Crisis Standards of Care and COVID-19: What EMS Needs to Know

Today► Crisis Standards of Care, EMS and the Law

► Minnesota EMS Crisis Standards of Care Plan

► The Local Perspective – Operationalizing Crisis Standards of Care

► Questions

Today’s Speakers► James G. Hodge, Jr, JD, LLM

► Director, Center for Public Health Law and Policy, Arizona State University

► Professor, Sandra Day O’Connor College of Law

► Aaron Burnett, MD, FACEP► EMS Medical Director, State of Minnesota

► Associate Professor of Emergency Medicine, University of Minnesota

► John L. Hick, MD► Deputy Chief EMS Medical Director and Medical Director for Emergency

Preparedness, Hennepin County Medical Center

Implementing Crisis Standards of Care in Response to COVID-19: Legal & Policy Issues

James G. Hodge, Jr, JD, LLM

Purposes

► Emergency Declarations – Federal, State, Local

► Emergency Powers and Waivers

► Core Legal Issues

► Focus on Crisis Standards of Care Legal Concerns

Multi-Level EmergenciesPublic health authorities, powers, liabilities and immunities vary depending on the type of emergency declared at each level of government

8

HHS Public Health

Emergency

Stafford Act

Emergency

National Emergencies

Act

Defense Production

Act

Federal Emergencies/Invocations

January 31

March 13

March 13

March 20

Select Emergency Waivers► EMTALA sanctions re: patient relocation

► HIPAA Privacy Rule regulations following implementation of hospital disaster protocol

► Licensure requirements for HCWs in the state where they are providing services

► Certain conditions of participation in Medicare, Medicaid and SCHIP

► Telehealth allowances to facilitate healthcare services and payments when visiting physical facilities

Santa Cruz Co. 3/2Placer Co. 3/3

Marin Co. 3/3

Bellevue 3/3

COVID State & Select Tribal/Local Emergency Declarations

AK – Alaska

HI - Hawaii

PR - (Puerto Rico)

VI - (Virgin Islands)

San Diego Co. 2/19

San Fran City 2/25

Orange Co. 2/27

Solano Co. 2/27

2/29

Co. of Hawai’i 2/28

3/13/9

Seattle-King Co. 2/29

Clackamas Co. 3/2

Bexar Co. 3/2San Antonio 3/2

Sonoma Co. 3/2

Alameda Co. 2/19

Seattle 3/3

Santa Rosa 3/2

Redmond 3/3

Los Angeles Co. 3/4

Pasadena 3/4Long Beach 3/4

Lummi Nation 3/3

3/4

Washington Co. 3/4

Snohomish Co. 3/4

Emergency 3/4

Honolulu Co. 3/4Maui, Kaua’i 3/4

Click on the date of each state to view the declaration

Nevada Co. 3/4

Cowlitz Co. 3/4

Sacramento Co. 3/4

Edmond 3/5

Emergency - 33

Disaster - 4

Public Health Emergency/Disaster - 9

County/City

Emergency + Public Health Emergency - 4

Tribal

3/6

3/6

D.C. 3/11

Auburn 3/6Des Moines 3/6Mason Co. 3/6

3/6

Austin 3/6

3/6

Lexington (KY) 3/6

Eagle Co. (CO) 3/7

Travis Co. 3/6

Salt Lake Co. (UT) 3/6

3/73/8

Montgomery Co. (PA) 3/9

3/93/16

RI 3/9

3/5

3/9

Cooke Co. (IL) 3/9

Delaware Co. (PA) 3/9

3/9

Kitsap Co. 3/9

Miami-Dade Co. 3/11

3/10

3/4

3/10

Whatcom Co. 3/10

3/10

Pierce Co. 3/6

Houston 3/11

Salt Lake City (UT) 3/11

Cincinnati (OH) 3/11

3/11

3/11 3/11

3/11Public Health Disaster 3/11

Navajo Nation 3/11

Broward Co. 3/10

McHenry Co. (IL) 3/11

Northern Arapaho 3/11Oglala Sioux Tribe 3/11

3/12

3/12

3/12

Kansas City (MO) 3/12

3/12

New York City 3/123/12

3/12

Emergency 3/12

3/103/12

3/10

Cuyahoga Co. (OH) 3/12

NH3/13

VT 3/13

3/13

3/13

3/13

3/13

3/13

3/13

3/13

3/13

3/13 3/14

3/13

Emergency 3/13

3/14

3/15

St. Paul (MN) 3/15 Boston (MA) 3/15Milwaukee (WI) 3/13Minneapolis (MN) 3/16

Phoenix (AZ) 3/13

Umatilla Reservation 3/4

Hoopa Valley Tribe 3/4

Mendocino Co. 3/4

Santa Clara Co. 2/10

Los Angeles 3/4

DE3/12

3/9

Emergency Powers AK

AZ

AR

CA

CO

CT

DE

FL

HI

IL

IN

IA

KY

LA

ME

MD

MA

MI

NJ

NM

NY

NC

OH

OR

PA

RI

TN

VA

UT

WA

WV

WI

Altered Contracts | Procurements

■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Emergency Plans | ICS ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■Funding | Resource

Allocation■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Intrastate Coordination ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■Isolation | Quarantine ■ ■ ■ ■ ■ ■ ■Licensure Reciprocity ■ ■ ■ ■ ■ ■ ■

Price Controls re: Gouging ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Surveillance | Reporting ■ ■ ■ ■Testing | Screening |

Treatment■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Travel Restrictions ■ ■ ■ ■ ■ ■ ■ ■Waivers | Suspensions ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

This table tracks select, express authorities referenced via state emergency declarations (link on each state acronym for access). Additional emergency powers may be authorized under state law through which the declarations are issued.

