30 - Disaster Risk Management

Disaster risk management encompasses a holistic approach to all hazards throughout the disaster cycle of prevention, mitigation, preparedness, response, and recovery. Research during the COVID-19 pandemic highlighted numerous shortfalls globally in disaster preparedness and response within the health care setting. The results of multiple studies suggest that a lack of preparedness and high vulnerability remain significant challenges for health care organizations during disasters. Risk may also need to be reexamined in light of the increasing frequency, duration, and intensity of crisis events. Rather than focusing on an all-hazards approach to disaster risk management, it may be prudent to consider the top hazards an organization may face.

Avoiding Crisis Conditions in the Healthcare Infrastructure: 2 Case Studies in Statewide Collaboration.

In fall 2020, COVID-19 infections accelerated across the United States. For many states, a surge in COVID-19 cases meant planning for the allocation of scarce resources. Crisis standards of care planning focuses on maintaining high-quality clinical care amid extreme operating conditions. One of the primary goals of crisis standards of care planning is to use all preventive measures available to avoid reaching crisis conditions and the complex triage decisionmaking involved therein. Strategies to stay out of crisis must respond to the actual experience of people on the frontlines, or the "ground truth," to ensure efforts to increase critical care bed numbers and augment staff, equipment, supplies, and medications to provide an effective response to a public health emergency. Successful management of a surge event where healthcare needs exceed capacity requires coordinated strategies for scarce resource allocation. In this article, we examine the ground truth challenges encountered in response efforts during the fall surge of 2020 for 2 states-Nebraska and California-and the strategies each state used to enable healthcare facilities to stay out of crisis standards of care. Through these 2 cases, we identify key tools deployed to reduce surge and barriers to coordinated statewide support of the healthcare infrastructure. Finally, we offer considerations for operationalizing key tools to alleviate surge and recommendations for stronger statewide coordination in future public health emergencies.

Amplifying patient voices amid pandemic: Perspectives on tracheostomy care, communication, and connection.

OBJECTIVE: To investigate perspectives of patients, family members, caregivers (PFC), and healthcare professionals (HCP) on tracheostomy care during the COVID-19 pandemic. METHODS: The cross-sectional survey investigating barriers and facilitators to tracheostomy care was collaboratively developed by patients, family members, nurses, speech-language pathologists, respiratory care practitioners, physicians, and surgeons. The survey was distributed to the Global Tracheostomy Collaborative's learning community, and responses were analyzed. RESULTS: Survey respondents (n = 191) from 17 countries included individuals with a tracheostomy (85 [45 %]), families/caregivers (43 [22 %]), and diverse HCP (63 [33.0 %]). Overall, 94 % of respondents reported concern that patients with tracheostomy were at increased risk of critical illness from SARS-CoV-2 infection and COVID-19; 93 % reported fear or anxiety. With respect to prioritization of care, 38 % of PFC versus 16 % of HCP reported concern that patients with tracheostomies might not be valued or prioritized (p = 0.002). Respondents also differed in fear of contracting COVID-19 (69 % PFC vs. 49 % HCP group, p = 0.009); concern for hospitalization (55.5 % PFC vs. 27 % HCP, p < 0.001); access to medical personnel (34 % PFC vs. 14 % HCP, p = 0.005); and concern about canceled appointments (62 % PFC vs. 41 % HCP, p = 0.01). Respondents from both groups reported severe stress and fatigue, sleep deprivation, lack of breaks, and lack of support (70 % PFC vs. 65 % HCP, p = 0.54). Virtual telecare seldom met perceived needs. CONCLUSION: PFC with a tracheostomy perceived most risks more acutely than HCP in this global sample. Broad stakeholder engagement is necessary to achieve creative, patient-driven solutions to maintain connection, communication, and access for patients with a tracheostomy.

