Inaugural Address of the 150th President

President’s Page Inaugural Address of the 150th President

The following speech was given by Dr. Gary A. Delaney on Saturday, April 30, 2011 at the SCMA Annual Meeting in Greenville, South Carolina. Mr. Chairman, Trustees, Dr. Wilson, Dr. Lindstrom, honored guests, family and friends, I am truly humbled and honored to be the 150th president of the South Carolina Medical Association. I would personally like to thank Dr. Tarasidis for the great job he did this past year representing us. I also want to recognize the Board of Trustees for their time and effort they spend on behalf of all physicians of South Carolina. Before I begin my speech, I would like to take a moment to recognize my family and friends who took time out from their busy lives to join us for this occasion. First, my son Michael, a banker, and his wife Amy, my son Andy, a lawyer, and his wife Courtney, my daughter Sarah, an educational research advisor with the Florida Virtual Schools, and her husband Jeff, my son Joseph, a pediatrician, and his wife Leslie, and my daughter Frances, a neonatal ICU nurse, and lastly, my sister-in- law, the other Frances in our family. The married children have given us seven-soon to be eight- grandchildren. Our best beach buddies are here from Charleston, the Seigniouses. Then there are friends from Orangeburg, especially Connie Wise who ran my office for many years and her husband, Mike. There are other friends from Orangeburg, the Cohens, the Dicksons, the McDaniels, the Stovalls, the Williams and the Wyrosdicks who were gracious enough to come spend this time with us. It is a privilege to have a friend, mentor and past president of the AMA, Dr. Randy Smoak and his wife Saundra. Other colleagues include Dr. and Mrs. Horton and Dr. and Mrs. Rheney, and certainly I cannot leave out our District Eight Trustee Dr. Dallas Lovelace and his wife Debbie. The Lindstroms and Carmichaels, friends from Southern Medical who drove all the way from Mississippi as well as a past president of Southern Medical, Dr. Jan Basile and his wife Joellen from Charleston. We also have the president of the Southern Medical Alliance, Dr. Nancy Swikert and her husband Don. Ed Waldron, the CEO of Southern Medical is also here. Drs. Black and Tarasidis, in their last two inaugural addresses, made reference to the fact that they had a medical heritage. Mine was drastically different. As a preacher’s kid, I was taught to have love and compassion for our fellow human beings and to try and make a difference in those lives that we touched. If you think about it, something in your life gave you those same traits. This was made real to me when I developed pneumonia at the age of 10, and Dr. Claude Bays actually made a house call. When he came to our home I remember, in his black bag, this very large syringe and an even larger needle which was filled with penicillin. While it stung like fire, I recall being on the road to recovery the very next morning. I soon realized that medicine was my calling, but it is in

Volume 107 • June 2011

organized medicine that I realized that we as physicians must also care for each other. Being a part of the SCMA Board of Trustees has allowed me to realize this. As your SCMA President I want to constantly remind you that while there is much adversity there is also much opportunity for us to make a difference in the lives of so many who depend on us. Let me share a story with you. Two elderly gentlemen coming around the corner at Wal-Mart bang their carts together. The first one asks “What are you doing?” and the reply is, “looking for my wife, what are you doing?” “Looking for my wife too. What does yours look like?” “She’s 27, long blonde hair, a great figure and wearing the tightest shorts I have ever seen. What does yours look like?” “Never mind, let’s go look for yours.” Now you see one man’s adversity became another man’s opportunity. When we took our Hippocratic Oath, we promised to try and make opportunity for healing out of our patients’ adversity. One section of the oath says: “I will prevent disease whenever I can – for prevention is preferable to cure.” Dr. Charles Bryan had a recent article in our SCMA Journal detailing how he envisioned the practice of medicine in the future. And change it will. It is as if someone, somewhere had an “aha” moment. We will focus mainly on health, not disease, where health care is a personal responsibility, not viewed as a right. We will be asked to practice medicine based on good solid scientific evidence for if we don’t, we won’t be paid. All payments whether from Government institutions or private insurers want to get the most for their money. While this sounds good on paper, we all know too many times that our patients are just not compliant. The article suggests that beginning in grammar school onward that health is a personal responsibility. A great concept, but teaching that when teachers are having a hard time getting across reading, writing and arithmetic may be a large undertaking. We have had the opportunity to educate our legislators. There are those who would want to practice medicine based on changing the law, rather than through obtaining the proper training. This becomes not a turf war as some would suggest, but a patient safety issue. Many without adequate training are just waiting to get their foot in the door. We must

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insure that this doesn’t happen. We must make a difference. Additionally, we have met with Director Keck and others from Health and Human Services to help them understand that we want to make health care in South Carolina better and have even suggested ways to appropriately spend their limited reserves to do this. We will continue to care for the poor of this great state, yet we are working tirelessly on your behalf so that they understand the plight of payment cuts to physicians, especially those who practice in rural areas. We have tried to stress that a visit to the emergency room is far more expensive than office care. Diabetes, hypertension and heart disease for instance do not go away with a single ER visit, but we know that adequate, continuous care of the patient produces better health. We continue to be ever vigilant about the health care law passed by Congress and the affect it will have on physicians and patients alike. Many, many more patients will be included in this new law and stress the system that is currently in place. We must be prepared for the future by being proactive now. The SGR got a reprieve until the end of this year, but no one is able to predict what will happen after that.

tal canteen. I thought to myself—well never mind what I thought-- but suffice it to say that the chase began and she finally slowed up long enough for me to catch her. As those of you who are spouses of physicians know, a medical marriage is truly unique. During the course of our practice, we experience the emotional highs of babies born and the lows of lives lost, the highs of getting paid for what we do and the lows of reimbursement rates being cut. She has been my constant support throughout the years of our marriage making our home a place where I could recharge for the next day’s challenges. I truly am the luckiest man in the world for she has made a difference in my life. Thank you again for allowing me to serve as your 150th president. It is an honor and privilege I will not take lightly as I represent you throughout the state. I look forward to visiting each society throughout the coming year. Now, let’s go have some fun! Thank you.

