State Perspective: Texas Crisis Standards of Care Bruce Clements, MPH Preparedness Director Texas Department of State Health Services

State Perspective: Texas Crisis Standards of Care Bruce Clements, MPH Preparedness Director Texas Department of State Health Services

Local Public Health Agencies

Health Service Regions and Emergency Medical Task Forces

Texas Healthcare Over 60,000 Physicians Over 186,000 Nurses 630 hospitals with 83,000 licensed beds A mix of facilities providing general acute-care, pediatric, long-term acute-care, psychiatric, rehabilitation and other specialized services. o 27% located in rural areas o 73% located in urban areas Hospital Ownership o 51% Private Investors o 28% Non-Profit o 21% Government

Crisis Standards of Care Development 2009-10 Developed an ethical framework to support decision-making in the allocation and distribution of scarce state-owned resources 2010 Extensive lit review and report from UTMB ethics staff 2012 DRAFT Hospital and ICU Triage Guidelines (North Texas Mass Critical Care Guideline) 2013 Commissioner, Dr. Lakey, approved CSC initiative 2014 Establish CSC Advisory Group and draft Texas CSC documents 2015 Accomplish public and stakeholder engagement 2016 Finalize Version 1 of Texas CSC Core Documents

A Medical Ethics Framework to Support Decision-Making in the Allocation and Distribution of Scarce Medical Resources During Pandemic Influenza: A Report to the Texas Department of State Health Services

Frameworks for Public Health Ethics and Their Application to the Statewide Allocation of Resources in Novel H1N1 Influenza (2010) The Institute for the Medical Humanities, University of Texas Medical Branch

Texas CSC Project Kick-off In June 2013 Commissioner David Lakey approved the establishment of a Texas Crisis Standards of Care Initiative The objectives of this project are to: 1. Establish a state-level, multidisciplinary CSC work group 2. Research and summarize existing planning approaches and strategies 3. Develop a state-level crisis standards of care document to include a (1) framework document; and (2) supporting appendices 4. Seek input from stakeholders and the public throughout each phase of the project to help inform the development of the statelevel crisis standards of care document(s)

CSC Project Organizational Structure DSHS Commissioner David Lakey, MD Executive Sponsor DSHS Assistant Commissioner David Gruber, MS Other DSHS Representatives CCEA, OGC, Regulatory Services Section Sponsor DSHS Section Director Bruce Clements, MPH Section Steering Committee DSHS Community Preparedness Managers Litaker Group Facilitation John R. Litaker, PhD Managing Director Section Project Management Don Sheahan, PMP Project Manager

Terminology and Functional Relationship Texas Crisis Standards of Care Initiative Panel Members (Input, expertise, and recommendations) Advisory Group (Non-DSHS SME Input and expertise) DSHS SME (Input and expertise) Who they are Panel Members What they will create Appendices Advisory Group DSHS SME Texas Framework Document 1 2 3 4

Membership Categories Panel Member Categories (n=21) At Large / Chair At Large / Vice-chair X 2 Clinical social work Disability Rights DO (Physician) DSHS, Executive DSHS, Regional Medical Director Emergency Medical Services Ethicist, Medical Faith Based Lawyer, Non-Government LHD, medical LHD, non-medical MD, Critical Care MD, Emergency Medicine MD, Family Practice MD, Geriatrics MD, Pediatrics RN Hospital CEO Advisory Group Categories (non- DSHS SME) (n=19) MD, Neonatologist MD, Pulmonologist MD, OB/GYN Administrator, Rural and Community Hospital School of Public Health Long Term Care Sheltering Operations Texas Regional Advisory Council (RAC) Business Private Health Insurance and Texas Medicaid Texas Military Forces Medical Reserve Corp TDEM Texas Task Force 1 Bioterrorism Expert Weapons of Mass Destruction Expert Medical Surge Expert Psychologist DSHS Subject Matter Expert (n=15) DSHS, CPS - Section Director DSHS, CPS Director, Response and Recovery Unit DSHS, CPS - Manager, Preparedness Grants DSHS, CPS - Manager, Preparedness Coordination DSHS, CPS - Manager, Response and Recovery Unit DSHS, CPS - Project Manager DSHS, General Counsel DSHS, Regulatory - Food and Drug DSHS, Regulatory - Hospital DSHS, Regulatory - Texas Trauma System DSHS, CCEA DSHS, Risk Communications DSHS, State Epidemiologist DSHS, MHSA - Disaster Behavioral Health DSHS, MHSA - Psychologist