Treatment, Care, and Ethics

This chapter examines the ethical challenges of treating and caring for Covid patients. Healthcare professionals are at risks to be infected by SARS-CoV-2, and in all countries illness and death has affected them as well as their families. The ethical discussion focuses on whether professionals have a duty to treat and to care, when there is substantial personal risk, particularly when sufficient protective equipment is not available. Ethical issues also exist for patients. They can experience various kinds of harm as a result of having contracted an infectious disease, and as the result of being in isolation during treatment in the healthcare facility. Patients with other diseases are harmed because modalities of treatment and care are cancelled or postponed since priority is given to Covid patients. A further ethical concern relates to the difficulty to maintain ordinary standards of care in conditions of emergency. Specific attention is subsequently given to ethical questions of research. The only way to improve the treatment of Covid patients is sustained research to test and develop medication. Intensive public debate has emerged on the subject of triage. If resources, especially in intensive care, are limited, which patients will be selected for treatment, and which criteria are ethically justified? The last paragraph of this chapter will focus on end-of-life care, and the need to provide palliative care to seriously ill Covid patients. © 2022, The Author(s), under exclusive license to Springer Nature Switzerland AG.

The Future in Standards of Care for Gynecologic Laparoscopic Surgery to Improve Training and Education.

Standards of care offer doctors and patients the confidence that an established quality, evidence-based, care is provided, and represent a tool for optimal responding to the population's needs. It is expected that they will increasingly express a multimodal relationship with gynecologic laparoscopy. Laparoscopy is, now, a standard procedure in operative gynecology, standards are embedded in many laparoscopic procedures, standardization of the skills/competency assessment has been progressively developed, and the proof of competency in laparoscopy may become a standard of care. A continuous development of surgical education includes standard equipment (that may bring value for future advance), standardized training, testing (and performance) assessment, educational process and outcome monitoring/evaluation, patients' care, and protection, etc. Standards of care and training have a reciprocally sustaining relationship, as training is an essential component of standards of care while care is provided at higher standards after a structured training and as credentialing/certification reunites the two. It is envisaged that through development and implementation, the European wide standards of care in laparoscopic surgery (in close harmonization with personalized medicine) would lead to effective delivery of better clinical services and provide excellent training and education.

Healthcare inequalities in antenatal care in the European Region: EBCOG Scientific review.

It is now well recognized that unacceptable inequalities in maternity care that exist due to a woman's ethnicity, socio-economic deprivation, age, residential social status within a country can have adverse effects on the outcomes of their pregnancies. Perceived attitudes can lead to dismissal of concerns, breakdown of trust and can affect interactions with maternity services. Women from black and Asian ethnicity are at 2-4 times higher risk of maternal mortality. Similarly women with underlying mental health issues and those with undocumented status are also at higher risk of adverse outcomes during pregnancy and within the first postnatal year. There is need for research, to understand why these different practices exist and how we can more effectively understand and overcome the barriers and factors which can lead to inequality in access to uniform standard of care. Covid-19 pandemic created challenges for the provision of maternity services. Each country responded by their own creative and pragmatic solutions. It is important that individualized care based on a woman's individual social and medical needs must remain a priority to improve maternity care. It is proposed that EU funding should be made available to set up large scale European wide research to inform future policies.

Patient Information Items Needed to Guide the Allocation of Scarce Life-Sustaining Resources: A Delphi Study of Multidisciplinary Experts.

OBJECTIVE: Plans for allocation of scarce life-sustaining resources during the coronavirus disease 2019 (COVID-19) pandemic often include triage teams, but operational details are lacking, including what patient information is needed to make triage decisions. METHODS: A Delphi study among Washington state disaster preparedness experts was performed to develop a list of patient information items needed for triage team decision-making during the COVID-19 pandemic. Experts proposed and rated their agreement with candidate information items during asynchronous Delphi rounds. Consensus was defined as ≥80% agreement. Qualitative analysis was used to describe considerations arising in this deliberation. A timed simulation was performed to evaluate feasibility of data collection from the electronic health record. RESULTS: Over 3 asynchronous Delphi rounds, 50 experts reached consensus on 24 patient information items, including patients' age, severe or end-stage comorbidities, the reason for and timing of admission, measures of acute respiratory failure, and clinical trajectory. Experts weighed complex considerations around how information items could support effective prognostication, consistency, accuracy, minimizing bias, and operationalizability of the triage process. Data collection took a median of 227 seconds (interquartile range = 205, 298) per patient. CONCLUSIONS: Experts achieved consensus on patient information items that were necessary and appropriate for informing triage teams during the COVID-19 pandemic.