Gary A. Delaney, MD 2011-2012 SCMA President

Finally, we must remember that in all that we do, we must take care of each other. The motto of my home state, Kentucky, is “United we stand, divided we fall.” That can easily translate into the “Voice of one, the power of many.” Sound familiar? It is what you must remember when we call upon you for your support, whether it is in membership dues, contributions to MEDPAC, or a phone call to a legislator. In the end, it is about the care and safety of our patients. We must make a difference. We must not, we cannot fail. Many of you are wondering why I haven’t mentioned the lady sitting on the front row, my wife, Gail. When she became President of the Southern Medical Association Alliance, she said, “I would like to say something nice about my husband, but I can’t.” I will try to do better. I remember, many years ago, seeing this blue-eyed beauty in the hospi-

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The Journal of the South Carolina Medical Association

The Journal

of the South Carolina Medical Association

The mission of The Journal is to advance the art and science of medicine; to promote the ideals of the South Carolina Medical Association; to encourage scholarship and good will among South Carolina physicians; and to disseminate information specifically applicable to the health care of South Carolinians.

Editor Charles S. Bryan, MD Managing Editor Kate Crosby

Daniel P. Bouknight, MD T. Edwin Evans, MD Ivar Frithsen, MD Gerald E. Harmon, MD Edgar O. Horger, MD Neil L. Kao, MD

Associate Editors Lawrence B. Afrin, MD Richard A. Hoppmann, MD A. Weaver Whitehead, Jr., MD

Melanie A. Lobel, MD James Majeski, MD E. Conyers O’Bryan, MD J. David Osguthorpe, MD Robert M. Sade, MD Anand Sharma, MD

Student Editors Caroline Hunter – MUSC Jill Maxwell – USC

Gregory T. Squires, MD Hunter R. Stokes, MD W. Curtis Worthington, MD James L. Young, MD

SCMA Officers Gary A. Delaney, MD President Andrew J. Pate, MD, President-Elect Gregory Tarasidis, MD, Immediate Past President Alexander Ramsay, MD, Secretary Marshall L. Meadors, III, MD, Treasurer H. Tim Pearce, MD, FACS, Chairman of the Board Bruce A. Snyder, MD, Vice Chairman of the Board Larry L. Ware, MD, Executive Committee Member-at-Large Jennifer R. Root, MD, Speaker of the House March E. Seabrook, MD, Vice Speaker of the House Trustees Delegates to the AMA H. Tim Pearce, MD, FACS, First District Gerald E. Harmon, MD, Delegate Todd E, Schlesinger, MD, First District (Metro) John P. Evans, MD, Delegate Ponce D. Bullard, MD, Second District Stephen A. Imbeau, MD, Delegate Vincent J. Degenhart, MD, Second District (Metro) Boyce G. Tollison, MD, Delegate J. Brantley Parramore, MD, Third District Gary A. Delaney, MD, Alternate Bruce A. Snyder, MD, Fourth District (Metro) Gregory Tarasidis, MD, Alternate Robert C. Waters, MD, Fourth District H. Timberlake Pearce, Jr., MD, Alternate Terry L. Dodge, MD, Fifth District Gerald A. Wilson, MD, Alternate Sunil V. Lalla, MD, Fifth District Terry L. Dodge, MD, Alternate Richard C. Osman, MD, Sixth District W. Dean Lorenz, MD, Sixth District (Metro) James R. Ingram, MD, Seventh District Chief Executive Officer Dallas W. Lovelace, III, MD, Eighth District Mr. Todd K. Atwater James G. Mumford, MD, Ninth District Larry L. Ware, MD, Ninth District (Metro) John C. Ropp, III, MD, Young Physicians Section Ashley E. Harte, MD, Resident and Fellow Section Mary Kathryn Keane, Medical Student Section


The Journal of the South Carolina Medical Association (ISSN 0038-3139) is published by the South Carolina Medical Association business office: 132 Westpark Blvd., Columbia, SC 29210. Subscription price for the printed issue to non-members is $25.00. SCMA members’ subscription cost is $15.00 (included with payment of annual dues). To advertise in the printed issue: Contact Kate Crosby, Managing Editor, [email protected]. SCMA Address 132 Westpark Blvd, Columbia, SC 29210 Mailing Address: P. O. Box 11188 Capitol Station, Columbia, SC 29211 Phone: (803) 798-6207 or (800) 327-1021 Website: www.scmanet.org E-mail: [email protected]

Periodicals postage paid at Columbia, SC. POSTMASTER: Send address changes to The Journal of the South Carolina Medical Association, P. O. Box 11188, Columbia, SC 29211 Copyright© 2011 by the South Carolina Medical Association. All rights reserved. The views expressed in this publication are those of the writers and do not necessarily reflect the opinions of the South Carolina Medical Association.