Select State Emergency Powers

Government

Actors

Partners

Laws

Legal Triage: Efforts of legal actors and others during declared emergencies to build a favorable legal environment by prioritizing issues and solutions facilitating legitimate public health responses

Legal Triage

Legal Triage in Emergencies

Topics

Crisis Standards of

Care

Social Distancing Measures

Surveillance & Reporting

Privacy Liability & Insurance

Emergency Powers -

TriageTesting/ Screening/ Treatment

Emerging Legal Issues

14

► Coordination► Allocation► Reimbursement► Licensure► Scope of Practice► Patient’s Interests► Duty to Care► Uniformity► Liability

Click on article image to access

CSC Legal Issues

CSC: substantial change in usual healthcare operations and level of care due to a pervasive or catastrophic disaster

Prospective Civil Liability Claims

► Negligence/Malpractice► Intentional Torts► Privacy Infringements► Discrimination► Worker’s Compensation

Umbrella of Liability Coverage

Despite risks, many legal liability protections apply in routine events and declared emergencies, especially concerning health care volunteers, workers and entities

16

Emergency Liability Protections – Health Practitioners & Entities

Good Samaritan Acts and

Entity Liability Protection

InsuranceCoverage

EMAC

FederalPREP Act

Indemnification

State VPA

State EHPA

Mutual AidAgreements

FederalVPA

MOUs

Joint Commission Standards/

Policies and Practices

Acknowledgements

► Special thanks to Leila Barraza, JD, MPH, and Erica White at our Network -Western Region Office for their research and assistance

► Ask the Network re: questions/commentsjames.hodge.1@asu.edu | @jghodgejr

Minnesota EMS Crisis Standards of Care Plan

Aaron Burnett, MD, FACEP

Minnesota► Population 5.6 million

▷ 3.2 million in Twin Cities metro

► Level 1 Trauma Centers▷ 6 total (1 in across border in SD)

▷ 3 in Twin Cities

► Regionalized systems for:▷ Stroke

▷ STEMI

▷ Trauma

▷ Peds +/-

▷ Psych +/-

Minnesota EMS Regulatory Board► Emergency Med. Physician

► Minn. Hospital Rep.

► Fire Chief

► Full-time Firefighter

► Volunteer Firefighter

► EMS Provider

► EMS Service Manager

► Minn. Sherriff Rep.

► Local Board of Public Health

► Regional EMS Program Reps. (2)

► Emergency Dept. RN

► Pediatrician

► Family Practice Physician

► Public Member

► OTHERS:▷ Commissioner of Public Safety Rep.

▷ Commissioner of Health Director Rep.

▷ State Senator

▷ State Representative

Medical Direction Standing Advisory Committee“A forum for physicians to discuss

prehospital care and work toward the

improvement of medical direction

statewide. Its membership includes

physician members of the EMSRB, medical

directors from the eight EMS regional and

other interested emergency physicians”

Minn. CSC Development► EMSRB and State Dept. of Health (MDH)

work independently but in partnership

► Crisis Standards of Care first developed in

2010 for H1N1

► Reviewed and endorsed by MDH as well as

EMSRB

► Unified front for patient care in Minn.

Suspension of EMS RegulationsEmergency Suspension of Ambulance Service Requirements

Minn. Statute 144E.266

The requirements of the following statues are suspended in the geographic areas of the state affected during a governors declared peacetime emergency:

▷ 144E.10: Staffing, 24-hr response, BLS/ALS licensure, EVOC-drivers, PSA suspension, equipment

▷ 144E.121: Air ambulance licensure and staffing requirements

▷ 144E.123: Prehospital care data submission

▷ 144E.127: Interfacility transfer staffing requirements

▷ 144E.15: Relocating a base of operations

The Local EMS Perspective: Operationalizing Crisis Standards of Care

John L. Hick, MD

Hennepin Emergency Medical Services Crisis Contingency StrategiesDRAFT March 1, 2020

MN Metro Region EMS System Pandemic Response MatrixApproved March 12, 2020 – EMS TOC Executive Committee

Coronavirus/COVID-19 EMS Resourceswww.ems.gov/projects/coronavirus_covid-19_resources.html

Legal Emergency Preparedness Resourceswww.networkforphl.org/wp-content/uploads/2020/01/Western-Region-Emergency-Prep-8-23-18.pdf

Minnesota EMS Considerations – Crisis Standards of Carehttps://www.health.state.mn.us/communities/ep/surge/crisis/ems.html

Minnesota Suspension of Ambulance Service Requirement FAQshttps://mn.gov/emsrb/assets/Emergency%20Suspension%20Requirements%202020-03.19_tcm1116-423037.pdf

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