What Anesthesia Providers Should Know About Emergency Preparedness, Mass Casualty and Trauma
SUMMARY
The mass shooting in Las Vegas reminds us of the vital role of anesthesiologists and nurse anesthetists in large-scale emergency preparedness and disaster response. We present a selection of items on this topic, including an OR Mass Casualty Checklist developed by the American Society of Anesthesiologists, a comprehensive must-read chapter in the ASA Manual of Anesthesia Department Organization and Management and a national effort to train civilians and others in hemorrhage control techniques to reduce the number-one preventable cause of death in mass casualty events, including mass shootings.
The recent mass shooting in Las Vegas that killed 59 people and injured more than 500 others—the largest in United States history—painfully reminds us, again, that large-scale emergencies can happen virtually anywhere, at any time. Of course, this means anesthesiologists and nurse anesthetists in any hospital and geographic location could be required, on extremely short notice, to deliver emergency anesthesia care for many people with life-threatening and other traumatic injuries. That did happen to anesthesiologist Dean R. Polce, DO, of Sunrise Hospital and Medical Center in Las Vegas, who reported in an article in the Washington Post that he provided anesthesia for 27 surgeries in the wake of the shooting. Dr. Polce and anesthesia providers in area hospitals undoubtedly endured one of the harshest tests they'll ever face of their clinical and crisis management skills.
This eAlert offers a selection of pertinent facts, resources, compliance reminders and links related to emergency preparedness and the role of anesthesia providers in responding to mass casualty events like the fatal and critical injuries recently inflicted on concert-goers. Although this compendium barely skims the surface of the available information, we intend it to help you start an exploration that will refresh and enhance your knowledge and readiness, should you, your anesthesia colleagues and your hospital be thrust into a crisis situation similar to the one in Las Vegas.
Mass Casualty Checklist
The American Society of Anesthesiologists (ASA) Committee on Trauma and Emergency Preparedness (COTEP) has developed an Operating Room Mass Casualty Management checklist for use by hospitals, physicians and OR staff. The checklist provides step-by-step instructions and identifies specific tasks that should be completed when a mass casualty has occurred, such as ensuring adequate supplies, verifying blood availability and assigning an anesthesiologist as the emergency department liaison. The list is guided by principles of emergency preparedness but is designed to be customized by individual facilities to ensure an optimally effective response in crisis situations.
MADOM Chapter
COTEP has added a chapter on anesthesia emergency preparedness to the ASA Manual for Anesthesia Department Organization and Management (MADOM). This extensive document prepares hospitals and physicians for disaster response, serves as a guide for trauma anesthesia, and covers all aspects of disaster preparedness planning and execution.
According to the MADOM, anesthesiologists should be considered "first responders," because they are very likely to be directly involved in the operative and critical care of patients in any type of public health emergency, large or small. Their knowledge and training in trauma and critical care perioperative medicine and pain management uniquely qualify them to respond during a disaster by stabilizing patients and providing lifesaving treatment, including intubation and resuscitation. Anesthesia practitioners are encouraged to read this document and become involved in their facilities' emergency preparedness plans and drills. We also encourage you to check your service agreements to make sure you understand your facilities' expectations and requirements regarding your group's participation in emergency preparedness planning and response.
Stop the Bleed
The leading cause of preventable death in mass casualty events such as mass shootings, terrorist attacks and earthquakes is hemorrhage, and programs have been developed to train civilians and other nonclinicians in life-saving blood loss prevention before professional help arrives.
As specialists trained in the care of bleeding patients, anesthesiologists can use their skills to help educate the public, law enforcement professionals, firefighters, teachers and security personnel in these emergency actions.
In October 2015, the White House initiated Stop the Bleed, a national awareness campaign to give out-of-hospital bystanders the tools and knowledge to help in a bleeding emergency. The website of the Department of Homeland Security provides resources, including links and information for those interested in teaching a course.
