The Pandemic Flu in Action ”What are the Patient Care Issues”

1. The Pandemic Flu in Action ”What are the Patient Care Issues” Carole A. Klove RN, JD Chief Compliance and Privacy Officer UCLA Medical Sciences

2. Operational Issues to Consider • Impact on obligations under the Emergency Treatment and Active Labor Act (EMTALA) • Exchange of Protected Health Information (PHI) and HIPAA Privacy and California Confidentiality Laws • Understanding Surge Capacity and the impact on resources, including personnel, services and supplies and patient safety • Meeting the needs of “your community” and training your staff

3. EMTALA – Does an catastrophe make a difference? • Hospital must provide screening and stabilization for person presenting at ED • Waiver of sanctions during Katrina emergency • HHS Secretary has authority to temporarily waive EMTALA requirements in declared emergencies • HHS waived sanctions for EMTALA violations for hospitals with ERs located in “emergency areas” if have to transfer prior to stabilization if due to Katrina • Hospital still obliged to conduct screening

4. HIPAA and Confidentiality • Under HIPAA, covered entity may not use or disclose protected health information (PHI) except as permitted under Privacy Rule • In emergency, tension between privacy rights and need to share health information to inform families, friends, and public health workers • California law defines several specific reportable conditions, including “when the disclosure is otherwise specifically authorized by law” Civil Code § 56.10 (c)(14)

5. HIPAA and Confidentiality (cont.) • Sharing PHI during emergency • Privacy Rule allows sharing of PHI without authorization to public health authority in response to bioterrorism or public health emergency. 45 CFR Section 164.512(b). • Privacy Rule allows release of PHI to public health authority without authorization for certain public health activities, such as surveillance, but limited to “minimum necessary” information

6. HIPAA and Confidentiality (cont.) • HIPAA Waivers during Katrina • Section 1135 Waivers (referencing Social Security Act) • HHS waived certain privacy requirements in emergency areas affected by Katrina and Rita (i.e., needing to obtain consent to share info with family/friends; notice of privacy practices) • HHS Bulletin Reminders • Katrina bulletins reminded providers how Privacy Rule allows sharing PHI in disaster relief efforts for treatment purposes and to notify caregivers

7. HIPAA and Confidentiality (cont.) • Other Issues • Health information is protected whether person living or dead • Release of patient information to media • Security and storage of records (offsite storage; electronic records) • EHRs – allows record to follow patient

8. Patient Safety and Surge Capacity Assumptions to consider: • 30% of population will be affected • 50% of those affected will seek care • Most seeking care will need hospitalization • Significant mortality rate • Vaccine will be virtually non-existent in early phases • Resources for mass casualties may be inadequate • Hospitals will experience staffing shortages • Standards of care may have to be ‘sufficiency of care’ “No amount of planning will allow response to a major pandemic to be ‘business as usual’.”

9. Patient Safety and Surge Capacity (cont.) Emergency Response: • Hospital Surge Capacity • Need for hospital beds will exceed capacity • Illness among workers or their families will exacerbate the shortage of staff • County DHS agencies have identified key components of surge capacity and response to the demand

10. Patient Safety and Surge Capacity (cont.) • Telemedicine • Consider telemedicine capability and privileges so physicians not required to attend hospital • Hospital Admissions • May need to cancel elective admissions during triage phase • Use non-acute beds for acute patients • Early discharge of patients

11. Patient Safety and Surge Capacity (cont.) • Credentialing and Privileging • Need for temporary credentialing and relaxation of standards during emergency • JCAHO requires hospitals to establish procedure for verifying credentials and granting privileges during and after disaster (HAS Std MS 4.10) • Consider pre-credentialing programs and established agencies, e.g., San Mateo County Medical Reserve Corps • HRSA’s ESAR-VHP Program assisted with registration, credentialing, and deployment of volunteer professionals to Gulf region by using online systems

12. Patient Safety and Surge Capacity (cont.) • Licensing Issues • Out-of-State Professionals – Nat’l Emergency Management Assistance Compact (EMAC), which CA ratified, allows for reciprocity • Medicare requirements also waived for Katrina providers • JCAHO – If hospital’s disaster plan is activated, may implement modified process for determining qualifications and competence of volunteer practitioners (Std HR 1.25 and MS 4.110) • Still limited to activities under license • Must verify identity and licensure • Need to address emergency licensing in Med Staff Bylaws

13. Patient Safety and Surge Capacity (cont.) • Standard of Care • Legal concept – Action a reasonably prudent practitioner would take under same or similar circumstances • Would adapt to emergency situations • Informed consent • Good Samaritan Statute • In CA, person not liable where render emergency care at scene of emergency (not including EDs or medical care site) in good faith and not for compensation

14. Patient Safety and Surge Capacity (cont.) • Government Code Section 8659: Physicians, hospitals, pharmacists, nurses and dentists who render services during a state of emergency or local emergency at the request of a health officer have no liability for injuries sustained by any person from those services, regardless of the circumstances or cause, except for willful acts or omissions

15. Patient Safety and Surge Capacity (cont.) • Prescription Medications and Treatment • Only authorized individuals to have access to drugs • Only licensed individuals to prescribe and administer drugs • Maintain drug integrity • Relaxation of standards for emergencies? • Volunteer physicians and pharmacists to act • Acceptance of donated drugs

16. Planning – What does it Require? Surge capacity for beds, personnel, morgue Personnel protective equipment Ventilators ? Tamiflu Major isolation plan Staff education Develop internal rationing plan Facilities Supplies Infection control Vaccine/ anti-virals Coordinate with State/County

17. Training – Who and What • Disaster Policy for Staff • Accessible via hardcopy or intranet • Telecommuting policy for emergency • Voluntary Nat’l Stds for Disaster Preparedness (NFPA 1600) www.nfpa.org • Identify critical staff and personnel • Medical staff • Nurses and allied health professionals • Patient support • Plant operations • Vendors

18. Training – Who and What (cont.) • Communicating with Staff (before, during, and after) • Call-in line or website for further info • Public announcement postings • Chain of command/Telephone chain • Security of communications (passwords) • Public Health Education for Staff

19. Training – Who and What (cont.) • Cross Training Staff for various job functions • Understand the job functions that impact an employees function • Recognize Union issues • Conduct the Job Skills inventory and keep it current, including language capability and interpretation

20. Training – Who and What (cont.) • Train on Attendance Concerns • Consider flex time alternatives for jobs that don’t require presence at hospital • “Presenteeism” of sick workers may be problem for spreading disease • FMLA issues for prolonged absences • Health Officer can order staff to be tested and cleared before returning to work • Have contingency plan for high absenteeism • Consider Temporary housing

21. Questions and Answers