Second IOM Crisis Standards of Care Report Guides Implementation

During the 2009 global H1N1 influenza pandemic, the Department of Health and Human Services (HHS) asked the Institute of Medicine (IOM) to convene a committee of experts to answer a challenging question: How do we give the best care possible under the worst possible circumstances? ¹ Indeed, disasters can overwhelm health systems, creating shortages of critical medical resources and disrupting delivery of medical services. In September 2009, the committee issued a report defining “crisis standards of care” (CSC) and a plan for care in catastrophic events that includes fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. ²

Under CSC conditions, considerations defining delivery of medical care shift from focusing on individuals to promoting careful use of limited resources for the best possible health outcomes for the population as a whole. Thus, care delivered during a catastrophic disaster may be modified to address the needs of the community, rather than the needs of individuals.

Last March, responding to a request by HHS, the Department of Veterans Affairs, and the National Highway Transportation Safety Administration, the committee released a second report, Crisis Standards of Care: A Systems Framework for Disaster Response, which provides a resource manual and important templates to guide state and local officials in implementing the CSC framework created in the 2009 report. ³

The committee recommends using a “systems” approach to incorporate CSC into disaster planning more broadly, finding that for CSC planning to be successfully implemented, it must be embraced by the full spectrum of stakeholders that participate in emergency response, including state and local governments, emergency medical services (EMS), healthcare organizations, and healthcare providers in the community. The committee developed a multitiered framework for catastrophic response that can be integrated into existing emergency response plans and programs.

The report provides milestones, which emphasize state-level interagency cooperation, to guide implementation:

1. Establish a State Disaster Medical Advisory Committee (SDMAC).

In addition, the committee calls on hospitals, walk-in clinics, and private medical practices to fulfill their “duty to plan” for catastrophic incidents and to be prepared to shift from conventional standards of care to CSC during a crisis surge response according to predefined triggers and thresholds. During a crisis, medical providers may be without important resources, such as electricity, trained staff, medicines, supplies, and hospital beds. Under crisis conditions, adjustments to the scope of practice, treatment options, staffing, and response plans may be necessary and should be factored into planning.

Because public engagement is considered critical to the development and use of crisis standards of care, the report provides a model process and set of tools that health authorities can use to hold public sessions on crisis planning and disaster response. The report also provides templates meant to enable organizations and agencies to quickly transition to CSC. By defining the criteria and process for shifting to CSC, and identifying in advance the core functions that must be carried out in a crisis and who will be responsible for each task, stakeholders will be better prepared to reallocate staff, modify facilities, and rely on other resources. Templates are specifically designed for state-level planning, EMS planning, and planning for out-of-hospital facilities, such as long-term care facilities.

To facilitate implementation, the committee recommends that CSC functions be integrated into federal disaster preparedness and response grants, contracts, and programs, including the Hospital Preparedness grant Program (HPP), the Public Health Emergency Preparedness cooperative agreement grants (PHEP), the Metropolitan Medical Response System (MMRS), the Community Environmental Monitoring Program, and the Urban Areas Security Initiative (UASI).

Ryan Morhard

PAHPA Reauthorization Passed by House and Senate, Awaits Reconciliation and Final Passage

The Pandemic and All-Hazards Preparedness Reauthorization Act of 2011 was first introduced in the 112th Congress in the House of Representatives by Congressman Mike J. Rogers (R-MI) and 4 cosponsors on June 28, 2011. The House Bill (HR 2405) was referred to the Committee on Energy and Commerce and was reported out of Committee on November 16. The bill passed the full House by voice vote on December 6, 2011. ¹

On November 10, 2011, Senator Richard Burr (R-NC) and 10 cosponsors introduced companion PAHPA reauthorization legislation in the Senate (S 1855). The bill was referred to the Committee on Health, Education, Labor, and Pensions, which reported the bill with amendments out to the full Senate on December 16. On March 7, 2012, the Senate passed the legislation by Unanimous Consent. ²

At the time that this summary went to print (May 20, 2012), the bill had not yet been presented to the President for his signature and was still awaiting reconciliation by the House and Senate and full passage by Congress.

PAHPA reauthorization, if passed by Congress and signed by the President, will help preserve gains in preparedness achieved since the original PAHPA legislation was passed in 2006; it aims to further improve preparedness by:

1. Reauthorizing important preparedness programs in the Department of Health and Human Services, including public health and healthcare preparedness grant programs, the Biomedical Research and Development Authority (BARDA), and the Strategic National Stockpile (SNS), among other programs;

Crystal Franco

FEMA Releases the 2012 National Preparedness Report

On May 3, 2012, the Federal Emergency Management Agency (FEMA) released the 2012 National Preparedness Report (NPR), the first in a series of annual reports on the nation's preparedness. ¹ The report is a requirement of Presidential Policy Directive 8 (PPD-8), which also called for the development and maintenance of a National Preparedness Goal, issued last year. The Goal describes 31 core capabilities used in the National Preparedness Report that are distinct critical elements necessary to achieve national preparedness.

To produce the report, FEMA and interagency partners identified performance assessment data for each of the 31 core capabilities, including data from the 2011 State Preparedness Reports. The report identifies areas of progress in strengthening community resilience to disasters such as prevention, protection, mitigation, response, and recovery. It also details how federal grant funds have been used to build and sustain the 31 core capabilities.

Overall, the report concludes that preparedness has increased across the nation in recent years. The report identifies areas of strength in preparedness, including planning, operational coordination, intelligence and information sharing, environmental response/health and safety, mass search and rescue operations, operational communications, and public health and medical services. Nationally, demonstrable progress has also been made in addressing gaps identified after 9/11 and Hurricane Katrina. However, gaps were still found in the areas of cybersecurity and disaster recovery.

The report highlights the contribution of multiyear federal preparedness assistance programs at the state, local, tribal, and territorial levels and the use of risk analysis by decision makers to shape and prioritize preparedness activities as major contributors to progress in preparedness. Feedback from states indicates that the most progress was made in capabilities deemed high priorities. The importance of integrating people with disabilities, those with access and functional needs, children, pregnant women, older adults, and people with chronic medical conditions into preparedness activities was also emphasized by the National Preparedness Report.

The report will serve as a baseline evaluation for progress made toward the National Preparedness Goal. However, as noted in the report, many programs that build and sustain the core capabilities are difficult to measure. Even with this difficulty, the National Preparedness Report has established a routine repeatable process to measure preparedness in the future.¹

Tara Kirk Sell