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The Journal

Volume 107 Number 3 June 2011 Pages 63 - 109


Guest Editorial 67 Appropriate Medical Standards of Crisis Care Robert T. Ball, Jr., MD, MPH, FACP; Phil Schneider, PhD Scientific Articles 70 Creating a Standardized System for Allocation of Scarce Clinical Resources in Response to an All Hazards Mass Casualty Disaster

Walter Limehouse, MD; Rick Foster, MD

74

Surge Capability: CHPTER and SC Healthcare Worker Preparedness

Lancer A. Scott, MD; Andrew P. Ross, MD; Jennifer G. Schnellmann, PhD, ELS;

Amy E. Wahlquist, MS

78

Efficacy and Safety of Influenza Vaccines Eric Brenner, MD

83 Influenza 2010–2011 in one South Carolina Community: Report of Four Cases in Young Adults and Plea for Wider Immunization Charles S. Bryan, MD; Anthony R. Gregg, MD 87 Cost Containment and Policy Changes for HIV Services in a Resource Limited Setting

ASSOCIATION

Anand Nagarajan, MD; Noreen O’Donnell, MSW; Wayne A. Duffus, MD, PhD

91

All-Hazards COOP for Medical Facilities

Tom Russo, MA, MSEd, CEM

Commentary 96 Is There Much Limited Legal Liability Protection for Physicians in Crisis Standards of Care in SC?

Stephen P. Williams, JD

Alliance Page

99

All Hazards Planning and Response in the Veterans Administration

106

SCMA Updates

Joseph F. John, Jr., MD, FACP, FIDSA; James M Baker, MBA, CHEP;

108

CME Calendar

Mary Fraggos, RN, MS, NEA-BC; Carolyn Aams, Director;

102

Annual Meeting

Florence Hutchison, MD, FACP

63

President’s Page

101

Highlights

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Guest Editorial Appropriate Medical Standards of Crisis Care Robert T. Ball, Jr., MD, MPH, FACP and Phil Schneider, PhD Co-Chairs, South Carolina Pandemic Influenza Ethics Task Force In 2008, thanks to a federal grant obtained by the SC Department of Health and Environmental Control (DHEC), the multi-disciplinary South Carolina Pandemic Influenza Ethics Taskforce was formed to develop statewide medical and public health standards of care appropriate for a pandemic influenza crisis. The Task Force adopted a solid ethical foundation upon which to base a public policy of preparedness. This foundation would have to be seen as transparently fair by the citizens of South Carolina as to its moral framework and, equally importantly, as to its implications for coping with a widespread medical emergency. The Task Force defined a “medical emergency,” whether an influenza pandemic or, indeed, any other sort of emergency, as any situation where the demand for medical treatment (e.g., vaccines, medicines, health care workers, or facilities) far exceeds the resources available. In such an emergency, it would not be possible to insure that every patient need could be addressed. It would be necessary, therefore, to allocate limited medical resources based on morally acceptable and scientifically objective principles.

doctrine of utility or “the greatest good for the greatest number of people,” developed by John Stuart Mill in the nineteenth century. Classical utility theory allows the majority interest to supersede some individual rights. Distributive justice, on the other hand, views citizens as cooperating to wisely use the available resources they need, even if it means some degree of self-sacrifice. In medical emergencies, these resources most importantly require allocation decision methods for optimal mass patient treatment. “When everyone follows the publicly recognized rules of cooperation, and honors the claims the rules specify, the distribution of [medical] resources that results is acceptable as just (or, at least, not unjust).” [J. Rawls, Justice as Fairness, Harvard, 2001.] The Task Force considered “justice as fairness” to be the appropriate primary guiding ethical principle for allocating (sometimes referred to as “rationing”) the scarce resources needed to cope with a pandemic emergency. The acceptability of this principle to the citizens of South Carolina was gratifyingly demonstrated during public hearings held by the Task Force throughout the State.

In non-emergency times, the patients most in need of treatment receive the first or highest priority of attention. This is consistent with the ethical principles of personal autonomy in decision-making and beneficial welfare for individual patient choices, based upon the four cardinal virtues of courage (fortitude), wisdom (prudence), temperance, and justice. In mass emergency situations, however, it is not possible to focus solely on these traditional values for unlimited patient access to medical resources. In any medical crisis, patients range from those whose illness is so severe as to make any treatment (other than palliative comfort care) unlikely to prevent death, to those patients whose survival is very likely given available treatment such as ventilators and other intensive care. With the scarcity of medical resources in various medical crises such as pandemic influenza, the Task Force felt it necessary to make allocation decisions that are transparent, rational, and morally acceptable, based upon the cornerstones of individual liberty, trust, fairness, and community solidarity, with the latter including fair distribution of limited resources.

“Justice as Fairness” is the guiding ethical principle embodied in the all-hazards disaster triage mechanisms described in the article “Creating A Standardized System for Allocation of Scarce Clinical Resources…” by Drs. Rick Foster and Walter Limehouse in this issue of the Journal. Routine triage focuses on how best to serve individual patients and reflects the values of personal autonomy and patient welfare as mentioned above. On the other hand, disaster triage in medical emergencies, as defined by the Task Force, shifts focus from preserving one life to preserving as many lives as possible with available resources. Community-focused emergency triage ensures fair and equitable allocation of scarce resources based on objective medical criteria – the Sequential Organ Failure Assessment (SOFA) scoring system – that treat similarly situated patients equally. Within this framework, there is a companion focus on palliative care, strongly recommended by the Task Force, which is essential to the welfare of patients who cannot receive the full range of scarce medical resources. In summary, the ethical framework adopted by the Task Force preserves the fullest possible exercise of individual liberty while providing the maximum possible survival in a pandemic or other medical emergency.

