Crisis Standards of Care

1. Crisis Standards of Care A Wisconsin Initiative for Better Overall Preparedness

2. Doug Hill • Program Director, Wisconsin Crisis Standards of Care Initiative • 21 + years workin federal government • FEMA, NIH, CDC, State & Local EM, First Responders • 5 + years private work – consulting • Know Your Care (ACA), WI Association for Justice, Google, CenturyLink • Extensive work in project management and policy adaptation • Extensive work involving diverse parties with competing objectives

3. Who Is In The Room Partners in the room? • Public Health • Hospitals & Providers • MD, RN, Others • First Responders and EMS • Emergency Management • Legal • Ethics • Others

4. Crisis Standards of Care Knowledge • What do you feel is your overall knowledge of Crisis Standards of Care? • Extensive • Some to a Fair Amount • Minimal to None • What have you heard about Crisis Standards of Care and relevant issues?

5. Let’s Talk About Crisis Standards of Care (CSC) • 30,000 Foot View • Start of the Conversation – No Immediate Answers • CSC History and Guidance • When CSC and Why • Possible CSC Disaster Types • “Crisis Care” vs. Crisis Standards of Care • CSC in Wisconsin • Research and Outreach To Date • Questions and Feedback

6. Institute of Medicine (IOM) In 2009, the IOM produced Red Letter Report outlining the need for health care emergency preparedness in disaster type situations: Loma Prieta earthquake, Oct. 17, 1989, California • 51 acute care hospitals affected in six northern California counties, twenty-two hospitals had partial evacuations. Hurricane Katrina, Aug, 29, 2005, New Orleans • Numerous hospitals affected, most notably Memorial Hospital documented in the book “Five Days at Memorial”. Tornado, May, 2011, Joplin, Missouri • Loss of back up generator affecting 183 patients, not flying debris or building collapse attributed to 5 deaths – respirator failure. Snowstorm, Nov. 2014, Buffalo, New York • 60 inches of snow, many hospital staffers who tried to get to work, only to turn back. Route 91 Music Festival, Oct. 1, 2017, Las Vegas • Loss of life – 58 people and casualties of 850+ Unprecedented patient surge.

7. Institute of Medicine (IOM) • The basis for Crisis Standards of Care planning in many states has been the 2012 IOM Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations. • Key Elements: • Seek community and provider engagement; • Adhere to ethical norms with strong ethical grounding; • Seek Necessary Legal Protections for Healthcare Practitioners; • Consistency in Crisis Standards of Care Implementation with Clear Indicators, Triggers, and Lines of Responsibility; and • Evidence-based Clinical Processes and Operations.

8. When Might We Need Crisis Standards of Care?

9. Possible CSC Disaster Types • Relatively small-scale mass injury/illness events: • bus crash, tornado, multiple shootings, local epidemics/small disease out- breaks • Large-scale natural disasters: • Hurricanes Maria, Sandy, Katrina; moderate earthquake; large-scale flooding, such as Hurricane Harvey • Complex mass casualty events: • large-scale shootings (Las Vegas, Orlando) or bombings (Boston Marathon) with many victims, mass casualty burn events (Rhode Island nightclub), chemical or radio- logical incidents, limited-scale bioterrorism, limited outbreaks of lethal and contagious infectious diseases, such as Ebola or SARS • Catastrophic health events: • nuclear detonation, large-scale bioterrorism, severe pandemic, or major earthquake

10. When Is CSC Necessary? “Note that in an important ethical sense, entering a crisis standard of care mode is not optional, It Is A Forced Choice, based on the emerging situation. Under such circumstances, failing to make substantive adjustments to care operations – i.e., not to adopt crisis standards of care – is very likely to result in greater death, injury or illness.” Institute of Medicine - 2012

11. ”Crisis Care” vs. Crisis Standards of CareExample of Care Continuum

12. Now What - CSC in Wisconsin?

13. CSC Initiative Goals in Wisconsin The CSC Initiative will not immediately seek to write standards, guidelines or rules. • Start of the Conversation • Collaboration and Extensive Input • Establish work groups to provide guidance, input and expertise on the initiative and potential paths of approach • Research and report on currently utilized CSC policies and procedures in other states and WI. • Convene partners to acquire a better understanding of utilized CSC best practices

14. CSC Initiative Goals in Wisconsin - continued • Work with partners to develop an inventory of CSC barriers and possible solutions. • Work with partners to identify possible CSC triggers • Seek to start a meaningful dialogue among partners of general CSC guidelines and principles • Develop outcome documentation for the purpose of presenting results to partners to educate and raise awareness of CSC initiative findings • Lay the groundwork for follow-on activities, if identified as necessary and desirable

15. Partnerships and Working Together

16. Crisis Standards of Care (“CSC”)--- a piece of the puzzle

17. Research and Outreach • Review of other state’s CSC plans • CSC Plans - MN, IL, NV, AZ, TX, MS, CO, DC • Allocation of Scare Resources – DE, IN, KS, LA, MI, OR, SC, VA • CSC Plans – 11 pages to 188 pages • Varied in scope • Outreach and Work in Wisconsin • Health Care Systems/Hospital/Healthcare Providers • Public Health • EMS & First Responders • Wisconsin Emergency Management • Legal & Ethics Community • Affiliated Wisconsin Associations

18. Feedback and Questions • After the presentation do you feel that your overall knowledge of Crisis Standards of Care has improved? • Outstanding questions, additional questions or other issues? • What Crisis Standards of Care issues do you think about or worry about most? • Are there barriers in your scope of work, that during a disaster, would impede you from providing care? • Does your organization have set CSC guidance, plans or protocols? • Are you familiar with them? • Do you exercise them? • During a disaster situation what type of direction would be most helpful in making care decisions about patient treatment? • General guidance or Specific Direction •  Would you be willing to participate in a work group to help develop Crisis Standards of Care in WI?

19. Contact Information Doug Hill djh1967@gmail.com 715-581-5730