Crisis Standards of Care

Watch a video of this session.

At our 2019 Annual Meeting, three representatives on the Vermont workgroup that is creating a standards of care plan for possible crises in Vermont reported on their progress and solicited feedback on the current draft. Facilitating the breakout session was Michael Leydon, MPH, Emergency Management Director at UVMHN-Porter Medical Center.
Leydon explained that in a catastrophic crisis, like a pandemic or widespread serious flooding, our health care systems may not be able to maintain the standards of care to which it typically adheres.

He introduced a “newly minted plan”—in draft form—that could help providers make decisions about how to optimize the quality of care and administer finite resources to those most likely to benefit.

“Our overall goal for this initiative is to develop a framework which includes tools and parameters under which we render care and quality benchmarks to guide us in high-consequence decision making with limited information, an incomplete picture of the situation and limited resources,” he said.

He noted that the plan would help providers with consistent and equitable resource allocation among patients. Leyden warned participants that the Crisis Standards of Care Plan was not a substitute for each organization’s emergency preparedness planning. He said that hospitals and health systems can mitigate the effects of a future crisis by planning now.
“Where is your hospital’s command center going to be? What equipment will you need? Who’s going to staff it? Where do you get fuel for your generator?” he asked.

He explained that there has been a national movement to develop crisis standards for care. Amid discussions about death panels and rationing of resources, health care providers and ethicists are looking for ways we can make decisions during crises that maximize patient survival and minimalize worst-case outcomes.

To help facilitate such decision-making, there is a regulatory waiver (1135) through which states can petition the federal government through federal channels to absolve them from the usual CMS standards.

Dr. Ryan Sexton, medical director of emergency services and president of the medical staff at Northeastern Vermont Regional Hospital, said that for much of his medical training, he had no idea what an 1135 waiver is. He suggested that Vermont make learning about crisis management part of its medical curriculum. He said that because of this lack of training and awareness, physicians will have to depend on administrators to help them anticipate needs.

“Emergency physicians are the best ones to use [a framework like the Crisis Standards for Care],” he said. “They triage day in and day out . If you ask a surgeon to do a procedure without an overhead light or an ENT to remove a foreign body without the right extractor, it’s not going to go well. If you ask an emergency physician to do a procedure without the overhead light because the light has burned out, they’re going to ask for a flashlight. We’re the front line and we don’t even know about [crisis care management.] We rely on administrators to help us embrace this. Provide us with the guidance and framework that we’re going to need,” he stressed.
He described how care could change during a critical supply shortage or a pandemic, positing that extreme staff shortages could drastically affect the way teams could provide care.
“Usually when we’re triaging, we do everything we possibly can for each patient—a disaster moves us away from this,” he said, adding that providers have a need to feel legally protected when having to make tough decisions about allocating scarce resources.

He drew a distinction between conventional care, contingency care (which happens when, for example, just one hospital is affected by outside elements) and crisis care. He lists indicators that crisis care is warranted as:     

A hospital’s emergency operations center is activated 
A health care facility is unsafe or closed
Trained staff are unavailable or unable to care for patients
Critical supplies have been exhausted, requiring re-allocation of life-sustaining resources
Patient transfer is insufficient or impossible
All local, regional, and broader reaches for health care facility resources are unavailable or inadequate to prevent further increased patient morbidity and/or mortality
Despite all efforts by public health, health care administrators, medical providers and others, extensive patient morbidity and/or mortality cannot be eliminated, but merely lessened
Sexton stressed that the draft plan was not meant to provide exact treatment decisions. Front-line staff will need to make decisions in a crisis. The plan is merely a framework to fall back on.

He explained that in a crisis, caregivers must move from a standard of care model to a sufficiency of care model. The goal, Sexton noted, must be to do all we can with the resources we have, i.e.,“the best we can do.”

David Casey, public health program administrator at the Vermont Department of Health, said the workgroup’s next steps are to educate people and to ask for feedback.
“The plan needs input from all Vermonters,” he said

“We need to keep improving it,” he explained, encouraging participants to read it and give input. “The plan should work with your plans,” he said,” so that you can refer to it in a time of need. Review the document to determine if it aligns with your organizational policies,” he added.

The team gave the following resources for learning more:

Vermont Crisis Standards of Care Plan     
Author Sheri Fink:
•       Fink, S. (2013). Five days at Memorial: life and death in a storm-ravaged hospital. First edition. New York: Crown Publishers