In considering the appropriate guiding ethical principle for an influenza pandemic emergency, the Task Force closely examined the principle of “distributive justice,” as articulated by John Rawls. This principle goes beyond the classical ethical


SC DHEC’s Office of Public Health Preparedness served as

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the primary sponsor of the 2008-2009 Pandemic Influenza Ethics Task Force, and further detailed information is found at http://www.scdhec.gov/administration/ophp/pandemic-ethics. htm . The state’s plan “SC Prepares for Pandemic Influenza: An Ethical Perspective” is found therein and at http://www. scdhec.gov/administration/library/CR-009538.pdf . This plan reflects the above principles and provides detailed information to providers in medical crises. Organizations that have formally posted endorsement of this work and its recommended emergency standards of care are: S.C. Department of Health and Environmental Control (pdf) S.C. Area Health Education Consortium (AHEC) (pdf) S.C. Board of Medical Examiners S.C. Board of Nursing S.C. Board of Pharmacy S.C. Hospital Association (SCHA) S.C. Medical Association (SCMA) S.C. Nurses Association (pdf) S.C. Obstetrical and Gynecological Society (pdf) Doctor’s Care and other medical organizations such as the S.C. Infectious Disease Society and many individual hospitals. Providers may be concerned about their potential liability in triage and other critical clinical situations. The SC Board of Medical Examiners endorsement states, “The South Carolina Board of Medical Examiners endorses the need for the South Carolina Pan Flu Ethics Task Force published guidelines, by title, as acceptable crisis procedures in public health emergencies such as pandemic influenza. The Board supports legislation to codify these recommendations.” The intention is to provide safety of our medical licenses if crisis standards of care are accepted and implemented widely. In this issue of the Journal, Steve Williams, JD, a member of the Task Force Legal Committee (who worked with Matthew Penn, JD and Lynne Bailey Appleton, RN JD) provides several key legal points for physicians and other providers who may be concerned about potential liability to enact altered standards of care. Mr. Williams states, “the duty of care is the degree of care observed by a competent practitioner acting in the same or similar circumstances.” The key element here is the changed circumstances, in which patient triage and a “battlefield medicine” response replace the individual physician’s usual response to provide maximum care to the patient before him/ her, regardless of the needs of other patients in the emergency room or indeed in the entire community. The Task Force’s legal team feels - that by achieving the consensus among the

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aforementioned Boards and organizations – “we are there” regarding statewide acceptance of these guidelines as crisis standards of care (M. Penn, personal email communication). These principles and guidelines apply to many forms of medical emergencies, including but not limited to: extreme flooding, deadly tornado clusters, hurricanes, earthquakes, tsunamis, nuclear disasters, pandemics, mass casualty incidents such as airplane crashes, and even man-made crises such as mass shootings and terrorist bombings. Although these examples differ in terms of impact on people versus infrastructure, the principles described herein extend to the entire medical community of health care providers, often calling for an “all hands on deck” response. Do all physicians respond equally? Do all physicians respond effectively? Perhaps not, and if not, why not? In this issue of The Journal, Drs. Charles Bryan and Anthony Gregg make a compelling plea for universal influenza immunization, especially among health care workers. Dr. Eric Brenner describes in splendid detail the safety and efficacy of (mass) influenza vaccinations. Dr. Joseph John and Mr. Tom Russo describe several response approaches by hospitals and other systems to support the providers in the front lines. Dr. Wayne Duffus extends our concerns of society’s responses to wise use of limited resources in addressing the medical needs of persons afflicted with HIV-AIDS. Dr. Lance Scott’s team provides detailed information regarding training providers to adopt and implement crisis standards of care. As Samuel Johnson stated, “To preserve health is a moral and religious duty, for health is the basis of all social virtues. We can no longer be useful when we are not well.” And to quote the Buddha, “Without health, life is not life; it is only a state of languor and suffering- an image of death”. Hence, we must all become wiser in our use of limited medical resources. For example, during the 2009 pandemic influenza H1N1, several hospitals in SC had to divert patients to other facilities for necessary ICU and ventilator support, and several hospitals required all staff to receive the pandemic monovalent H1N1 vaccine (in addition to seasonal influenza vaccine). What if all S.C. hospitals were full of critical patients? What if one critically ill patient with nil chance of survival consumed a ventilator that could have been used to save many? What if health care providers simply refused vaccination for “personal reasons”? In two SC hospital cases, several workers who refused vaccination for non-medical reasons were terminated, and the SC Employment Security Commission and a Circuit


Court supported the hospitals and upheld the terminations. Also, many patients were saved by medical colleagues working together for the well being of the entire community. And we must learn that sometimes the needs of the greater community supersede the immediate needs of the first patient at hand. We must remove our medical blinders to see the greater good. Then we must teach others, not only in the medical profession but also in the greater community, our citizens and decision-makers. The unfortunate case of Dr. Anna Pou during Hurricane Katrina [see article by S. Okie, M.D. in The New England Journal of Medicine, 358:1, January 3, 2008], drives home the failure of society to provide altered standards of care for crisis situations and compels us to ask questions such as, “how and who can develop such standards”, “what events should trigger such standards” and “how can the provider be enabled to learn new standards and be protected simultaneously?” So, what have we learned, for example, from the still-present 2009 H1N1 pandemic influenza virus, and what can we carry forward for future medical challenges? “Lessons learned” can


be valuable teaching experiences, and we remind ourselves that the etymology of “doctor” is the Latin verb “docere” (from “doceo”), which translates “to teach” (not to heal or to serve). First, we must learn from hard lessons, such as the history of pandemics and other medical crises, especially regarding disaster triage care. We must also continually learn from the latest published guidelines and other information sources (admittedly increasingly voluminous in this electronic technical age) and teach others, albeit time-consuming. We must also learn the imperative for basic community-focused needs such as mass vaccinations, the widespread use of antivirals during influenza pandemics, appropriate testing with newer methodologies, and wiser use of increasingly limited resources. And perhaps the greatest lesson learned is to communicate more articulately than ever before these issues with our patients, our colleagues, and all in our community who must listen. This type and degree of communication becomes all the more important as we address looming complex issues such as endof-life care, advance life directives, and more standardized approaches to end-stage disease and terminal patient management.

