2. Washington State: A Focus on Preparedness Nancy J. Auer, MD WSHA Disaster Readiness Conference Wenatchee, WA May 30, 2013

3. Objectives Learn the Work of the Altered Standards of Care Committee Learn the Recommendations of the Committee Learn the Work of the Legal Workgroup Learn the Recommendations of the Workgroup Take Home Recommendations

4. Altered Standards of Care Project Workgroup Created Under a Grant from Asst. Secretary for Preparedness and Response, Health and Human Services ACS Evolved to Crisis Standards of Care Focused on Preparing for an Influenza Pandemic

5. Workgroup Objectives Develop a Set of Guiding Principles to Be Used for Decision Making about Crisis Standards of Care During a Pandemic Identify Gaps in Current Response Plans Create a Set of Recommendations for Secretary of Department of Health Compile Recommendations into a Guidance Document

6. Guiding Principles Decisions Will Be Based on Clear Ethical Standards with a Transparent Decision-Making Process Autonomy Beneficence Proportionality Distributive Justice

7. Guiding Principles Care Will Be Altered (Crisis Care) Multi-Level Triage System Based on Ethical Distribution of Care Is Essential Access to Care Will Be Equitable Health Care Worker and Patient Safety Will Be of Primary Concern Resource Allocation Will Be Essential

8. Guiding Principles Planning for Vulnerable Populations Will Occur Communication with the Public Will Be Clear, Transparent and Culturally Relevant Legal and Liability Issues Will Be Addressed Clearly and Comprehensively

9. Gap Analysis cient Legal and Regulatory Gaps Exist Coordination Across All Public Health Sectors Is Insufficient The Public Is Currently Unaware of the Implications of a Pandemic and Must Be Engaged with Effective Messaging

10. Gaps with Health Professionals Need to Be Engaged in Setting Scope of Practice Determinations Need to Better Understand Duty to Provide Care Need to Understand Ethical Principles in Play Need Training on Incident Command Structure Need Training in Triage

11. Recommendations Establish a Workgroup to Focus on Scope of Practice and Standards of Care −Allocation of Scarce Resources −Alternate Care Facilities −Guidelines for Transport to Alternate Care Sites Legal and Liability Issues Decision-Making and Authority −Recommend Governor’s Declaration when Social Distancing is Necessary

12. Recommendations Documentation and Reporting −Define Minimal Data Set Acceptable for Medical Records −Clarify Hospital Reporting Requirements about Births, Deaths, Transfers, Vaccinations Triage −Develop Statewide Triage System of Emergency and Intensive Care Specialists −Designate Triage Officers for Every Health Care Facility

13. Recommendations Reimbursement −Determine Who Has Authority to Relax Health Insurance Restrictions −Identify Compensation Issues for Responders −Assure Portability of Insurance Across Carriers Registration of Emergency Workers −Encourage Voluntary Registrations with License Renewal −Develop In-Hospital and Just-in-Time Registration Link Volunteer Registration with MRC

14. Recommendations Mass Critical Care −Prepare Hospitals to Implement Emergency Mass Critical Care when Capacity Is Reached −DOH Will Communicate this Expectation to All Acute Care Facilities Staffing Standards −DOH to Work with Acute Care Facilities and Professional Organization on Plans for Reallocating Staff −Plans Address Schedules and −Hours of Staff

15. Recommendations Ventilator Usage −Each Hospital Should Have One Mechanical Ventilator, Supplies and Training −Routine Use Discontinued Before Ventilator Triage Instituted −Decrease Elective Surgeries −Reduce O2 Flow

16. Recommendations Emergency Medical Services −Alter Pick-Up and Delivery Protocols −Alter Response Requirements −Alter Processes for Response to Routine Emergencies Clinical Actions −Individual to Community Level of Care −Cease Elective Cases When Social Distancing −Relax HIPAA and EMTALA

17. Recommendations Call Centers and Nurse Lines −Develop Statewide Network Using Existing Sites −Develop State Level Algorithms with Common Protocols −LHJs Should Coordinate with Call Centers Vulnerable Populations –Develop Plan to Reach Those with Limited English –Be Alert to Emerging Populations at Special Risk –Local Governments to Identify Populations at Risk

18. Recommendations Risk Communications −Develop Communication and Education Plans for At-Risk, Vulnerable Populations −Teach Families How to Provide Care at Home −Involve Communities, Including Faith-Based Organizations in Implementation of Recommendations

19. Recommendations Tribes −DOH and Local Governments Will Work with Tribes −Plans Will Address Specific Needs −Special Populations within a Tribe Will Be Identified and Their Specials Needs Addressed

20. Final Recommendation Workgroup Charged with Addressing a Pandemic Influenza Scenario Workgroup Believes Most Recommendation Applicable to All Hazards Preparation

21. Legal Workgroup Convened in 2012 Objective: Identify Possible Regulatory Waivers and Legislative Barriers Impeding A Health Care Provider’s Ability to Provide Care During a Disaster Make Recommendations for Regulatory Waivers and Legislative Changes to Promote Effective Care While Protecting Health Care Providers During a Disaster

22. Core Objective: Do No Harm Focus on Suspending Impediments to Care Retain Minimal Standards for Safe Care Focus First of Elements that could be Addressed through a Governor’s Emergency Proclamation or Executive Order

23. Partial List of Waiver Recommendations Patient Transport to Non-Hospital Setting First Responder Scope of Practice Provider Licensing Expirations Limited In-State Worker Supply Alternate Care Facility Health Care Information & Medical Records Pharmaceutical Dispensing & Labeling

24. Legislative Recommendations Workgroup Recognized Significant Liability Exists Protection Needed for Workers Responding to Disaster Who Are Not Registered Emergency Workers WSHA Proposed Legislation: Would Provide Immunity for Such Workers

25. Department of Health Washington State Is at Forefront of Planning Much Has Been Done Much Is Left to Accomplish Next Steps

26. Stakeholder Meetings Additional Stakeholder Meetings: −Public Health Representatives −Tribal Governments −Community Health Centers Identify Additional Issues Related to Disaster Response and Coordination

27. Creation of New Council Disaster Medical Advisory Council Clinician Led New Guidelines for Clinical Issues in Disaster Response

28. Take Home Messages Get Involved in Your Community Become Familiar with Your Hospital’s Disaster Plan Work with Other Healthcare Facilities in Your Areas on Mutual Aid Contingencies Encourage Your Professional Organization to Host Programs on Preparedness Have a Strong Transparent Communication Plan

29. Questions???