. Often, when professionals try to talk about CSC, they are told by elected officials not to discuss it, he said. But if more groups knew they were not “alone” from a legal perspective with what they are doing, and that neighboring facilities are doing similar work, it would be easier to begin some of these conversations knowing they are consistent with like-minded institutions.

Opportunities was our richest area of discussion, Toner noted, especially regarding getting the message of CSC out to those who have not heard it yet: practitioners, members of the public, and people in government. Another novel idea was to leverage large employers that have their own health offices—specifically those of large health systems. These companies often have robust occupational health programs that serve employees and families, and he said they were an untapped resource for CSC messaging. He also advocated for peer-to-peer teaching and learning on the topic, saying nurses want to hear from nurses, doctors from doctors, and so on, so they can best understand the implications of CSC within their own discipline. Toner also reiterated Nemeth’s suggestion for better using national conferences and specialty societies for extending current messaging. We do not think about frequently occurring events as enough of a crisis to meet the threshold for CSC discussion at this national stage, he said, noting that this is another challenge with using the term “crisis.” But incidents happen all the time that

force area health institutions to consider some of these principles, such as the ongoing problem of drug shortages, resulting in contingency situations happening every day. For example, he said, why do we not use the mass shootings that are becoming more and more frequent as an opportunity to discuss altered standards of care? We could find providers in hospitals who have experienced this to share how they reacted and handled the event. Whereas those of us who have been working on this a long time initially started with catastrophic scenarios to force people to think differently, Toner said, we had a lot of discussion about using the contingency scenario as a better way to introduce the topic and concepts. It could be helpful to learn from these drug shortages and surge events and acknowledge them as managed crises—reaching a threshold requiring different thinking for provision of care. Additionally, this could allow for recognition and documentation of the providers who found creative ways to handle patient surge. Lastly, he suggested another potential opportunity of mirroring the position of a historian at the Centers for Disease Control and Prevention (CDC). He said their job is to record events for future learning whenever something happens, and because they are not intimately involved in the response, they are somewhat removed with a more objective observer perspective.

Exploring the Way Forward

For concrete suggestions on immediate future actions for the health care setting, John Hick, professor of emergency medicine and medical director of emergency preparedness, Hennepin Healthcare, University of Minnesota, shared a series of ideas from their wide-ranging discussion:

• Enhance the CSC conversation—share more of the conceptual elements at national conferences to advance the framework.
• Partner with large employers—their crisis communications and ability to leverage occupational health offices, closed points of dispensing, and other resources can provide an extension of the health care system.
• Education: Continuing and Medical School
  • Work with providers to offer bite-sized education pieces, especially with emergency managers within hospitals.
  • Work with medical schools to introduce the idea of scarcity thinking, whether it is choosing different antibiotics or approaches to patient care, with the idea of getting comfortable with restrictions on their options.
• Leverage cooperative agreements
  • The new hospital preparedness program (HPP) clinical advisor position is required within the HPP agreement. These medical

• • providers can be key champions in advancing planning efforts, but they need the right education.
  • Find ways to leverage HPP and CDC’s Public Health Emergency Preparedness program to expand the contingency care phase so people are less likely to jump straight to crisis mode.
• Test CSC operational frameworks—offering functional exercises and scenarios based on real-world examples. Drawing on lessons learned from events like the Las Vegas shooting can inform exercise toolkits that health care facilities can use to advance their process.
• Decrease emphasis on specific tools—the evidence base is not currently robust enough for predictive tools. Reinforce the concept of triage as a spectrum and think equally about offering more resources to people as the resources become available during a response.
• Leverage technology
  • There is a huge opportunity to leverage programs like Project ECHO (an online collaborative platform currently in use in many institutions), clinical consultation and discussion, just-in-time education, and telemedicine to expand clinical practice.
  • Merge data streams with solutions like Digital Bridge to put information together in relevant, usable ways to understand the impact of illness on systems and help improve patient tracking and family reunification.
  • Convene discussions on PPPs in health and technology to better understand the needs of the end user.
• Develop a research agenda in disaster medical care
  • While there has been a lot of research effort by various individuals, having a more set agenda for the right questions that need to be addressed, as well as the right data sources and analyses to use, can create an opportunity to advance medical care during these events, as Fink has called for numerous times.
  • Also needed is a more robust toolkit, including a step-by-step approach, for expansion of critical care research at hospitals.