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The Journal


Creating a Standardized System for Allocation of Scarce Clinical Resources in Response to an All Hazards Mass Casualty Disaster Walter Limehouse, MD Rick Foster, MD “Crisis standards of care” according to the Institute of Medicine represent a substantial change in usual healthcare operations and the level of care possible to deliver during a widespread or catastrophic disaster. Circumstances specific to the disaster then justify this change in level of care. The IOM states that, when state government declares that crisis standards of care are in effect, specific legal/regulatory powers and protections enable healthcare providers to allocate scarce medical resources and implement alternate care facility operations.1 However, ethical principles must guide state workgroups and healthcare organizations developing clinical guidelines covering crisis standards of care. When a mass casualty disaster occurs, regardless of the cause, hospitals and clinicians will face difficult clinical and ethical decisions actively balancing the rights of individual patients against the protection of the greater community. A New York State workgroup on allocation of ventilators, for example, incorporates duty to plan within an ethical framework including duty to care, duty to steward resources, distributive justice and transparency.2 During widespread or catastrophic disaster, the paramount duty of a physician to the patient shifts from the individual Address Correspondence to: Walter Limehouse, MD, MUSC, 169 Ashley Avenue, MSC 300, Charleston, SC, 29425. Email: [email protected]

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to the community. So a duty to plan for this contingency at all levels of the healthcare system applies. Government officials and health care providers must establish standards for the stewardship of clinical resources during true scarcity, so that obligations to all patients can be most fairly balanced with primary duty to care for each patient. Commonly, critical care providers measure estimated benefit of a given intervention for an individual patient against use of relatively scarce resources; disasters on the scale of a severe pandemic or earthquake magnify such limits in available resources. In the face of a major mass casualty disaster, clinicians must balance obligations to save the greatest possible number of lives against care for each patient. Patients who might survive under ordinary circumstances may not receive even the ordinary level of critical care resources, and may die while waiting for access to those resources. As number of affected patients increases, accommodating these two goals requires more and more difficult ethical and clinical decisions. Therefore, the community has an obligation to produce acceptable guidelines for allocation of scarce resources in the face of foreseeable crises. Failure to do so represents failure of responsibility toward both patients and providers. Moreover, appropriate guidelines for providers may mitigate potential legal consequences of providing crisis care during such a disaster. Following Hurricane Katrina, when these guidelines

were not in place, multiple providers faced major legal challenges for making difficult critical care triage decisions. These events provide strong evidence for the need to have guidelines in place before a mass casualty disaster occurs. Because clinical parameters of any mass casualty disaster are uncertain and will likely vary by the type of disaster and over time, any guidelines devised will provide only general guidance. The circumstances of the specific disaster in the relevant clinical setting at a specific point in time will dictate indicated modifications. Variations in viral infectiousness or immune responses in patients, for example, increase difficulty of predicting survival or duration of critical symptoms. However, this does not lessen the essential importance of planning for all hazards disasters by creating standards to guide allocation of scarce clinical resources in such mass casualty situations.3 Disaster planning does not alleviate the need to routinely provide adequate resources. Guidelines should also reflect an ongoing duty to protect the rights of the disabled. Moreover, a just allocation system seeks to avoid rationing by the purchase and use of supplemental ventilators, cancellation of elective surgeries, utilization of alternate care sites and altered standards of care for staffing ratios prior to implementation of crisis standards.4 The State should trigger crisis standards of care only during situations of true scarcity.5 Ultimately this system must also address the parameters establishing inclusion and exclusion criteria


Table 1. Sequential Organ Failure Assessment (SOFA) Score Variable

SOFA Score 0

1

2

3

4

PaO2/FiO2 mmHg

> 400

301 – 400

201 – 300

101 – 200

< 100

Platelets, x 10³/μL

> 150

101 – 150

51 – 100

21 – 50

< 20

Bilirubin, mg/dL

12

Hypotension

None

Mean arterial pressure < 70 mmHg

Dop < 5

Dop 6 – 15 or Epi < 0.1 or Norepi < 0.1

Dop >15 or Epi > 0.1 or Norepi > 0.1

Glasgow Coma Score

15

13 - 14

10 - 12

6-9

5 or anuric

Clinicians determine total SOFA score for each patient by summing the scores for each variable. Dopamine [Dop], epinephrine [Epi], norepinephrine [Norepi] doses in μg/kg/min. *Adapted from: Ferreira et al., 2001. Explanation of variables: PaO2/FiO2 indicates blood oxygen level with respiratory support. Platelets, bilirubin, and creatinine measure hematopoietic, hepatic, and renal system functions, respectively. Hypotension scores of 2, 3, and 4 indicate blood pressure maintained for at least one hour by dopamine, epinephrine, or norepinephrine. The Glasgow coma score measures neurologic function; low scores indicate worse function.

for access to critical care services and resources, including withholding or withdrawal from ventilator support, and appropriate use of palliative care services The Institute of Medicine (IOM) incorporated these mid-level principles into a Vision on Crisis Standards of Care in 2009.6 The IOM follow-up Crisis Standards of Care Summary of a Workshop Series in 2010 acknowledged eight states building consensus crisis protocols.7 Although South Carolina was not listed, the SC Pandemic Influenza Ethics Task Force published in November 2009 a comprehensive ethics white paper entitled, “South Carolina Prepares for Pandemic Influenza: an Ethical Perspective.”8 This document includes specific guidance from a clinical and ethical standpoint related to allocation of scarce resources in a pandemic and offers a recommended system for critical care triage in this type of disaster setting. As this white paper was nearing completion in early 2009, novel H1N1 influenza outbreaks started in several regions of South Carolina. SC DHEC, in partnership with the SC Hospital Association, established the Ethics Taskforce to develop and implement a formal hospital pandemic


