While a number of frameworks, guidance documents, and resources are available to help healthcare systems and stakeholders prepare for and respond to the emergence of crisis standards of care, relatively few address the unique circumstances and information needs of post-acute and long-term care (PALTC) facilities. In response to the COVID-19 pandemic, the Federal Healthcare Resilience Working Group has developed COVID-19: Considerations, Strategies, and Resources for Crisis Standards of Care in PALTC Facilities to inform changes to operations and care processes. It is intended to complement, not supplant, existing state and/or local guidance and plans for implementing crisis standards of care. Similarly, sample tools and resources are provided for illustrative purposes only and should be modified to locally adopted protocols as necessary.
In this article, AAPACN will cover the need and purpose for the Healthcare Resilience Working Group (HRWG) project, the standards of care and areas of impact, how a facility should use this document to guide decisions, and how to access this important new resource.
Addressing the needs of PALTC providers
“PALTC providers need crisis standards of care to meet the unique challenges of the pandemic,” states Amy Stewart, MSN, RN, DNS-MT, QCP-MT, RAC-MT, AAPACN vice president of education and certification strategy. “These challenges include limited resources, such as staffing, personal protective equipment (PPE) and supplies, and readily available testing. So for PALTC facilities in a crisis, when the demand for these resources has exceeded what you have, or your supply has been depleted, you need to make changes in your day-to-day practice to continue to operate utilizing your resources to the very best of your ability. The new crisis standards of care this group put together will help PALTC facilities do just that.”
In regard to why these crisis standards of care are important, AAPACN curriculum development specialist, Alexis Roam, MSN, RN-BC, DNS-CT, QCP explains, “These standards provide PALTC facilities with strategies they should consider to help guide decision making when their operations must change, which thus changes the standards of care. In an emergency situation, the status quo standards of care may not be achievable. So, in those instances, it’s important to have guidance that outlines what care takes priority that results in the most positive outcomes as possible.”
The standards of care and areas of impact
Under General Considerations in the Crisis Standards of Care document, the HRWG notes, “Changes to standards of care should take place along a continuum of levels of care.” It lists the following three levels:
Conventional: Normal level of healthcare resources;
Contingency: Demand for healthcare resources begins to exceed supply but adaptations are possible to still deliver functionally equivalent care;
Crisis: Resources are exceeded by demand or depleted; functionally equivalent care is no longer possible to address all requirements and there is a risk to patient/resident or provider.
The document also provides “examples of the kinds of strategies that PALTC facilities might adapt or adopt when contingency and crisis standards of care are anticipated or triggered in the following domains:”
Roam elaborates on how the transition in the standard of care shifts priorities within the domains. “For the category of medical care and treatment, when you are functioning in a conventional mode, it’s how you would deliver care normally. But when you shift to a crisis standard of care, it becomes triaging care. You look at how to provide essential supportive services, medicines and treatment, and comfort care. You are triaging and prioritizing.”
With COVID-19, the transition between the levels of care could happen very quickly, so planning is critical. However, the Crisis Standards of Care document also emphasizes that this transition could also occur slowly or in phases. Change from one level to the next may not happen all at once; rather, the Crisis Standards of Care document says:
. . . actions meant to preserve conventional standards of care in one area of operations may require introduction of contingency or crisis level standards in another area. For example, efforts to conserve staff and PPE resources may require a general shift towards virtual visitations using remote communication technologies, while still allowing access to support persons for individuals with disabilities and compassionate care, including end-of-life visits by family, friends, and clergy. (HRWG, 2020, p. 5)
How should facilities use this resource?
The Crisis Standards of Care are designed for practical application and personalized adaptation for every PALTC facility. Roam advises, “Facilities should review these standards right now, so that you have plans for the contingency and the crisis levels of care if they arise during the COVID-19 pandemic.”
Steps facilities should take to utilize this new Crisis Standard of Care for PALTC facilities include:
Review the standards – Nurse leaders should read through the document and familiarize themselves with the standards for each of the domains in their PALTC facility that may be impacted in a crisis.
For example, for the domain Medical Care and Treatment, it states, “The medical care and treatment rendered to residents in an emergency or crisis should be designed to assure appropriate and effective responses to a variety of situations and conditions. The overall purpose is to provide person-centered care, while ensuring the safety of facility staff” (HRWG, 2020, p. 23).
Update facility plans – Review the suggested strategies for each domain and incorporate the unique challenges of COVID-19 into the facility’s emergency preparedness plan and emergency operations plan. Ensure the response structure is updated to address an outbreak of COVID-19.
For example, the first two strategies listed for the Response & Operations domain are:
Develop and institute an Incident Command System (ICS).
Develop new, or repurpose existing, systems to monitor and proactively identify potential shortages in critical internal and external resources, such as staff, PPE, testing supplies (e.g., swabs), and body bags. (HRWG, 2020, p.18)
Implement the plans depending on the level of care the facility is functioning at presently - Update policies and procedures, add new systems in place, develop internal and external communication networks and methods, maintain legal and ethical standards, ensure advance care planning discussions are occurring, and be ready for a shift in the standard of care if an outbreak were to occur. Or, if the facility is already in an outbreak, utilize the strategies provided to work toward getting back to a conventional level of care.
For example, creating transparency through communication is very important during a crisis that impacts everyone, and if you are at a contingency level, other care settings nearby may need to know in order to assist the facility with resources. “Communication is needed not only for residents and families, but other local care settings too, like the hospital, because you may be transporting residents between settings. Resources may need to be diverted from the hospital to the PALTC facility, and the hospital may need to divert resources to accept very sick patients,” says Roam.
Note: There are also sample triggers and indicators for contingency and crisis standards of care within the document that can help nurse leaders determine which level of care they are functioning at, as well as tactics to help with transitioning back to a previous level, with the ultimate goal of returning to a conventional standard of care.
Sample table showing indicators, triggers, and tactics:
(HRWG, 2020, p. 13)
How to access this document
Access the “COVID-19: Considerations, Strategies, and Resources for Crisis Standards of Care in Post-Acute and Long-Term Care Facilities” here.
For more information, contact the Federal Healthcare Resilience Working Group at: HCSRTF-COVIDfirstname.lastname@example.org.
COVID-19 Healthcare Resilience Working Group. (2020). COVID-19: Considerations, strategies, and resources for crisis standards of care in Post-Acute and Long-Term Care (PALTC) facilities. U.S. Department of Health and Human Services, U.S. Department of Homeland Security, et al. https://files.asprtracie.hhs.gov/documents/covid-19-considerations-strategies-and-resources-for-crisis-standards-of-care-in-paltc-facilities.pdf
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