The Ethics of Unilateral Do-Not-Resuscitate Orders for COVID-19 Patients.

This paper examines several decision-making models that have been proposed to limit the use of CPR for COVID-19 patients. My main concern will be to assess proposals for the implementation of unilateral DNRs - i.e., orders to withhold CPR without the agreement of patients or their surrogates.

Impact of COVID-19 pandemic on frequency of clinical visits, performance of MRI studies, and therapeutic choices in a multiple sclerosis referral centre.

INTRODUCTION: To evaluate the impact of the COVID-19 pandemic on (1) number of clinical visits, (2) magnetic resonance (MR) scans, and (3) treatment prescriptions in a multiple sclerosis (MS) referral centre. METHODS: Retrospective study covering January 2018 to May 2021. RESULTS: The monthly mean (standard deviation [SD]) of visits performed in 2020 (814[137.6]) was similar to 2018 (741[99.7]; p = 0.153), and 2019 (797[116.3]; p = 0.747). During the COVID-19 period (2020 year), 36.3% of the activity was performed through telemedicine. The number of MR scans performed dropped by 76.6% during the "first wave" (March 14 to June 21, 2020) compared to the mean monthly activity in 2020 (183.5[68.9]), with a recovery during the subsequent two months. The monthly mean of treatment prescriptions approved in 2020 (24.1[7.0]) was lower than in 2019 (30[7.0]; p = 0.049), but similar to 2018 (23.8[8.0]; p = 0.727). Natalizumab prescriptions increased in the "first wave" and onwards, whereas anti-CD20 prescriptions decreased during the COVID-19 period. CONCLUSION: Maintenance of the number of clinical visits was likely due to telemedicine adoption. Although the number of MR dramatically dropped during the "first wave", an early recovery was observed. Treatment prescriptions suffered a slight quantitative decrease during 2020, whereas substantial qualitative changes were found in specific treatments.

Quality initiative to improve emergency department sepsis bundle compliance through utilisation of an electronic health record tool.

INTRODUCTION: Sepsis is a common cause of emergency department (ED) presentation and hospital admission, accounting for a disproportionate number of deaths each year relative to its incidence. Sepsis outcomes have improved with increased recognition and treatment standards promoted by the Surviving Sepsis Campaign. Due to delay in recognition and other barriers, sepsis bundle compliance remains low nationally. We hypothesised that a targeted education intervention regarding use of an electronic health record (EHR) tool for identification and management of sepsis would lead to increased EHR tool utilisation and increased sepsis bundle compliance. METHODS: We created a multidisciplinary quality improvement team to provide training and feedback on EHR tool utilisation within our ED. A prospective evaluation of the rate of EHR tool utilisation was monitored from June through December 2020. Simultaneously, we conducted two retrospective cohort studies comparing overall sepsis bundle compliance for patients when EHR tool was used versus not used. The first cohort was all patients with intention-to-treat for any sepsis severity. The second cohort of patients included adult patients with time of recognition of sepsis in the ED admitted with a diagnosis of severe sepsis or septic shock. RESULTS: EHR tool utilisation increased from 23.3% baseline prior to intervention to 87.2% during the study. In the intention-to-treat cohort, there was a statistically significant difference in compliance between EHR tool utilisation versus no utilisation in overall bundle compliance (p<0.001) and for several individual components: initial lactate (p=0.009), repeat lactate (p=0.001), timely antibiotics (p=0.031), blood cultures before antibiotics (p=0.001), initial fluid bolus (p<0.001) and fluid reassessment (p<0.001). In the severe sepsis and septic shock cohort, EHR tool use increased from 71.2% pre-intervention to 85.0% post-intervention (p=0.008). CONCLUSION: With training, feedback and EHR optimisation, an EHR tool can be successfully integrated into current workflows and appears to increase sepsis bundle compliance.