preparedness and response plan, consistent with HRSA and CDC recommendations and guidelines. This plan focuses on a number of key strategic aims and tactical actions; including methods for mass influenza immunization of healthcare workers (HCW), specific human resource policies and procedures related to HCW protection, identification of and determination on when to activate alternate care sites, immunization plans for high risk patients, and policies and procedures for allocation of scarce clinical resources and implementation of critical care triage processes. One of the most important products of this partnership between DHEC, SCHA and SC hospitals has been the development of a template hospital all hazards disaster “allocation of scarce resources” policy and distribution of this policy, including a recommended critical care triage process, to all SC hospitals. This policy defines specific conditions when critical care disaster triage may need to be instituted and delineates a “scarce resource allocation” team under the Hospital Incident Command structure, including recommended team composition. This policy also defines the composition, functions and scope

of responsibilities for critical care triage teams, which are established by and under the direction of the scarce resource allocation team. For allocation of critical care resources, this South Carolina policy - like Ontario & New York – has recommended utilizing the Sequential Organ Failure Assessment (SOFA) scoring system as an appropriate, evidence-based clinical decision tool. SOFA scoring uses general physiologic parameters and applies to a wide range of conditions requiring critical care, including influenza. SOFA validly predicts mortality in critical care settings, regardless of the specific disease process. The score tracks organ failure in six organ systems with a scoring range from 0 – 24.9 [See Table 1] While not ordinarily used to ration critical care resources, under pandemic or other mass casualty disaster conditions, the SOFA system can objectively facilitate allocation decisions, particularly related to utilization of available ventilators. Such decisions could include both withholding patient access to and withdrawing patients from ventilator support. The SOFA scoring system is composed

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Table 2. Multi-principle Triage for Persons with Equal SOFA Priority for Critical Care during Public Health Emergency Principle

Specification

1

2

Save the most lifeyears

Prognosis for long-term survival(medical assessment of comorbid conditions)

No comorbid Minor comorbid conditions that limit conditions with long-term survival small impact on long-term survival

Life-cycle principle

Prioritize those Age 12-40 y who have had the least chance to live through life’s stages (age in years)

Age 41-60 y

3

4

Major comorbid conditions with substantial impact on long-term survival

Severe comorbid conditions; death likely within 1 year

Age 61-74 y

Age ≥75 y

Adapted from: White, DB, et al, 2009. For persons with equal critical care priority by SOFA score, those with the lowest cumulative multi-principle score receive highest priority for mechanical ventilation and critical care services. Consider small pediatric patients separately, since their size requires different mechanical ventilators and personnel.

of specific objective criteria for inclusion or exclusion from critical care and minimum qualifications for survival. Scores place patients in four treatment categories: patients in the green category receive care outside of critical care units; patients in the red scoring range have highest priority for critical care, followed by yellow; and patients scoring in the blue category receive palliative care. Reassessment of scores at defined time intervals permits movement between categories factoring in changes in the clinical status of patients and currently available critical care resources at time of reassessment. Patients identified by SOFA for critical care admissions generally require ventilatory support for respiratory failure. Availability of invasive ventilatory support separates critical care units from other acute care areas. During widely spread or catastrophic disaster conditions, surge capacity may offer hemodynamic support in alternate monitored areas which do not usually provide that level of care. However, non-ventilator dependent patients may also receive care in critical care units, if adequate space and staffing is available in these units and hemodynamic support is not available elsewhere. SOFA excludes from critical care, however, patients with poor prognosis or

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chance of survival even with aggressive interventions, specifically patients with SOFA scores > 11, who have a >90% predicted mortality even with full critical care under normal conditions. SOFA also excludes patients needing resources not available during pandemics or other disasters, such as traumatic or medical conditions in need of high volume transfusions. Individual patients with advanced medical illnesses consistent with high short-term mortality, even without concurrent critical illness, also receive exclusions. The Minimum Qualifications for Survival (MQS) component of the SOFA system limits resources allocated to each individual patient. In addition, SOFA includes ongoing 48 hour and 96 hour patient reassessments after admission to critical care. A SOFA score of > 11 on reassessment or the development of any other exclusion criterion moves a patient from critical care to palliative care. Because scarce resources during a pandemic or other mass casualty disaster preclude prolonged critical care, MQS attempts to identify early those patients who are not showing any significant clinical improvement and/or who are likely to die despite continued critical care management. The severity of the specific disaster event and the number of patients potentially needing access to critical care may require more frequent

reassessments. Consultants and hospital ethics committees should review triage criteria and clinical decisions periodically as the disaster progresses to ensure fairness. Local hospitals also should establish a process for evaluating and responding to formal appeals related to determinations of patients not being eligible for critical care or eligible for withdrawal from ventilator support using the SOFA system. SOFA-based triage predicts probability of short-term survival to save the most lives. Severe pandemics or other disaster situations, however, may require triage officers to allocate critical care between patients having equal SOFA scores. The SC template allocation of scarce resources policy, therefore incorporates a multi-principle strategy that adds scoring based upon “save the most life-years” or the “life-cycle” principles. “Save the most life-years” prioritizes scoring based upon prognosis for long-term survival using medical assessment of number & severity of comorbid conditions; “life-cycle principle” uses age in years to prioritize those who have had the least chance to live through life stages. Persons with lowest cumulative score receive highest priority for mechanical ventilation and critical care. One important caveat with the critical care triage process recognizes that the youngest pediatric patients require sepa-


rate consideration because they need special ventilators and personnel.10 [See Table 2] As noted, even with planning, as severity of the crisis increases11 “Things fall apart; the centre cannot hold.” SOFA uses laboratory-based assessments of survivability to prioritize access to ventilators; under severe enough conditions, however, laboratory supplies may no longer be available. Ventilator supplies may require sterilization and use with other patients. Family members of critically ill patients may need to assist with bag-valve-mask ventilations. Triage then may depend only upon the “life-years saved” and “life-cycle” composite scoring, perhaps with second-order decisions based upon “first-come, first served” or upon a lottery type system.12 South Carolina, like several other states and Ontario, has recognized that during public health emergencies where available clinical resources are overwhelmed, clinicians must treat the community, not individuals, as the paramount patient. This balancing of the ethical and clinical demands created by any mass casualty disaster allows our state and its many health systems and providers to meet the Institute of Medicine vision that, “when state government declares that crisis standards of care are in effect, specific legal/regulatory powers and protections enable healthcare providers to allocate scarce medical resources,”13 especially those related to critical care.


