Covid 19 Crisis Standards of Care: How Are They Operating?

[Susie2310]

I understand that Covid 19 Crisis Standards of Care have been instituted and are now operating. I read that in some state/s health care providers have been granted immunity from personal injury lawsuits. I am interested in how EMTALA, COBRA, CMS, and State Department of Health regulations are being complied with in practice under Covid Crisis Standards of Care.

On another thread, someone posted that they had been told that the normal Standards of Care don't apply now, and that it is acceptable for them to have higher patient ratios than their state normally permits.

[tnbutterfly - Mary, BSN]

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Definition: Crisis Standards of Care – a substantial change in usual healthcare operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g. pandemic influenza) or catastrophic (e.g. earthquake, hurricane) disaster. This change in the level of care delivered is justified by specific circumstances and is formally declared by a state government, in recognition that crisis operations will be in effect for a sustained period. The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternative care facility operations. (IOM Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, 2012)

Here is a link to the ANA website that addresses Crisis Standard of Care for the COVID-19 Pandemic.

https://www.nursingworld.org/~496044/globalassets/practiceandpolicy/work-environment/health--safety/coronavirus/crisis-standards-of-care.pdf

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There is a tension between the patient-centered approach to providing the maximum individual good for each patient (which is the focus of clinical ethics under normal conditions) and the public-focused approach to fair resource allocation during crisis conditions. A public health approach to ethics can provide guidance in balancing the tension between the needs of the individual and those of the group. “Public health emergencies require clinicians to change their practice, including in some situations, acting to prioritize the community above the individual in fairly allocating scarce resources.” (Berlinger, et al., 2020)

The ANA site provides separate guidelines for Registered Nurses and Institutions.

[tnbutterfly - Mary, BSN]

Here is a link that discusses how states are protecting health care providers from legal liability in the COVID-19 Pandemic.

https://blog.petrieflom.law.harvard.edu/2020/05/05/legal-liability-health-care-covid19-coronavirus-pandemic/

[NRSKarenRN, BSN, RN]

42 minutes ago, Susie2310 said:

I understand that Covid 19 Crisis Standards of Care have been instituted and are now operating. I read that in some state/s health care providers have been granted immunity from personal injury lawsuits. I am interested in how EMTALA, COBRA, CMS, and State Department of Health regulations are being complied with in practice under Covid Crisis Standards of Care. 

On another thread someone posted that they had been told that the normal Standards of Care don't apply now and that it is acceptable for them to have higher patient ratios than their state normally permits. 

ANA's Crisis Standard of Care COVID-19 Pandemic outlines how

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...the changing ethical framework in pandemics as a shift from “patient-centered practice” which is the “focus of clinical ethics under normal conditions” to “public-focused” considerations of care“to promote equality of person and equity in distribution of risks and benefits in society.”

https://www.nursingworld.org/~496044/globalassets/practiceandpolicy/work-environment/health--safety/coronavirus/crisis-standards-of-care.pdf

With the declaration of a PANDEMIC, standards change to considerations for the greater good, so regulations are scaled back via regulatory relief orders.

HHS ASPR, the Technical Resources, Assistance Center, and Information Exchange (TRACIE) has multiple COVID-19 Crisis Standards of Care Resources; includes

• COVID-19: Considerations, Strategies, and Resources for Emergency Medical Services Crisis Standards of Care.
• COVID-19 Hospital Resource Package-covers hospital surge, crisis standards of care, staffing surge and resilience, workforce protection, regulatory relief, equipment supply surge, and telemedicine.
• Fair Allocation of Scarce Medical Resources in the Time of COVID-19
• COVID-19 Crisis Standards of Care Resource List - includes links to state plans

https://asprtracie.hhs.gov/technical-resources/112/covid-19-crisis-standards-of-care-resources/99

[NRSKarenRN, BSN, RN]

Major CMS Waivers and Regulatory Changes During COVID-19 .

https://www.healthcareittoday.com/2020/03/31/major-cms-waivers-and-regulatory-changes-during-covid-19-pandemic/

COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers

https://www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf

EMTALA and Disasters

https://files.asprtracie.hhs.gov/documents/aspr-tracie-fact-sheet-emtala-and-disasters.pdf

Dept of Labor- COBRA: COVID-19 FAQs for Participants and Beneficiaries

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The rule applies as follows:

The COBRA election period. Under COBRA, employees and dependents who lose active coverage as a result of a qualifying event, such as termination of employment or reduction of hours, normally have 60 days to elect continuation of coverage after receiving a COBRA election notice. Under the rule, the 60-day time frame doesn't start until the end of the Outbreak Period.

The COBRA premium payment period. COBRA enrollees normally have 45 days from their COBRA election to make the first premium payment, and subsequent monthly payments must be made within a 30-day grace period that starts at the beginning of each coverage month. The new rule extends the initial premium payment and grace period deadlines beyond the Outbreak Period.

https://www.dol.gov/sites/dolgov/files/EBSA/about-ebsa/our-activities/resource-center/faqs/covid-19.pdf

[Susie2310]

13 minutes ago, NRSKarenRN said:

Dept of Labor- COBRA: COVID-19 FAQs for Participants and Beneficiaries

I appreciate your reply. To clarify, when I referenced COBRA I was referring to Emergency Care Transfers.

[Susie2310]

I would like to thank the above posters for the very useful information they have provided.

To clarify, I am particularly interested in learning how facilities are applying Covid 19 Standards of Care in day-to-day practice, I.e. actual examples of how Covid 19 Standards of Care are being applied daily in clinical practice in facilities in regard to EMTALA, COBRA, CMS, and State Department of Health regulations.

[NRSKarenRN, BSN, RN]

CMS: Emergency Medical Treatment and Labor Act (EMTALA) Requirements and Implications Related to Coronavirus Disease 2019 (COVID-19)

https://www.cms.gov/files/document/qso-20-15-hospitalcahemtala.pdf

Law office article: EMTALA Waivers During the COVID-19 Pandemic

https://www.bassberry.com/news/emtala-waivers-covid-19/

[NRSKarenRN, BSN, RN]

Off top of my head, EMTALA examples:

• Screening exams being conducted in tent outside facility entrance
• Asking Patients to Wait in their Vehicle or Outside of the Hospital.