Centering Social Justice for Covid-19 Resources and Research.

In the September-October 2021 issue of the Hastings Center Report, neither the article by MaryKatherine Gaurke et al. nor the article by Alex Rajczi et al. offers a comprehensive analysis of a just allocation of scarce resources-one "rooted in a collective agreement about what constitutes health in/justice." This omission reflects a larger problem in bioethics: the field's praxis continues to fail to recognize and respond to the obligation to address the fair distribution of burdens and benefits that comes with the principle of justice. This commentary calls on bioethics to incorporate a community-based participatory research (CBPR) framework as part of its praxis. The cocreation of crisis standards of care with community stakeholders, whether the standards were focused on treatments, vaccines, or novel community-engagement strategies, could set a new gold standard for the practice of social justice in research.

Drastic changes in the practice of end-of-life care during the COVID-19 pandemic.

This article discusses drastic changes in the practice of end-of-life care during the COVID-19 pandemic. It reviews the ethical dilemmas of individual autonomy versus societal justice, human beneficence versus public health non-maleficence that arose during the pandemic due to prolonged, high acutity,= critical illness in the setting of a highly contageous respiratory virus, protective personal equipment shortages,m crisis standards of care to distribute scarce medical resources, and changes in interactions between treating clinicians, patients, and visitors. The lessons learned during the pandemic response will directly inform and impact the appraoch to future pandemic events.

European board and college of obstetrics and gynaecology position statement to mark "World Patient safety day - Safe maternal and newborn care" on 17th September 2021.

Maternal morbidity and mortality remain stubborn highly in many parts of the world. Similarly Neonatal morbidity, mortality and five years survival in most of the under-resourced countries has not declined significantly over the past decades. Furthermore sexual reproductive health services provision has not met the needs of the women and there remains a huge unmet need for reliable contraception globally. This is the time for a global action plan and for all agencies to work together to achieve meaningful outcomes to improve health of women and their babies. Covid 19 pandemic has led to increase in gender based violence as well which is deplorable. European Board and College of Obstetrics and Gynaecology welcome this initiative and commits to work with all the stakeholders to improve safety and quality of care for women and the newborn.

The Crisis in Standards of Care.

Since the start of the Covid-19 pandemic, debates have waged about "crisis standards of care" ("CSC")-the guidelines for the allocation of resources if those resources are too scarce to meet the needs of all patients. The Hastings Center Report's September-October 2021 issue features a collection of pieces on this debate. In the lead article, MaryKatherine Gaurke and colleagues object to the idea that the allocation of scarce resources should aim to save the most "life-years," arguing instead that the objective should be to save the most lives. Gaurke et al. assert that it is only theorists who have favored the life-years strategy; the public has not-or at least, there is no good evidence that the public has. This claim is elaborated in the article by Alex Rajczi and colleagues, who argue that identifying and applying the public's will-a process they call "political reasoning"-is the core work in developing CSC. Five commentaries-two coauthored, by Douglas B. White and Bernardo Lo and by Anuj B. Mehta and Matthew K. Wynia, and three solo authored, by Govind Persad, Virginia A. Brown, and Robert D. Truog-offer further arguments about and insights into CSC.

Crisis Standards of Care-More Than Just a Thought Experiment?

As described in two articles in the September-October 2021 issue of the Hastings Center Report, most crisis standards of care (CSC) plans include triage algorithms to guide the allocation of critical care resources to some patients and not others under conditions of extreme scarcity. The plans also include other important CSC strategies, but it is the notion of rationing scarce resources via triage that especially captured the imaginations of ethicists. Vigorous arguments have arisen over whether triage algorithms should be designed to prioritize patients based on predictions of short-, near-, or long-term survival. Additionally, there are ongoing debates about the ability of current algorithms to estimate patient survival accurately enough to be useful in triage and about the role of values like equity in triage protocols. Relatively few debates have noted, however, that while the development of CSC triage protocols has been based in medicine, public health, and ethics, the activation of CSC plans remains a political decision.