References

1. National Academy of Sciences: Crisis Standards of Care: Summary of a Workshop Series, 2010; 70. http://www. nap.edu/catalog/12787.html (accessed 2011.01.12) 2. NYS Workgroup on Ventilator Allocation in an Influenza Pandemic/ NYS DOH/ NYS Task Force on Life & the Law: Allocation of Ventilators in an Influenza Pandemic: Planning Document, March 2007 http://www.health.state.ny.us/diseases/ communicable/influenza/pandemic/ventilators/docs/ventilator_guidance.pdf (accessed 2011.01.12) 3. Ontario Ministry of Health & Long-Term Care: Ontario Health Plan for an Influenza Pandemic 2008, http://www.health. gov.on.ca/english/providers/program/ emu/pan_flu/pan_flu_plan.html (accessed 2011.01.12) 4. Rubinson L, et al: Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: Recommendations of the Working Group on Emergency Mass Critical Care; Critical Care Medicine, 2005; 33(10):E1-13. 5. Centers for the Law & the Public’s Health: Model State Emergency Health Powers Act; http://www.publichealthlaw. net/ModelLaws/MSEHPA.php (accessed 2011.01.12) 6. Institute of Medicine: REPORT BRIEF • Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report, National Academy of Sciences, SEPTEMBER 2009; 2http://www.iom.edu/~/media/Files/

Report%20Files/2009/DisasterCareStandards/Standards%20of%20Care%20report%20brief%20FINAL.pdf (accessed 2011.01.12) 7. McKenna M: The Most Good for the Most People: Emergency Physicians Lead push for Creating “Crisis Standards of Care” in Tough Political Climate; Annals of Emergency Medicine, 2010; 56(1): 22A-24A 8. SC DHEC, http://www.scdhec.gov/administration/library/CR-009538.pdf (accessed 2011.01.12) 9. Ferreira FL, Bota DP, Bross A, Melot C, Vincent JL: Serial evaluation of the SOFA score to predict outcome in critically ill patients; JAMA, 2001; 286:1754-1758; Table 1: Copyright ©2001, American Medical Association. All rights reserved. 10. White DB, et al: Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions; Annals of Internal Medicine, 2009; 150:132-138 11. Yeats WB: The Second Coming; http:// classiclit.about.com/library/bl-etexts/ wbyeats/bl-wbye-second.htm (accessed 2011.01.12) 12. National Academy of Sciences: Crisis Standards of Care: Summary of a Workshop Series, 2010; 18; http://www. nap.edu/catalog/12787.html (accessed 2011.01.12) 13. National Academy of Sciences: Crisis Standards of Care: Summary of a Workshop Series, 2010; 70; http://www. nap.edu/catalog/12787.html (accessed 2010.07.26)

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The Journal


Surge Capability: CHPTER and SC Healthcare Worker Preparedness Lancer A. Scott, MD Andrew P. Ross, MD Jennifer G. Schnellmann, PhD, ELS Amy E. Wahlquist, MS Introduction

The next major regional disaster will significantly affect hospitals and healthcare facilities faced with hundreds to thousands of patients simultaneously seeking care. Up to 80% of patients bypass first responders when major disasters strike, proceeding directly to hospitals or other healthcare facilities.1 Unfortunately, health professionals are commonly unprepared and poorly trained to handle large numbers of patients, posing grave risks to both patients and healthcare workers. After the 1995 Tokyo Subway attacks, 23% of one hospital’s staff suffered secondary exposure to sarin due to inadequate personal protective equipment (PPE) and training.1 And following Hurricane Katrina, the lack of physician training in Disaster Medicine was cited as a significant contributor to adverse patient outcomes.2, 3 The train derailment and chlorine spill in Graniteville, SC in 2005 highlights the impact of disasters in rural communities. Of the nearly 600 patients reporting exposure to chlorine that day, 63% of self-transported to local hospital emergency rooms, severely limAddress Correspondence to: Lancer A. Scott, MD, MUSC, 169 Ashley Avenue, Charleston, SC, 29425; Ph: 843-801-3980; Email: [email protected]

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iting already scarce healthcare resources in this South Carolina community.4, 5 The benefits of emergency preparedness training (EPT) are multifold, including learning rapid interventions to triage and save patient lives, personal protection measures to protect against unnecessary exposures, and basic security precautions to maintain the integrity and business continuity of healthcare facilities. Unfortunately, the American College of Emergency Physicians (ACEP) ranked SC 34th in the nation in Disaster Preparedness as part of their 2009 Report Card.6 Of the many factors considered when awarding this ranking, ACEP considered the low percentage (38.2%) of South Carolina nurses who participate in disaster training as significant.6,7 The lack of preparedness of SC health professionals represents a significant yet modifiable risk to the health and safety of all South Carolinians.