VENDORS

Challenges and Opportunities

Suzet McKinney, executive director and chief executive officer, Illinois Medical District, provided insight on the discussion from the perspective of vendors in the CSC context, especially the supply chain. She highlighted a challenge from the 2014–2015 Ebola outbreak, where one federal agency

was driving decisions around supply chain and how resources would be redirected, but those decisions were made without the context of other federal agencies redirecting travel for incoming persons from West Africa to certain U.S. cities. This led to the realization that greater levels of coordination are really needed across the federal government and extending down to state and local government and private industry. Using this context as a backdrop, McKinney provided four leverage points to enhance CSC planning across the country:

• Defining decision triggers across distributors, manufacturers, and government, recognizing the critical need to advance understanding across systems. Whereas private companies may make decisions from a business-case lens, these decisions may not necessarily align with governmental needs for response. There is a need to use peacetime to advance understanding between these two sectors.
• Examining systems and processes to increase manufacturing capacity, avoid bottlenecks, and identify mechanisms for quickly resolving problems with the supply chain once it occurs, for response effort.
• Exploring the threats and barriers to integration of CSC principles. Understand what role predictive modeling tools play in driving decision making, who owns those decisions, and who is looking at trigger points across the supply chain and making those decisions.
• Ensuring consistency across sectors with regard to planning assumptions, so that all supply-chain stakeholders can operate under the same scenarios.

Exploring the Way Forward

With regard to operationalizing some of these leverage points and opportunities over the coming months, Nicolette Louissant, executive director of Healthcare Ready, gave four priority actions for improving supply-chain planning related to CSC. First, she said, there should be a focus on streamlining coordination across government. This can help distributors have a clearer picture of what the demands are and who is prioritized and when. It would also assist for those working under contracts and to better order how to move products during events. She also suggested a need for improving the understanding of legal and regulatory levers, as well as other emergency actions that would be available in a crisis, and how those levers might change the resources that can be used during an event. Next, she called for entities to be clearer about characterizing events where contingencies are needed and having coordination points with supply-chain

vendors to understand the needs for alternative products, how much elasticity exists for those products, and what cascading impacts might result from using these alternative products during an event. Louissant also proposed developing a supply-chain playbook that outlines decision triggers, the public health impacts of these decision triggers, and what a PPP would look like during a declared emergency. She saw this effort as being largely driven by the private sector and presented to the public sector for partnership and input from providers and a range of associations, including medical toxicologists, EMS, pharmacists, and supply-chain actors. Finally, she highlighted the role of various technologies, and said that we need to do a better job of understanding manufacturing technology and other changes in medical product production that could enable greater elasticity during catastrophic events.

SUBSPECIALTIES

Challenges and Opportunities

Freda Lyon, vice president of emergency services at Wellstar Health System, described a need to measure CSC across the system from prevention all the way to recovery and rehab—and importantly, including the voices of survivors. She emphasized the importance of those voices, saying care providers often do not hear much about these, making it difficult to incorporate their perspective. Reinforcing other points about communication and dissemination challenges, she also saw a need to talk more about metrics and dissemination science to better understand the optimal ways to share the message. She suggested a national institute of trauma to address all elements of care, and then look at what is missing related to guidance. Lyon also highlighted a weakness of emergency plans as being “all-hazards responses,” which really does not work for implementation of response, but is required by regulatory bodies in health care.

As an opportunity to improve engagement, she suggested that government agencies try to meet stakeholders where they are, and first ask them what they need, and address their goals, before sharing their own. She also called for more research specifically on combined burn and radiation, and highlighted the importance of a trained workforce in this area and the current lack of capacity for subspecialties.

