In the event of a public health emergency, there may be disruptions in governmental operations and infrastructure as well as in the clinical health care system. At the same time, there may be a surge of patients and individuals in the community who require services. It is critical that the District of Columbia (the District) take steps to address a medical surge. Such steps may include modifying scopes of practice for health professionals, using volunteer health practitioners, and switching to crisis standards of care (CSC). Another way to address medical surge is through the use of mobile medical clinics that may be deployed in the areas of the District that are most in need.
11.2 Scope of Practice
Scope of practice refers to the range of services that licensed practitioners are authorized to perform. In the District of Columbia (the District), scopes of practice are defined by the Health Occupations Boards. D.C. Official Code § 3-1201.01. During disasters and emergencies, the Mayor may determine that it is necessary to modify the scope of practice for health professionals to meet increased demand for services. In that case, the Mayor may issue a Mayor’s Order enlarging the permitted activities practitioners may perform or expanding the types of practitioners that are authorized to perform certain activities (e.g., a physician assistant may be permitted to provide certain services without the supervision of a physician).
Mayor's Orders prepared before disasters or emergencies strike will ensure that the necessary providers’ scopes of practice are modified so that response to medical surge is adequate.
11.3 Licensure Portability and Volunteer Health Practitioners
The portability of health care practitioners’ licenses may become an issue during and after a disaster or emergency if there is a surge in the number of individuals who require medical care. Licensure portability is addressed in the Emergency Management Assistance Compact (EMAC), which the District has signed. D.C. Official Code § 7-2332. See section 4.9 of the Manual for more information regarding EMAC.
The EMAC mechanism provides for interstate recognition of licenses held by professionals responding to disasters and emergencies. It also addresses liability issues. However, EMAC’s provisions related to licensure and portability have been interpreted to apply to state government employees only, with no application to private sector workers. See Darby C. Allen & Susan Feigin Harris, Licensure Issues in the Event of a Disaster or Emergency. Am. Health Law. Ass’n Emergency Preparedness Toolkit (2012).
The Uniform Emergency Volunteer Health Practitioners Act (UEVHPA) is model legislation developed in 2006 by the Uniform Law Commission in response to criticisms made after Hurricane Katrina regarding health care practitioner licensure under EMAC. The District adopted sections of the UEVHPA in 2010. D.C. Official Code §§ 7-2361.01 to - 2361.12.
While an emergency declaration is in effect, a volunteer health practitioner registered with a registration system that complies with D.C. Official Code § 7-2361.04 and who is licensed and in good standing in the state where the practitioner’s registration is based may practice in the District as if the practitioner was licensed in the District. D.C. Official Code § 7-2361.05(a). However, a volunteer health practitioner may not provide services outside of the practitioner’s scope of practice, even if permissible under District law. “Scope of practice” is defined as the extent of the authorization to provide health or veterinary services, including any conditions imposed, granted to the practitioner by the relevant licensing authority. D.C. Official Code § 7-2361.01(14).
“Volunteer health practitioner” is defined as a health practitioner who provides health or veterinary services, with or without compensation for those services, including an employee of the federal government. Practitioners who receive compensation pursuant to a preexisting employment relationship with a host entity or affiliate that requires the practitioner to provide health services in the District are not considered volunteer health practitioners unless the practitioner is employed by a disaster relief organization while an emergency declaration is in effect. D.C. Official Code § 7-2361.01(17).
Nothing in D.C. Official Code §§ 7-2361.01 to -2361.12 precludes a health facility from waiving or modifying its credentialing and privileging standards if an emergency declaration is in effect. D.C. Official Code § 7-2361.06(a).
11.3.1 Provision of Services during Declared Emergencies
While an emergency declaration is in effect, the Mayor may issue an order that limits, restricts, or otherwise regulates:
- The duration of practice by volunteer health practitioners;
- The geographical areas in which volunteer health practitioners may practice;
- The types of volunteer health practitioners who may practice; and
- Any other matter necessary to coordinate effectively the provision of health or veterinary services during the emergency.
Limitations on liability of volunteer health practitioners who provide health or veterinary services under D.C. Official Code §§ 7-2361.01 to -2361.12 may be found at D.C. Official Code § 7-2361.10, 7-401(a). Liability limitations for other emergency personnel at D.C. Official Code § 7-401(d-1).
11.4 Crisis Standards of Care
The standard of care generally refers to the duty owed by health care practitioners to their patients. Crisis standards of care (CSC), on the other hand, have been defined by the Institute of Medicine (IOM) as a “substantial change in usual healthcare operations and the level of care it is possible to deliver … justified by specific circumstances and … formally declared by a state government in recognition that crisis operations will be in effect for a sustained period.” IOM (Institute of Medicine). 2009. Guidance for Establishing Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. A formal declaration that CSC are in operation enables specific legal/regulatory powers and protections for healthcare providers as they work to treat as many patients as possible with limited resources.
11.4.1 Institute of Medicine Guidance
The IOM has issued various guidance documents related to crisis standards of care since 2009:
- Guidance for Establishing Standards of Care for Use in Disaster Situations: A Letter Report (2009). Washington, DC: The National Academies Press.
- Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response (2012). Washington, DC: The National Academies Press.
- Crisis Standards of Care: A Toolkit of Indicators and Triggers (2013). Washington, DC: The National Academies Press.
Through these various guidance documents, the IOM viewed surge capacity and its accompanying issues across a continuum of care based on demand for health care services and the available resources. Moving along the continuum of care from conventional care to CSC enables health practitioners to treat more patients with limited resources.
CSC does not authorize the provision of substandard care. Instead, the standard of care becomes what a “reasonable” practitioner would do given the limited resources available.
The switch to CSC may be prompted by different events, such as loss of essential services (i.e., electricity, water, parts of the supply chain) or disruption to health system infrastructure. Shortages of certain health care practitioners and/or shortages of medications and other supplies may also initiate the switch to CSC.
There is no official mechanism for a shift to CSC under District law. A public health emergency order issued by the Mayor under D.C. Official Code § 7-2304.01(a) would address provisions of law that would need to change in the event a shift to CSC is necessary. Such action is taken on a case-by-case basis.