chapter 4 operational infrastructure [enter facilitator’s name and contact information] developed...

Ch

apte

r 4

OPERATIONAL INFRASTRUCTURE

[ENTER FACILITATOR’S NAME AND CONTACT INFORMATION]

Developed by Troutman Sanders LLPDeveloped for the Virginia Department of Health

Funded by Centers for Disease Control and Prevention

2Operational Infrastructure


Toolkit Presentations Instructions for Use

Toolkit Presentations are intended to be a companion to the Hospital Implementation Guide and should not be used in isolation.

The Presentations are intended to serve as a starting point for the facilitator. The facilitator should thoroughly review the Presentation prior to use in Implementation Team, CRAG or Subcommittee meetings and customize the Presentation to meet the unique needs of the meeting participants.

Pay particular to attention to the information provided in brackets ([ ]), which must be completed by the facilitator prior to use.

Included in the “Notes” section of each slide are the following types of information:

• Slide Type, which indicates whether the slide is for information or discussion, serves as a placeholder, or is some combination thereof

• Planning Guide Section(s), which will direct the facilitator to the corresponding sections of the Planning Guide and Hospital Implementation Guide for further information

• Special Instructions, which provides directions for the facilitator to customize the slide for the intended audience

• Speaker’s Notes, which provides more detailed information to supplement the material on the slide

Refer to the Hospital Implementation Guide for further guidance and helpful hints on effectively completing the process described in the Planning Guide.


CRAG Members

[Enter names and departments of each CRAG member]


Add slides from Altered Standards Overview and/or Chapter 1 presentation, as needed, to re-introduce the CRAG to the concept of altered standards and critical resource shortage response planning, especially if new members are involved.


Introduction


Why do we need an Operational Infrastructure?

Many hospitals already have an emergency response infrastructure

Most hospitals do NOT have the type of infrastructure that will be needed to respond to a critical resource shortage event

An overall operational infrastructure will provide consistency to Protocol development, implementation, and operationalization


Chapter Overview

Determine process for activation and termination of the CRSRP

Determine process for activation and termination of each Protocol

Develop structure for making resource allocation decisions

Develop infrastructure for reviewing and revising CRSRP during a CRSE

Define “essential documentation”


Chapter Overview cont.

Develop process for responding to non-compliance

Identify resources for psychological and emotional support

Develop a communication plan Develop strategy for providing palliative care

during a critical resource shortage event• Determine goal• Develop standard definition• Identify mechanisms for providing palliative care


Review of Ethical Framework


Strong Foundation

Ethical Framework

Operational Infrastructure

Education & Communication

Building the CRSRP

Protocol

Protocol

Protocol

Protocol

Protocol

Protocol

Protocol

Protocol

Ad Hoc


[HIGH PRIORITY [HIGH PRIORITY ETHICAL VALUE]ETHICAL VALUE]




[MEDIUM PRIORITY [MEDIUM PRIORITY ETHICAL VALUE]ETHICAL VALUE]





[LOW PRIORITY [LOW PRIORITY ETHICAL VALUE]ETHICAL VALUE]





[Withdrawal/Withholding] [Withdrawal/Withholding] of Resourcesof Resources [Exclusion Criteria][Exclusion Criteria]

[INSERT GOAL DEVELOPED IN [INSERT GOAL DEVELOPED IN SECTION 3.2]SECTION 3.2]

Ethical FrameworkOperational Infrastructure

Ethical Framework


What’s Next?

Ethical Framework


Development of the operational infrastructure


CRSRP Process

Termination

Maintenance

Implementation

Activation


CRSRP ACTIVATION AND

TERMINATION


Activation of CRSRP

Supply of Critical Resources


Activation Flow Chart

Event Occurs

Identify Critical Resource Shortage

Event

Report Critical Resource Shortage

Event

Declare Critical Resource Shortage

EventActivate CRSRP

Who is responsible for each step in the activation process?

Resource levelsbegin to diminish &demand increases


Hospital Incident

CommandStructure


Identifying a Critical Resource Shortage Event

STATUS

Does demand exceed supply?

