Sep 2, 2010 (CIDRAP News) – The necessity for good communication among the many parts of the healthcare system was a major theme today in a Centers for Disease Control and Prevention (CDC) teleconference on planning for public health emergencies.
The conference dealt with preparing for major events likely to generate many casualties, such as an influenza pandemic, hurricane, major fire, or earthquake. It was titled, "Preparing for Large-Scale Surge Incidents: Alternate Care Systems and Crisis Standards of Care."
Deborah Levy, PhD, MPH, chief of healthcare preparedness activity in the CDC Division of Healthcare Quality Promotion, said the CDC has been holding some workshops around the country to help health leaders prepare for such events. The goals have been to "develop a model of healthcare delivery at the community level" and to examine strategies for establishing an alternate care system in response to an emergency.
So far workshops have been held in Summit County (Akron area), Ohio, and Oregon Hospital Preparedness Region 2, Levy reported.
She said leaders have emphasized including in the planning all the components of the healthcare system, such as home health agencies, assisted living and long-term care facilities, call centers, emergency medical services, community clinics, hospitals, dialysis centers, and elective surgery sites, Levy said.
Workshops have grappled with such problems as determining what kind of care will be altered in an emergency and how that will affect other parts of the system, how to find alternative care sites, figuring out what resources are needed, identifying legal and regulatory issues, and deciding what will "trigger" activation of the system, she said.
"You need to have triggers that are not extremely rigid, such as one number," she said. The 2009 H1N1 flu pandemic demonstrated the need for flexibility, she observed, adding, "Think of it more as having a framework you can easily adjust."
One major lesson from the workshops is that different healthcare sectors often didn't know what others in the system were doing to prepare for emergencies.
"What we've seen is most of the time the sectors did not know of each others' plans and/or ended up making incorrect assumptions about those plans," Levy said. "Keep in mind that it's really important that communication occur and you share plans you have in place."
She listed several other lessons from the workshops:
- "Hospital leadership has not grasped the complexity of the issue and the need to integrate the plan with the community."
- Local governments were not aware of the complex types of issues they would have to deal with.
- The role of public health was not always to clear to public health and to other sectors; sometime it involves providing care, and other times it's mainly providing lab services and epidemiologic investigations.
"Most effective communities included public health, healthcare, and emergency management in their planning," and including all those sectors is critical for success, Levy said in concluding her part of the presentation.
Kerry Kernen, BSN, RN, emergency preparedness administrator for the Summit County Health District in Stow, Ohio, discussed planning efforts that the district launched in late 2007. The district proposed eight different options for providing surge capacity and presented them at meetings involving many stakeholders.
"We needed to make sure we had buy-in from as much of the community as we could," including law enforcement, fire departments, emergency medical services, school superintendents, hospital administrators, social service agencies, and long-term care facilities, among others, she said.
Kernen said some of the options that were presented were:
- Programs to help people care for themselves at home
- A "motel-hotel" option for people who are isolated and would have great difficulty caring for themselves at home
- Neighborhood emergency health centers
- Patient triage and rapid screening systems
- Overflow hospitals providing a full range of care
- A "mobile hospital" that could move throughout the county
Of those, the only one that stakeholders decided wasn't worth pursuing was the mobile hospital, Kernen said.
Umair A. Shah, MD, MPH, deputy director of Harris County Public Health and Environmental Services in Houston, discussed crisis standards of care—the challenge of changing standards when resources run short in an emergency. Shah served on an Institute of Medicine (IOM) committee that issued a report on the topic in 2009.
"In crisis planning there's a recognition that setting up a protocol in advance of a disaster is absolutely critical," he said.
Shah cited guidelines for use of supplemental oxygen as an example of altered standards of care. Normally, oxygen is given when the patient's blood oxygen saturation drops below 95%, but if supplies begin to run short, oxygen might be used only when saturation drops below 90%.
"In a crisis, oxygen would be used only for those in respiratory failure," he said. "That continuum is an example of why standards of care may change."
Shah encouraged participants to read the IOM report, which lays out five general recommendations for communities seeking to develop crisis standards.
In a question-and-answer session, a participant from Florida asked how to build political support for developing altered standards of care and related steps. "We'd love to enact this, but unless we have political support, we're not going to get anything done," he said.
Kernen said several mayors and other local elected officials participated in the Summit County workshop, which led to "fairly strong buy-in" on their part.
Levy commented, "You may want to put some talking points together, questions you'd be posing to them [local elected officials] given certain scenarios. I think that's when they have their 'aha' moment and realize they don't have easy answers."
In other comments, Levy said a CDC ethics advisory group is working on a report on how to cope with a shortage of ventilators, and it is expected to be released soon.
Sep 2 CDC Clinician Outreach and Communication Activity (COCA) session page
2009 IOM report on establishing standards of care in a disaster