Articulating the Way Forward

Providing thoughts on future actions for subspecialties in the CSC planning context, Lyon explained that there is a need to identify levers of implementation and spread of CSC, including champions for each lever. She

said that their group discussed three components of these levers: regulatory, data, and science, and described specific actions as follows:

• Regulatory: Offer continuing medical education related to CSC for providers to renew licensure—including nursing, advanced practice providers, and physicians. Define reasons for collecting data. Include CSC in standards of emergency preparedness for regulatory bodies.
• Data: Establish a data registry for drills and actual events. Define common data elements, create a national data center, and define metrics and standards (with consensus) for CSC so that, when exercises occur, there is a framework for identifying success.
• Science: Fund and conduct research to understand barriers to the implementation and dissemination of CSC. What are end-user goals? There is a need for qualitative data to understand where respective groups are, similar to the national assessment that Huleatt suggested. Drafting white papers and other publications in well-read journals can amplify the work that has already been done around CSC. Identify information scientists to improve messaging. Develop degradation tables for specialties such as pediatrics, trauma, and weapons of mass destruction so that tools will be available for the end user to take and apply when the situation arises.

LEGAL ENVIRONMENTS

Challenges and Opportunities

Mirroring the robust ethical-and-legal panel discussion, Marie-Claire Brown, counsel at the Department of Health for the District of Columbia, provided highlights from the dynamic breakout discussion of CSC challenges and opportunities from a legal perspective. The overarching question they addressed was when laws should be a barrier in population-based responses to decisions. Another important question spurring conversation was how to incorporate special-needs populations. She acknowledged the changing legal landscape, including things like liabilities, duties to plan, reciprocity, and scope of practice. But in addition to the legal environment, there are also ethical issues related to defending tough choices. As one of the biggest barriers to future CSC work, she highlighted the fear of liability that so many jurisdictions have, resulting in avoiding the effort entirely. She said this is often likely due to uninformed counsel, as not every jurisdiction will have people well trained and ingrained in these types of issues, which are constantly changing. Brown mentioned the Network

for Public Health Law,¹ and offered their resources on legal preparedness that can support organizations that have legal counsel hesitating to get involved in planning.

Brown highlighted a gap, saying that counsel is typically not fully engaged in emergency preparedness scenarios and planning and she suggested creating a mechanism to the effect of a stat consult with learned counsel, to be rapidly mobilized in an emergency. This could provide rapid access, just-in-time legal advice with subject-matter experts. She also suggested having advanced standing orders that can be applied in various scenarios ahead of a declared emergency. Hick asked who would give permission for the standing orders and where they would come from. James G. Hodge, Jr., professor of law, Sandra Day O’Connor College of Law, Arizona State University, noted that it depends on the location. There is capacity within some states for the health commissioner or another designated person (via state legislature) to issue standing orders by pharmacists, nurses, or others, before a declared emergency that could be temporarily valid. For example, he continued, there are circumstances where vaccines can be given for a temporary period of time, or someone could be prescribed naloxone if needed due to the opioid epidemic.

Exploring the Way Forward

Reporting back again from the legal perspective, Brown explained that their underlying assumption during the discussion was that trigger standards are amorphous. We need to figure out how to go about consistent implementation, she said. She continued with three important actions to advance this sector in CSC planning:

• Reassess and redefine triggers for invoking CSC. This includes not only when to invoke alternate standards but also defining legal triggers for when CSC would not be invoked. Much of this could be added as annexes or appendices, without changing the foundational text and definitions of original reports and plans. More specifically, this effort would also include
  1. Developing more national triggers, particularly in cases where the crisis does not rise to the level of a “public health emergency” (i.e., the opioid crisis).
  2. Standardizing triggers so it is easier to operate across a region. Washington, DC, did not declare an opioid epidemic, but Vir

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¹ For resources on emergency legal preparedness and response, see https://www.networkforphl.org/resources/topics/emergency-legal-preparedness-and-response (accessed February 6, 2020).