FORECAST

When will demand exceed supply if it doesn’t already?

DURATION

For how long will demand exceed

supply?

MAGNITUDE

To what extent does or will demand exceed supply?

MITIGATION

Options for obtaining additional supplies of

the resource.


Declaration and Activation

Supply of the Resource

Who will declare the CRSE?

Who will activate the CRSRP?


Governmental Emergency Declarations

How will federal, state or local emergency declarations be identified?

Who will find, read and summarize the declaration(s)?

What is the role of legal counsel?


CRSRP Termination

Too soon

Not soon enough


BREAK


PROTOCOL ACTIVATION AND

TERMINATION


Activation of Protocols



Simultaneous Activation



Asynchronous Activation



Protocol Termination Options

Simultaneous

Asynchronous• Who will terminate the Protocols? • Will the decision vary by Protocol?• What information is required?

Termination by Tier


BREAK


AllocationInfrastructure


Model 1 – Treating Physicians


Model 2 – Triage Officer


Model 3 – Triage Committee


ED

Inpatients

Direct Admits

ELIGIBLE

INELIGIBLE

Model 4Model 4Triage Triage

Officer and Officer and Triage Triage

CommitteeCommitteeResource #1

Resource #2

INE

LIG

IBLE


Which model should we adopt?


Triage Officer Powers

AUTHORITY YES NO

Recommend resource allocation

Withdraw resources from patients and re-allocate

Research/monitor outcomes

Situational Awareness

Re-assess and modify Protocols

Require physicians and staff to provide care according to Protocol

Reprimand non-compliant providers

Other?


Triage Committee Powers

AUTHORITY YES NO

Recommend resource allocation

Withdraw resources from patients and re-allocate

Research/monitor outcomes

Situational Awareness

Re-assess and modify Protocols

Require physicians and staff to provide care according to Protocol

Reprimand non-compliant providers

Other?


BREAK


Re-assessment of CRSRP during the

CRSE


Reassessment of CRSRP

Implementation of CRSRP

Re-assessment of situational

factors

Revisionof CRSRP

Disseminationof CRSRP


Documenting CRSRP Modifications

Re-assessment of situational

factors

Revisionof CRSRP


BREAK


Additional Operational

Issues


Primary Functions of Documentation During a CRSE

Care and safety of patients Support Protocols Quality assessment Obtain timely reimbursement

How will you ensure the completion of “essential documentation”?

Essential DocumentationEssential Documentation


Reasons for Non-Compliance

That is outside my

scope of practice.

I don’t have the knowledge or

skills to successfully

complete this task.

My patient deserves to receive the resource.

The triage committee used the Protocol incorrectly.

My patient,my

responsibility,my decision.

I won’t do that because I don’t want to get sued.


Non-Compliant ProvidersHow will you respond?

Ignore Terminate employment/

revoke privileges

Assume controlof patient

Counseling/Persuasion

Directive Restrict/suspend

privileges


Psychological and Emotional Support


Updating Staff


BREAK


Palliative Care


Palliative Care “Normal” v. Disaster

“Normal” Times End-of-life care

Performed by select group of providers

Patient choice

CRSE Patients who in “normal” times would have received regular care Providers who are not used to this type of care Little, if any, patient choice


Potential GoalsTo relieve painTo manage symptoms without use of the

critical resourceTo ensure that patients are not abandoned

or ignoredTo minimize the physical/psychological

suffering of those not provided the critical resource

Others?


Define Palliative Care

Definition is important for consistency and understanding

Will be informed by the goals established in this meeting

No existing definition really captures palliative/comfort care in the disaster context


Providing Palliative Care

Who will provide palliative care?Can we partner with existing local

palliative care organizations?What training will be needed?Can palliative care be provided in

alternate care facilities?How will psychological/emotional support

be provided to palliative caregivers?


Questions?Questions?

chapter 4 operational infrastructure [enter facilitator’s name and contact information] developed...

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