Ethical Guidance for Disaster Response, Specifically Around Crisis Standards of Care: A Systematic Review.

BACKGROUND: Terrorism, disease outbreaks, and other natural disasters and mass casualty events have pushed health care and public health systems to identify and refine emergency preparedness protocols for disaster response. Ethical guidance, alongside legal and medical frameworks, are increasingly common components of disaster response plans. OBJECTIVES: To systematically review the prevalence and content of ethical guidance offered for disaster response, specifically around crisis standards of care (CSCs). SEARCH METHODS: We systematically indexed academic literature from PubMed, Google Scholar, and ISI Web of Science from 2012 to 2016. SELECTION CRITERIA: We searched for peer-reviewed articles that substantively engaged in discussion of ethical guidance for CSCs. DATA COLLECTION AND ANALYSIS: Researchers screened potential articles for identification and discussion of ethical issues in CSC planning. We categorized and cataloged ethical concepts and principles. MAIN RESULTS: Of 580 peer-reviewed articles mentioning ethics and CSCs or disaster planning, 38 (6%) met selection criteria. The systematic review of the CSC ethics literature since 2012 showed that authors were primarily focused on the ethical justifications for CSC (n = 20) as well as a need for ethics guidelines for implementing CSCs; the ethical justifications for triage (n = 19), both as to which criteria to use and the appropriate processes by which to employ triage; and international issues (n = 17). In addition to these areas of focus, the scholarly literature included discussion of a number of other ethical issues, including duty to care (n = 11), concepts of a duty to plan (n = 8), utilitarianism (n = 5), moral distress (n = 4), professional norms (n = 3), reciprocity (n = 2), allocation criteria (n = 4), equity (n = 4), research ethics (n = 2), duty to steward resources (n = 2), social utility and social worth (n = 2), and a number of others (n = 20). Although public health preparedness efforts have paid increasing attention to CSCs in recent years, CSC plans have rarely been implemented within the United States to date, although some components are common (e.g., triage is used in US emergency departments regularly). Conversely, countries outside the United States more commonly implement CSCs within a natural disaster or humanitarian crisis response, and may offer significant insight into ethics and disaster response for US-based practitioners. CONCLUSIONS: This systematic review identifies the most oft-used and -discussed ethical concepts and principles used in disaster planning around CSCs. Although discussion of more nuanced issues (e.g., health equity) are present, the majority of items substantively engaging in ethical discussion around disaster planning do so regarding triage and why ethics is needed in disaster response generally. Public health implications. A significant evolution in disaster planning has occurred within the past decade; ethical theories and frameworks have been put to work. For ethical guidance to be useful, it must be practical and implementable. Although high-level, abstract frameworks were once prevalent in disaster planning-especially in the early days of pandemic planning-concerns about the ethically difficult concept of CSCs pervade scholarly articles. Ethical norms must be clearly stated and justified and practical guidelines ought to follow from them. Ethical frameworks should guide clinical protocols, but this requires that ethical analysis clarifies what strategies to use to honor ethical commitments and achieve ethical objectives. Such implementation issues must be considered well ahead of a disaster. As governments and health care systems plan for mass casualty events, ethical guidance that is theoretically sound and practically useful can-and should-form an important foundation from which to build practical guidance for responding to disasters with morally appropriate means.

The Minnesota Medical Operations Coordination Center: A COVID-19 Statewide Response to Ensure Access to Critical Care and Medical-Surgical Beds.

BACKGROUND: COVID-19 led to unprecedented inpatient capacity challenges, particularly in ICUs, which spurred development of statewide or regional placement centers for coordinating transfer (load-balancing) of adult patients needing intensive care to hospitals with remaining capacity. RESEARCH QUESTION: Do Medical Operations Coordination Centers (MOCC) augment patient placement during times of severe capacity challenges? STUDY DESIGN AND METHODS: The Minnesota MOCC was established with a focus on transfer of adult ICU and medical-surgical patients; trauma, cardiac, stroke, burn, and extracorporeal membrane oxygenation cases were excluded. The center operated within one health care system's bed management center, using a dedicated 24/7 telephone number. Major health care systems statewide and two tertiary centers in a neighboring state participated, sharing information on system status, challenges, and strategies. Patient volumes and transfer data were tracked; client satisfaction was evaluated through an anonymous survey. RESULTS: From August 1, 2020, through March 31, 2022, a total of 5,307 requests were made, 2,008 beds identified, 1,316 requests canceled, and 1,981 requests were unable to be fulfilled. A total of 1,715 patients had COVID-19 (32.3%), and 2,473 were negative or low risk for COVID-19 (46.6%). COVID-19 status was unknown in 1,119 (21.1%). Overall, 760 were patients on ventilators (49.1% COVID-19 positive). The Minnesota Critical Care Coordination Center placed most patients during the fall 2020 surge with the Minnesota Governor's stay-at-home order during the peak. However, during the fall 2021 surge, only 30% of ICU patients and 39% of medical-surgical patients were placed. Indicators characterizing severe surge include the number of Critical Care Coordination Center requests, decreasing placements, longer placement times, and time series analysis showing significant request-acceptance differences. INTERPRETATION: Implementation of a large-scale Minnesota MOCC program was effective at placing patients during the first COVID-19 pandemic fall 2020 surge and was well regarded by hospitals and health systems. However, under worsening duress of limited resources during the fall 2021 surge, placement of ICU and medical-surgical patients was greatly decreased.

Maturing Into High-Functioning Health-Care Coalitions: A Qualitative Nationwide Study of Emergency Preparedness and Response Leadership.

OBJECTIVE: Health-Care Coalitions (HCCs) provide an important emergency response safety net function across the United States in preparedness and responses to disasters. A key challenge is the variation in the maturity and operational readiness of HCCs. The purpose of this study was to identify key tenets that define high-functioning HCCs and help mature HCCs into a higher-functioning state of operations. METHODS: This was a qualitative study based on grounded theory methodology using semi-structured interviews for data collection and thematic analysis. Participants were stakeholders (n = 39) of HCCs from across the United States at local, state, and federal levels. RESULTS: Through an institutional logics lens, the 3 key attributes for high functioning-HCCs were identified as (1) having an established and growing partnership, (2) being value-driven culture, and (3) being response ready. In addition, 3 logics were deemed essential for guiding HCCs: sources of governance, sources of partner engagement, and sources of sustainability. Participant responses describe the importance of these attributes and logics in influencing decision-making processes, supporting a community's resilience during a disaster, and fostering robust relationships among community partners. CONCLUSIONS: Addressing these attributes and logics in planning and management of HCCs can help establish the foundation for partner collaborations and high-functioning HCCs.