Following the mass shooting at Sandy Hook elementary school in Newtown, Connecticut, the American College of Surgeons formed a joint committee in collaboration with the medical and law enforcement communities and others to develop a national policy to enhance survivability from intentional mass casualty. The recommendations of this committee, collectively called the Hartford Consensus, are contained in four reports available here. Like Stop the Bleed, the Hartford Consensus emphasizes the value of training law enforcement personnel and civilians in hemorrhage control. According to the Consensus's call to action, "No one should die from uncontrolled bleeding. Preventable death after an active shooter or an intentional mass casualty event should be eliminated through the use of a seamless, integrated response system."
What is a nonclinician bystander's liability in situations such as these? According to the Association of State and Territorial Health Officials, every state has a Good Samaritan statute, but the qualifying circumstances vary. Most statutes cover the spontaneous, uncompensated rendering of aid and reduce the standard of care that would be required of a physician or nurse.
Complicating the issue is the fact that some state statutes "apply only to care provided to 'accident' victims, whereas others apply to patients who receive care due to an 'emergency.' The definition of 'emergency' varies from state to state, as do the exact clauses and protections of each of these volunteer protection laws," according to the Bulletin of the American College of Surgeons. One survey found that 40 percent of states either lack statutes that provide immunity to volunteers during declared emergencies or have ambiguous statutes that require clarification, the article states.
Deadline Nears
In September 2016, the Centers for Medicare and Medicaid Services (CMS) issued a final rule requiring covered entities to develop an emergency preparedness plan for natural and man-made disasters. The deadline for those plans to be in place is November 15, 2017.
The purpose of the Emergency Preparedness Rule is to provide comprehensive and consistent policies and procedures for responses to emergency situations, increase patient safety and establish a more well-coordinated response to disasters. The rule covers 16 types of healthcare facilities in addition to hospitals, including ambulatory surgery centers, transplant centers and critical access hospitals.
In the wake of Hurricanes Harvey and Irma, and most recently, the mass shooting in Las Vegas, it behooves anesthesia care providers to be aware of the status of their facilities' (including their ASCs') emergency preparedness plans and to become active participants in emergency preparedness planning and drills. Are your organizations ready for an urgent threat? What is your group's role and responsibilities?
HIPAA Decision Tool
The Office of Civil Rights has created an interactive decision tool to help emergency preparedness and recovery planners determine how to gain access to and use protected health information (PHI) in a manner consistent with the HIPAA Privacy Rule. For example, emergency planners would want to know how to care for elderly or disabled patients in the event of an evacuation. The Disclosures for Emergency Preparedness Decision Tool guides users through a series of questions to determine how the Privacy Rule would apply in specific situations. The tool is designed specifically for advance planning regarding issues relevant to emergency preparedness and does not address other federal, state or local confidentiality laws that may apply in specific circumstances.
According to a HIPAA bulletin released shortly after Hurricane Harvey, the HIPAA Privacy Rule is not suspended during a public health or other emergency, but the Secretary of Health and Human Services may waive certain provisions of the Privacy Rule under the Project Bioshield Act of 2004 and Section 1135 of the Social Security Act.
However, even without a waiver, the HIPAA Privacy Rule always allows patient information to be shared under certain circumstances, including PHI that is necessary to treat a patient who has been affected by an emergency situation. The HIPAA bulletin provides a detailed list and explanation.
In the April issue of ASA Monitor, Catherine Kuza, MD, and Joseph McIsaac, MD, write that, despite the depth and rigor of knowledge and skills that make anesthesiologists essential members of response teams for mass casualty events (MCEs) and other disasters, many institutions continue to exclude anesthesiologists from providing care to patients in the emergency department unless their services are absolutely required. That should change, they argue, noting that hospitals would benefit greatly from more active participation by anesthesiologists in emergency preparedness and disaster responses. They urge anesthesiologists to demonstrate their value in the perioperative management of critically ill victims of MCEs and other disasters in their institutions, stressing that "more departments should be participating in such activities to identify areas of improvement. . . Furthermore, anesthesiology departments should be involved in hospital emergency preparedness meetings and committees. We need to make our presence known and demonstrate our worth in the management of critically ill victims of MCEs throughout the perioperative course."
Emergency preparedness fee-for-service coding guidance is available from the Centers for Medicare and Medicaid Services here. ABC clients: If you have any questions regarding coding for services provided during mass casualty events, your account manager will be glad to assist you.
With best wishes,
Tony Mira
President and CEO