Texas Approach Proposed Major Activities to Support Development of the Texas CSC 1 Create Texas Framework 2 Create Texas Appendices Appendices 3 Obtain Stakeholder and Public Input 4 Final Formal Public Comment Texas CSC Framework Document 1. Background and general principles document 2. 10 15 pages 3. Address assumptions, goals, ethical considerations, legal issues, and triggers 1 2 3 4 1. Addresses specific topical areas of importance during a crisis 2. Number and topics TBD 3. For each topical area, critical issues are addressed 4. It will include background on the topic, assumptions, general principles, and details of the critical issues 1. Obtain stakeholder input (e.g., public health, hospitals, EMS, etc.) on the framework document and on the appendices 2. Obtain public input on the CSC framework and on the appendices 1. Post documents for formal public comment period 2. Revise documents as appropriate 3. Finalize and publish documents (Note: Additional formal public comment and public engagement will take place throughout the project time period.)

Texas Approach: Timeline 1 Create Texas Framework 2 Create Texas Appendices Appendices Proposed Timeline 3 Obtain Stakeholder and Public Input 4 Final Formal Public Comment Texas CSC Framework Document 1 2 3 4 (Note: Additional formal public comment and public engagement will take place throughout the project time period.) Proposed Deadline August 30, 2014 Proposed Deadline February 28, 2015 Proposed Deadline October 31, 2015 Proposed Deadline January 31, 2016 NOTE: The timeline is dependent on many external variables and should be used as a guide for project progress; adjustments will be made as needed to the timeline

Texas Approach: Framework Document 1 Create Texas Framework Provide background and general principles for Texas Texas CSC Framework Document How is This Created 2.5 day meeting of Panel Members, Advisory Group and SMEs Addresses o Assumptions o Goals o Ethical considerations o Legal concerns o Triggers Identifies topical areas to be addressed in appendices 15 25 pages Objectives: 1. Information sharing with the panel 2. Input to create the Texas CSC Framework document 3. Identify topical areas for appendix creation Meeting Activities: 1. Information sharing to include: project background, legal discussion, review of Texas ethical framework, and assessment of state and federal planning documents 2. Obtain input from Panel on triggers, roles and responsibilities, and general content of the framework Deliverable: 1. Texas CSC Framework document

Texas Approach: Appendix Development 2 Create Texas Appendices 1 2 3 4 Address specific topical areas, for example: o o o How is This Created Pre-hospital / EMS Alternate care facilities Hospitals Each appendix addresses critical issues appropriate to that topical area (e.g., EMS transfer protocols, liability issues, reimbursement, etc.) 15 25 pages in length 4 to 5 one day monthly meetings Objective: Develop CSC appendix documents for each topical area identified Meeting Activities: Address pre-identified critical issues for each topical area Deliverable: CSC Appendix document for each topic

Texas Approach: Stakeholder/Public Input 3 Obtain Stakeholder Input and Public Input Obtain stakeholder input on the Framework Document and appendices: o Local and regional public health o Hospital services o EMS and pre-hospital care o Health care providers Obtain public input At least one meeting in each of 8 Health Service Regions Meetings may occur over multiple days Feedback used to revise the Framework Document and appendices How is This Created Meetings in each of 8 Health Service Regions Objectives: 1. Obtain stakeholder input 2. Obtain public input 3. Approximately 15 meetings statewide Meeting Activities: Facilitated discussion to obtain input Deliverable: Revised Framework Document and Appendices

Texas Approach: Stakeholder/Public Input 4 Final Formal Public Comment Post Framework Document and appendices for public comment Revise documents based on public comment, as appropriate Obtain final review and approval of Framework Document and appendices from Advisory Panel and DSHS Commissioner (Note: Additional formal public comment and public engagement will take place throughout the project time period.) How is This Created Final Formal Public Comment Objectives: 1. Obtain final formal public comment Meeting Activities: 1. Post for public comment 2. Receive and review comments 3. Revise documents 4. Obtain final review and approval from DSHS Commissioner Deliverable: Final Framework Document and appendices for release