• 2. ginia and Maryland did, which can lead to confusion for a metropolitan area that crosses multiple state lines.
  3. Focus on consistent implementation across different scenarios.
• Create more accountability. There is not only a duty to plan, but also an implicit duty to learn. She supported the suggestion of a National Transportation Safety Board–like body to help manage accountability. This could also be used to appropriately oversee the use of volunteers and ensure that practitioners are held accountable for unwanted decisions.
• Operationalize CSC principles into planning. Baselines already exist, with lawsuits filed in New York, Los Angeles, and Washington, DC, that can provide lessons and gaps that still need to be addressed. We can no longer have the excuse that “we didn’t know,” she said, and being armed with all of the legal information available is the best way to proceed. Some potential methods for achieving this include
  1. Invoking a legal preparedness requirement for facility licensure or accreditation.
  2. Using continuing legal education to mandate or incentivize facility counsel and others involved in the process for standard education, tied to HPP funding or Centers for Medicare & Medicaid Services preparedness requirements.

EXPLORING NEXT STEPS FOR THE OVERALL SYSTEM

Several speakers acknowledged “engagement” as one of the key challenges encountered by CSC groups and planners over the past decade. Some examples were lack of engagement of elected officials during recent hurricanes, and others were difficulty engaging leadership from various non–public health sectors. Potential solutions ranged from presenting the topic at more national-level conferences across various sectors—whether health care or EMS or subspecialties—to broaden mindsets when thinking of what “CSC” looks like, or what type of event warrants a CSC discussion. A few participants had also suggested leaning away from the catastrophic examples of events that would result in CSC, because they are much lower in likelihood, and instead trying to engage more people by focusing on the more routine daily emergencies that might dictate contingency standards. These could include drug shortages, active shooter events, large bus crashes or motor vehicle accidents in rural areas, or small-scale epidemics like the 2015 botulism outbreak in Ohio (McCarty et al., 2015).

The question of terminology was brought up multiple times, with one participant saying that maybe we are still not addressing the issue that

people are fundamentally uncomfortable with—the term “crisis standards of care.” Though everyone’s talking about engagement, she said it might be difficult until people are comfortable with the term in their own communities. Hick replied that this has been discussed, and stakeholders involved have considered changing the term, but eventually decided to instead focus more on the concepts and elements instead of the term itself. For example, he said teaching the elements of CSC does not mean people even need to know the terminology and what happens next and how the spectrum looks. Teaching medical students scarcity thinking does not mean they have to learn this report with these definitions, he said. With the advantage of many years of hindsight now, Hick explained that shifting from conventional to contingency to crisis modes does not mean you are crossing a bright red line, it is more of a very blurry, gray area in between each phase. He proposed revisiting the spectrum to see if there was a better way they could articulate the graceful degradation more than the current diagram shows.

Several people also discussed the need to define common standards within the field to reduce confusion and ensure that decisions are being made the same way across a jurisdiction or region (or if not, understanding how they differ). Related to standards, Lyon specifically recognized the challenge of not having a common definition for pediatric age. Looking at all the entities I interact with, she said, including trauma, pediatrics, and burn centers, everyone has a different range of ages for who is considered a pediatric patient. We need a standard definition so everyone can operate with the same understanding, and so research could be stronger and more informative.

Dan Hanfling of In-Q-Tel made a final comment, saying that his takeaways from the discussion are the key fundamental goals of improved awareness, education, and implementation. Practice communities should be comfortable within their own domains with how things are defined, he said. In Illinois, we used the term “catastrophic emergency annex” because the emergency managers in the state said they did not understand “CSC,” but how an “annex” fits within their overall emergency operating plan makes sense to them. While multiple participants suggested the creation of a toolkit or implementation guides, and moving between phases in the continuum, Hanfling pointed out that the 2013 report released by the Institute of Medicine identified specific actions for each sector that could be used as a starter kit (IOM, 2013a). The report also has resources emphasizing that this process happens over a continuum, he said, and perhaps can be used as additional awareness campaigns are developed before creating anything new. Hick added that the gray areas represent a fundamental tenet of the 2012 report—that of proportionality. Implementing the least restrictive or least difficult decisions possible in order to maintain consistency of care throughout the system is constantly the goal, he said. We have seen cases

where proactive triage guidelines were well intentioned but having a fraught declaration with sweeping powers may not always be helpful for the problem at hand—so rushing to use legal powers just because they exist does not mean they are indicated to solve that problem in that setting. We need to help providers understand that they should be doing everything they can to stay as close to conventional care as possible, he said. Proportionality in CSC is important to keep in mind.