The Pandemic Flu in Action ”What are the Patient Care Issues”

Carole A. Klove RN, JDChief Compliance and Privacy

OfficerUCLA Medical Sciences

Operational Issues to Consider Impact on obligations under the Emergency

Treatment and Active Labor Act (EMTALA) Exchange of Protected Health Information

(PHI) and HIPAA Privacy and California Confidentiality Laws

Understanding Surge Capacity and the impact on resources, including personnel, services and supplies and patient safety

Meeting the needs of “your community” and training your staff

EMTALA – Does an catastrophe make a difference?

Hospital must provide screening and stabilization for person presenting at ED

Waiver of sanctions during Katrina emergency HHS Secretary has authority to temporarily waive

EMTALA requirements in declared emergencies HHS waived sanctions for EMTALA violations for

hospitals with ERs located in “emergency areas” if have to transfer prior to stabilization if due to Katrina

Hospital still obliged to conduct screening

HIPAA and Confidentiality Under HIPAA, covered entity may not use or

disclose protected health information (PHI) except as permitted under Privacy Rule

In emergency, tension between privacy rights and need to share health information to inform families, friends, and public health workers

California law defines several specific reportable conditions, including “when the disclosure is otherwise specifically authorized by law” Civil Code § 56.10 (c)(14)

HIPAA and Confidentiality (cont.)

Sharing PHI during emergency Privacy Rule allows sharing of PHI without

authorization to public health authority in response to bioterrorism or public health emergency. 45 CFR Section 164.512(b).

Privacy Rule allows release of PHI to public health authority without authorization for certain public health activities, such as surveillance, but limited to “minimum necessary” information

HIPAA and Confidentiality (cont.)

HIPAA Waivers during Katrina Section 1135 Waivers (referencing Social

Security Act) HHS waived certain privacy requirements in

emergency areas affected by Katrina and Rita (i.e., needing to obtain consent to share info with family/friends; notice of privacy practices)

HHS Bulletin Reminders Katrina bulletins reminded providers how

Privacy Rule allows sharing PHI in disaster relief efforts for treatment purposes and to notify caregivers

HIPAA and Confidentiality (cont.)

Other Issues Health information is protected

whether person living or dead Release of patient information to

media Security and storage of records

(offsite storage; electronic records) EHRs – allows record to follow patient

Patient Safety and Surge Capacity

Assumptions to consider:• 30% of population will be affected• 50% of those affected will seek care• Most seeking care will need hospitalization• Significant mortality rate• Vaccine will be virtually non-existent in early phases• Resources for mass casualties may be inadequate• Hospitals will experience staffing shortages• Standards of care may have to be ‘sufficiency of care’

“No amount of planning will allow response to a major pandemic to be ‘business as usual’.”

Patient Safety and Surge Capacity (cont.)

Emergency Response:• Hospital Surge Capacity

• Need for hospital beds will exceed capacity• Illness among workers or their families will

exacerbate the shortage of staff• County DHS agencies have identified key

components of surge capacity and response to the demand

Patient Safety and Surge Capacity (cont.) Telemedicine

Consider telemedicine capability and privileges so physicians not required to attend hospital

Hospital Admissions May need to cancel elective

admissions during triage phase Use non-acute beds for acute patients Early discharge of patients

Patient Safety and Surge Capacity (cont.)

Credentialing and Privileging Need for temporary credentialing and relaxation of

standards during emergency JCAHO requires hospitals to establish procedure for

verifying credentials and granting privileges during and after disaster (HAS Std MS 4.10)

Consider pre-credentialing programs and established agencies, e.g., San Mateo County Medical Reserve Corps

HRSA’s ESAR-VHP Program assisted with registration, credentialing, and deployment of volunteer professionals to Gulf region by using online systems

Patient Safety and Surge Capacity (cont.)

Licensing Issues Out-of-State Professionals – Nat’l Emergency

Management Assistance Compact (EMAC), which CA ratified, allows for reciprocity

Medicare requirements also waived for Katrina providers JCAHO – If hospital’s disaster plan is activated,

may implement modified process for determining qualifications and competence of volunteer practitioners (Std HR 1.25 and MS 4.110)

Still limited to activities under license Must verify identity and licensure

Need to address emergency licensing in Med Staff Bylaws

Patient Safety and Surge Capacity (cont.)

Standard of Care Legal concept – Action a reasonably prudent

practitioner would take under same or similar circumstances

Would adapt to emergency situations Informed consent

Good Samaritan Statute In CA, person not liable where render

emergency care at scene of emergency (not including EDs or medical care site) in good faith and not for compensation

Patient Safety and Surge Capacity (cont.)

Government Code Section 8659: Physicians, hospitals, pharmacists, nurses and dentists who render services during a state of emergency or local emergency at the request of a health officer have no liability for injuries sustained by any person from those services, regardless of the circumstances or cause, except for willful acts or omissions

Patient Safety and Surge Capacity (cont.)

Prescription Medications and Treatment Only authorized individuals to have

access to drugs Only licensed individuals to prescribe

and administer drugs Maintain drug integrity Relaxation of standards for emergencies?

Volunteer physicians and pharmacists to act Acceptance of donated drugs

Planning – What does it Require?

Surge capacity for beds, personnel, morgue

Personnel protective equipmentVentilators? Tamiflu

Major isolation planStaff education

Develop internal rationing plan

Facilities

Supplies

Infection control

Vaccine/anti-virals

Coordinate with State/County

Training – Who and What Disaster Policy for Staff

Accessible via hardcopy or intranet Telecommuting policy for emergency Voluntary Nat’l Stds for Disaster

Preparedness (NFPA 1600) www.nfpa.org Identify critical staff and personnel

Medical staff Nurses and allied health professionals Patient support Plant operations Vendors

Training – Who and What (cont.)

Communicating with Staff (before, during, and after) Call-in line or website for further info Public announcement postings Chain of command/Telephone chain Security of communications

(passwords) Public Health Education for Staff

Training – Who and What (cont.)

Cross Training Staff for various job functions

Understand the job functions that impact an employees function

Recognize Union issues Conduct the Job Skills inventory and keep

it current, including language capability and interpretation

Training – Who and What (cont.)

Train on Attendance Concerns Consider flex time alternatives for jobs that

don’t require presence at hospital “Presenteeism” of sick workers may be

problem for spreading disease FMLA issues for prolonged absences Health Officer can order staff to be tested

and cleared before returning to work Have contingency plan for high absenteeism Consider Temporary housing

Questions and Answers