By Megan M. Krischke, contributor
Oct. 16, 2009 - What changes need to be enacted in your community, and your health care facility, if faced with a public health crisis? It will take more than just an individual disaster response plan. Top health officials are urging local governments to work with the medical community to create standard protocols that can coordinate efforts and ensure the best outcomes for everyone involved.
In response to the anticipated H1N1 influenza pandemic, The Institute of Medicine (IOM) published a report, titled “Guidance for Crisis Standards of Care for Use in a Disaster Situation,” at the end of September. The Office of the Assistant Secretary for Preparedness and Response in the U.S. Department of Health and Human Services (HHS) requested the report, in order to help communities prepare for a situation in which perhaps hundreds of thousands of people across the country would simultaneously seek medical attention.
The committee that compiled the report was composed of top experts from across the United States in the areas of law, ethics, operational medicine and public health. Dan Hanfling, M.D., special advisor for emergency preparedness and response for the INOVA Health System, served as the assistant chair of the IOM committee.
“Hurricane Katrina really made it clear that as a country we need to take a look at developing guidelines and responses to disaster situations and consider that these sorts of terrible catastrophic events can happen. We need to figure out a way to create a transparent and consistent standard of care,” Hanfling explained. “The committee felt we should never let what happened during Katrina happen again.”
“One key component we address in the report is that vulnerable populations become even more vulnerable during catastrophes. So we have to ask, ‘Because everyone is deserving of care, how does everyone get care?’ We also had to recognize that even in this great country situations can arise where there are not enough resources for everyone. We saw this with Katrina and a pandemic could put us in that situation again.”
“The committee doesn’t have all the answers,” he continued, “but for those who are engaged in this discussion we hope this report will be helpful to them in getting this process [of creating crisis standards of care] underway.”
In the 150-page report, the committee outlines a series of recommendations with the intention of creating a uniform approach to crisis standards of care across the nation.
“The most significant recommendation we’ve made is that there needs to be a process of establishing consistency and communication across regional, state and intrastate boundaries,” Hanfling stated. “For example, I can’t know how to ration resources in D.C. when just across the river there are beds and medications available.“
“Another recommendation we make is that crisis standards of care have to be established in the context of community and provider input. Nurses who are at the bedside need to be in on these decisions because this is a big change from how we usually deliver care. We always try to do the best we possibly can for our patients, but in a disaster situation that simply may not be attainable. The public needs to understand what is feasible and likely during a disaster. We really need to have stakeholder engagement in these issues.”
One of the models used by the IOM committee in creating their report was Pandemic Influenza Guidelines developed by The Utah Department of Health (UDOH) along with the Utah Hospital Association in response to the potential avian flu outbreak.
“It is about keeping everyone prepared for situations that you hope will never happen,” said Paul Patrick, deputy director of UDOH Division of Family Health and director of emergency medical services and preparedness. “But you will see on the news that these types of events happen around the world. It is wise to have plans in place that have been exercised and can be used if need be. It is very difficult during an incident to just ‘wing it’ and have the results be in everybody’s best interest. Without guidelines, people who could have been saved are lost or overlooked.”
A number of states have begun work on developing crisis standards of care.
“It is a hot topic and there is a lot of interest in making good on trying to implement some of these recommendations and the committee is encouraged by the response. It is understood that this is hard work but that it is worth the effort,“ Hanfling said.
When it comes to the virus that instigated this report, Hanfling doubts that in the end it will call for crisis standards of care to be initiated.
“My sense of H1N1 is that it seems to be a relatively mild event for most patients,” Hanfling remarked. “So far it doesn’t appear that it is going to cause the degree of disease that is going to limit access to critical care resources.”
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