The Center for Health Professional Training and Emergency Response (CHPTER)

The Center for Health Professional Training and Emergency Response (CHPTER) is a SC training collaborative to save and protect patient lives by providing health care workers advanced, performance-based disaster training. Through inter-professional collaboration with our community partners (see Table 1 for members), we unified various EPT curricula around SC into a 1-day program with an ‘all-hazards’ approach. The CHPTER 1-day EPT curriculum is innovative, combining didactics, small

group exercises, and a performancebased Mass Casualty Incident (MCI) training experience with state-of-the-art patient simulators in an 11,000 ft2 technology center. Once fully developed, we will directly train hundreds of patient care providers each year and—via our Train the Trainer modules—hundreds to thousands more. We believe our training will help enhance surge capability in our region by giving health professionals hands-on lessons that will protect and save patient lives. Such training will also protect our most important surge capacity assets, our healthcare workers and hospitals, from being harmed, contaminated, or overrun during a disaster. In CHPTER’s review of the medical literature, we found no reports describing the level of emergency preparedness for SC health professionals—with the exception of nurses (see 2009 ACEP Report Card). In addition, no publications were found that described EPT deficiencies, obstacles to training, or other relevant workforce training topics. To our knowledge, an EPT needs assessment of SC emergency health professionals has never been published. This project describes the result of CHPTER’s 2010 survey of SC Emergency Department (ED) Medical Directors that assess the level of emergency preparedness and EPT needs—including hours, resources, obstacles and barriers—for our state’s ED care providers. Materials and Methods Survey content was developed by a subgroup of content experts (3 volunteer


Table 1. CHPTER Community Coalition Bon Secours St. Francis Hospital; Charleston Metro Chamber of Commerce; Charleston Police Department; Community and Regional Resilience Institute (CARRI); County Local Emergency Planning Committees (LEPCs); East Cooper Hospital; EMS, FIRE and Law Enforcement Agencies; MUSC, Emergency Medicine; Office of Mayor Joe Riley, City of Charleston; The Meridian Institute; MUSC, College of Health Professionals; MUSC, College of Nursing; MUSC, National Crime Victims Center; Naval Health Facility of Charleston; Ralph H. Johnson VA Medical Center; Roper Hospital; South Carolina AHEC; South Carolina DHEC, Region 7; South Carolina Hospital Association; South Carolina Medical Association; South Carolina State Ports Authority; Trident Health System; Trident Technical College; Trident United Way; US Department of the Navy, SPAWAR Table 2. Value and Utility of EPT Increased emergency preparedness training opportunities would:

Percent Agree

Be valuable to their hospital and/or health facility

100

Save health worker lives

94

Save patient lives

100

physicians) from the CHPTER Advisory Committee through a modified Delphi process. The subgroup defined ‘disaster’ as an event of local, regional or national significance that results in large numbers of patients simultaneously seeking care, depleting (or potentially depleting) available medical resources, capacity and/or capability. The Subgroup defined ‘Emergency Preparedness’ as the training, knowledge, and skills necessary to meet performance objectives (job appropriate) during a disaster and ‘Emergency Preparedness Training (EPT)’ as an organized and dedicated training event—including didactic, small group or hands-on performance objective training—designed to prepare staff to fulfill their expected duties during a disaster. Survey questions were collected by the Project Director and then redistributed to the subgroup through a repetitive process. By design, the survey was limited to 10 questions to ensure, based on prior experience with survey assessment, that we would have greater than 50% response rate. Survey questions included discrete and Likert-based analog scale questions. One Likert-based question assigned impact values to various barriers to EPT. For this question, “1” translated


into “Low Impact/Not a Barrier to Training” and a “10” translated as “High Impact/Greatest Barrier to Training.” Once consensus was reached on 10 questions, the survey was beta tested on a second group of volunteer ED physicians affiliated with regional academic institutions. From the comments of this second group, some survey modifications were made including requiring respondents to independently assess ED nurses, physician assistants, physicians, ancillary/ administrative staff and techs/nursing assistants. With the assistance of the SC of Emergency Physicians (SCCEP), we identified email addresses for 41 hospitalbased, SC ED Directors and contacted them electronically. Emails to these 41 were distributed to respondents between February and June 2010. The emails described the project and asked respondents to voluntarily click on a weblink embedded in the email. Follow-up letters were sent to email nonresponders. The survey was securely administered via Survey MonkeyTM. The Medical University of South Carolina IRB approved the research project and the survey.

Not all ED Directors responded to every question, and for some facilities the questions were not applicable. Percentages are calculated out of the total measurable responses and not always out of the total number of ED Directors surveyed.

Results

Of the 41 ED Directors, 21 (51%) completed the survey. Six of SC’s seven public health regions (Department of Health and Environmental Control [DHEC] regions) were represented in the survey. EDs were well-represented: rural (41%), urban (29%), and suburban (29%) communities were included. Although both teaching and non-teaching hospitals were included, most facilities (78%) were non-teaching. The survey included three ED’s based in Level 1 trauma centers. Survey sample EDs represented were small to moderate in size; greater than half (62%) treat fewer than 50,000 patients per year, with most (52%) treating 20,000–50,000 patients per year. Most ED’s (68%) were part of private hospitals; 32% of ED’s were affiliated with a public hospital. Most ED Directors agreed that at least 1 in 5 ED nurses, physician assistants, physicians, ancillary/administrative staff and techs/nursing assistants would fail to execute their expected roles during a disaster (76%, 75%, 76%, 76% and 85% ED Directors agreed, respective to job type). All respondents agreed that at least 25% of ED nurses, physician assistants and physicians would execute their expected roles during a disaster. All respondents agreed that increased EPT opportunities would be valuable to their hospital and/or health facility. Most 94% (17/18) agreed that increased EPT opportunities would potentially save health worker lives. All respondents agreed that increased emergency preparedness training opportunities would

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Table 3. Annual EPT Hours by ED Job Type ED Job Type

% with