SCOPE OF PRACTICE, VOLUNTEER HEALTH PRACTITIONERS, AND CRISIS STANDARDS OF CARE

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11.1 Summary

In the event of a public health emergency, there may be disruptions in governmental operations and infrastructure as well as in the clinical healthcare 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 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. 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

In general, scope of practice refers to the range of services that licensed practitioners are authorized to perform. In 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).

Model 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 healthcare 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), in which the District is a participant. D.C. Official Code § 7-2332.

The EMAC provides for interstate recognition of licenses held by professionals responding to disasters and emergencies. However, its provisions related to licensure and portability have been interpreted to apply to state government employees only, with no application to private sector workers. See Portability of Licensure and the Nation's Health. EMAC also addressed liability issues.

See section 4.10.2 of the Manual for more information regarding EMAC.

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 healthcare 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). A volunteer health practitioner, however, 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).

The Mayor can declare a public health emergency if there is the occurrence of other emergency events that create an acute and immediate need for volunteer health practitioners. See section 4.5.2 of the Manual.

Section 207: Improving All-Hazards Preparedness and Response by Public Health Emergency Volunteers of the Pandemic and All-Hazards Preparedness and Advancing Innovation Act of 2019 (PAHPIA) encourages states to both raise awareness of opportunities for public health professionals to provide medical services during emergencies and to structure their licensure programs so as to allow those professionals to provide care across state lines during an emergency.

Section 208: Clarifying State Liability Law for Volunteer Healthcare Professionals of the PAHPIA clarifies that, under certain circumstances, voluntary medical professionals who are providing out of state care in a state that has declared a state of emergency will be subject to the liability laws of the state in which the service was provided.

11.3.1    Provision of Services During Declared Emergencies

During a declared emergency, 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.

D.C. Official Code § 7-2361.03(a).

Volunteer health practitioners who provide health or veterinary services under D.C. Official Code §§ 7-2361.01 to -2361.12 are not liable for damages for acts or omissions in providing those services. D.C. Official Code § 7-2361.10(a). This liability limitation does not apply to willful misconduct or wanton, grossly negligent, reckless, or criminal conduct; an intentional tort; breach of contract; a claim asserted by a host entity or by an entity located in the District or another state which employs or uses the services of the practitioner; or an act or omission relating to the operation of a motor vehicle, a vessel, an aircraft, or other vehicle. D.C. Official Code § 7-2361.10(c). Moreover, in authorizing health services under D.C. Official Code §§ 7-2361.01 to -2361.12, the District has no liability for the act or omission of a volunteer health practitioner. D.C. Official Code § 7-2361.10(e).

See section 5.8 of the Manual for additional information regarding liability protection.

11.3.2    Medical Reserve Corps

The Medical Reserve Corps (MRC) is a national network of volunteers, organized locally to improve the health and safety of the community. MRC units engage volunteers to strengthen public health, improve emergency response capabilities, and build community resiliency.

DC Health has established the District of Columbia Medical Reserve Corps (D.C. MRC), a cadre of trained and qualified volunteers, to supplement public health and medical resources during emergencies and other times of community need, and to enhance the District’s capability. D.C. MRC volunteers include medical and public health professionals such as physicians, nurses, pharmacists, dentists, veterinarians, and epidemiologists. Non-medical volunteers include interpreters, chaplains, office workers, legal advisors, and others to fill key support positions.

The D.C. MRC is primarily designed to assist and supplement the existing emergency medical response and public health systems in emergencies and does not replace existing emergency medical response systems or their resources. Volunteers may be requested to support large-scale, complex emergencies involving multiple jurisdictions and interagency operations, or smaller incidents involving a single jurisdiction or agency. D.C. MRC volunteers are required to register in DC Health database, http://www.dcresponds.org.

The Emergency Law Inventory (ELI), a tool developed by the University of Pittsburgh Graduate School of Public Health Center for Public Health Practice, provides summaries and full text of laws impacting volunteers who prepare for and respond to disasters.

11.4 Crisis Standards of Care

The standard of care generally refers to the duty owed by healthcare practitioners to their patients. Crisis standards of care (CSC) are 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.” See Guidance for Establishing Standards of Care for Use in Disaster Situations: A Letter Report. A formal declaration that CSC are in operation enables specific legal/regulatory powers and protections for healthcare providers working 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, including:

Through these various guidance documents, the IOM identifies surge capacity issues across a continuum of care that are based on demand for healthcare services and the availability of 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 (e.g., electricity, water, parts of the supply chain) or disruption to health system infrastructure. Shortages of certain healthcare 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.

 



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