Almost three years after Hurricane Katrina, as natural disasters occur around the world with seemingly greater frequency, is the United States better prepared to respond to a disaster in our own backyard? And what improvements are still needed if health care providers, including NPs and PAs, are going to be utilized to the full extent of their capabilities?
Paul Bollinger, MPH, Emergency Medical Services Senior Advisor for the Portland, Oregon–based Medical Teams International (MTI), quotes MTI’s director of disaster response as saying, “It’s easier to send a doctor to Liberia than it was to Louisiana.” Bollinger adds, “That’s a huge issue, portability, in times of disaster—and yes, governors can change those laws, but I think by the time the bureaucracy wheels turn, it’s too late.”
Uniform Emergency Volunteer Health Practitioners Act
Greasing those bureaucratic wheels is the aim of the Uniform Emergency Volunteer Health Practitioners Act (UEVHPA), a piece of model legislation drafted by the Uniform Law Commission (ULC). According to Eric Fish, Legislative Counsel for the ULC, the goal of the UEVHPA is “to facilitate a better response to large-scale disasters by getting rid of some of the red tape and paperwork and things that could slow down responders.”
The ULC decided to address this issue as a direct result of what happened during and after Hurricanes Katrina and Rita struck the US Gulf Coast, laying bare the many levels on which bureaucracy and disorganization stymied relief efforts. “A few of the commissioners had family members involved with the medical response [to Katrina],” Fish says, “and it was brought up that way. And then, working with groups such as the Red Cross, it became apparent that some quick action in this field of law would be beneficial.”
Usually, it takes three to four years for the ULC to produce model legislation, from the time an area of interest (such as emergency response) is proposed to the point at which the commissioners approve the final version. In the case of the UEVHPA, most of the act was approved the year after the Katrina disaster, with additional sections addressing liability and workers’ compensation approved last year.
Colorado, Kentucky, and Tennessee were the first states to enact the UEVHPA in 2006 and 2007. In 2008, the act has been introduced in 12 states; so far, Indiana and New Mexico have enacted it. (See map.)
So how does the UEVHPA address some of the problems experienced in the aftermath of Katrina? Two key points are outlined in the prefatory note to the act (available as a PDF at www.uevhpa.org):
• “To protect the public health and safety, the act requires that, prior to deployment, volunteers must be registered with public or private systems capable of determining that they have been properly licensed and are in good standing with their principal jurisdiction of practice” and
• “To alleviate confusion and uncertainty regarding the types of services that may be provided by volunteer health practitioners, the act requires volunteers to limit their practice to activities for which they are licensed, properly trained, and qualified to perform. Further, volunteer health practitioners must conform to scope-of-practice authorizations and restrictions imposed by the laws of host states, disaster response agencies and organizations, and host entities.”
“It doesn’t supersede any existing state law,” Fish explains. “What this does is just set up a registry that a state can call upon in times of disaster.” He employs a baseball analogy for clarification: “It’s like having people in your bullpen. You know who’s in the bullpen, you know what they can do, you’ll bring them up for whatever situation.”
But is it enough?
Beyond the UEVHPA
No single piece of model legislation will iron out every wrinkle the nation faces in disaster response. PAs and NPs have particular issues when it comes to practicing outside the state in which they are licensed—supervision by and collaboration with physicians, respectively.
Long before Katrina, the American Academy of Physician Assistants (AAPA) drafted model language saying that “any PA who is licensed in the state or licensed in another state or authorized to practice by a federal employer as a physician assistant should be able to provide whatever care they are able to in a disaster or emergency situation, with whatever supervision is available,” summarizes Ann Davis, PA-C, AAPA Director of State Government Affairs. Five states (soon to be six) have adopted AAPA’s model language; overall, 38 states have some sort of provision for recognizing PAs in disasters or emergencies.
AAPA doesn’t have an official position on the UEVHPA, but Davis says, “In my opinion, the bill is fine as drafted, because it defines ‘health care practitioner’ as anybody who is licensed to provide health care services in a state. It’s broad enough that I don’t think anybody would question if PAs were meant to be included.”
While the UEVHPA does not specifically address PAs’ supervision requirements, it has provided opportunities for PAs in individual states to resolve those issues separately. When Indiana was considering passage of the UEVHPA, Davis says, “we flagged the issue and said, ‘You know, this might be a good time—while the legislators are thinking about disaster response—to talk to somebody about putting the PA language someplace.’”
That place didn’t have to be within the UEVHPA: “If you’re looking for a uniform law, you don’t necessarily stick your own provisions on it—that seems a little invasive,” Davis observes. Instead, the PA disaster response language was introduced through an omnibus bill that was in the works.
Jan Towers, PhD, NP-C, CRNP, FAANP, Director of Health Policy for the American Academy of Nurse Practitioners, is a bit less sanguine about the UEVHPA. “They still haven’t fixed the issue,” she notes, which for NPs is “shedding the shackles of law that requires physician collaboration or delegation within some of the states that have obsolete laws.”
Section 8 of the UEVHPA, “Provision of Volunteer Health or Veterinary Services,” contains the following statements:
• “… a volunteer health practitioner shall adhere to the scope of practice for a similarly licensed practitioner established by the licensing provisions, practice acts, or other laws of this state” and
• “Except as otherwise provided in subsection (c) [which allows states the right to modify or restrict services provided by a volunteer], this [act] does not authorize the volunteer health practitioner to provide services that are outside the practitioner’s scope of practice, even if a similarly licensed practitioner in this state would be permitted to provide the services.”
What concerns Towers is that “we’re still going to the lowest common denominator. