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IOM Issues New Report on Crisis Standards of Care

By Matthew Watson, March 30, 2012

On March 21, 2012, the Institute of Medicine’s (IOM) Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations released Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response,1 which is the second IOM report on crisis standards of care (CSC). The first, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations – Letter Report,2  released in 2009, defined CSC as a “substantial change in the usual health care operations and the level of care it is possible to deliver . . . justified by specific circumstances and . . . formally declared by a state government in recognition that crisis operations will be in effect for a sustained period.”1 This report is a valuable addition to the literature on CSC because it provides a comprehensive overview of the topic and much needed guidance for practitioners. It warrants review by all interested in this issue.

A comprehensive summary of the document is beyond the scope of the CBN; instead, we are highlighting  2 particularly important aspects― the disaster response framework and milestones for planning and implementation. (Of note: The report does not describe specific triggers, indicators, or operational guidelines, as they would vary according to the nature and location of a disaster.)

Practical Guidance on Implementation

The medical disaster response community has long recognized the need for well-defined CSC and practical guidance on implementation. However, planning has been slowed by the challenges of engaging and organizing the many disciplines, actors, and agencies involved in disaster response. This new guidance, organized into 7 volumes, addresses that issue by suggesting a systems-based approach that embraces the interests and needs of multiple communities of practice, including state and local government, emergency medical services (EMS), hospitals, alternate care systems, and public engagement specialists.

The IOM’s conceptual framework delineates the players and processes that comprise such a system. In this model, government efforts are supported by 5 operational pillars (e.g., public health and hospital care), which are undergirded by key organizational processes (e.g., community and provider engagement), all of which rest on a foundation of ethical and legal considerations.

Integrating CSC into Existing Plans

The IOM report also includes milestones to guide integration of CSC into existing disaster plans and suggests the appropriate agencies and entities to lead each stage of effort (below). Interagency cooperation is emphasized, particularly at the state level.

CSC Milestone

Proposed Lead Agencies

  • Establish a State Disaster Medical Advisory Committee (SDMAC)
  • Governor’s office
  • State health department
  • Ensure development of a legal framework for CSC implementation
  • Governor’s office
  • State legislature
  • State attorney general’s office
  • State health department
  • State emergency management agency
  • Promote understanding of the disaster response framework among elected officials and senior (cabinet-level) state and local government leadership
  • State health department
  • State emergency management agency
  • Develop a state health and medical approach to CSC planning that can be adopted at the regional/local level by existing healthcare coalitions, emergency response systems, including the Regional Disaster Medical Advisory Committee (RDMAC), and healthcare providers
  • RDMAC
  • State health department
  • Engage healthcare providers and professional associations by increasing their awareness and understanding of the importance and development of a CSC framework
  • State and local health departments
  • EMS agencies
  • Healthcare coalitions and member               organization
  • Encourage participation of the outpatient medical community in planning
  • State and local health departments
  • Healthcare coalitions
  • Professional healthcare organizations
  • Ensure that local and state CSC plans include clear provisions that permit adaptation of EMS systems under disaster response conditions
  • State and local health departments
  • State EMS agencies
  • Develop and conduct public community engagement sessions on the issue of CSC
  • State and local health departments
  • Support surge capacity and capability planning for healthcare facilities and the health care and public health systems
  • State and local health departments
  • Healthcare coalitions
  • Plan for an alternate care system capability
  • State and local health departments
  • Healthcare coalitions
  • Support scarce resource planning by the RDMAC (if developed) for healthcare facilities and the healthcare system
  • State and local health departments
  • Healthcare coalitions
  • Incorporate crisis/emergency risk communication strategies into CSC plans
  • Governor’s office
  • State and local health departments
  • EMS and emergency management agencies
  • Healthcare coalitions and member organizations
  • Exercise CSC plans at the local/regional and interstate levels
  • Governor’s office
  • State and local health departments
  • Emergency management and EMS      agencies
  • Healthcare coalitions and member organizations
  • HHS regional emergency coordinators
  • Refine plans based on information obtained through provider engagement, public/community engagement and exercises, and real-life events
  • Governor’s office
  • State and local health departments
  • EMS agencies
  • Healthcare coalitions and member organizations
  • Develop a process for continuous assessment of disaster response capabilities
  • Governor’s office
  • State health department and emergency management agency

  

                
Additional Recommendations

The report concludes with several additional recommendations as well:

  • Each level of government should ensure coordination of and consistency in the active engagement of all partners in the emergency response system, including emergency management, public health, emergency medical services, public and private healthcare providers and entities, and public safety.
  • Each level of government should integrate CSC into surge capacity and capability planning and exercises.
  • The Department of Health and Human Services/Assistant Secretary for Preparedness and Response (eg, through its regional emergency coordinators) should facilitate CSC planning and response among state and tribal governments within their region.
  • In CSC planning and response efforts, states should collaborate with and support local governments.
  • Federal disaster preparedness and response grants, contracts, and programs—such as the Hospital Preparedness Program, Public Health Emergency Preparedness Program, Metropolitan Medical Response System, Community Environmental Monitoring Program, and Urban Areas Security Initiative—should integrate relevant CSC functions.1

References

  1. Institute of Medicine. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. 2012. Washington, DC: The National Academies Press. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Accessed March 29, 2012.
  2. Institute of Medicine. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. 2009. Washington, DC: The National Academies Press. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations – Letter Report. Accessed March 29, 2012.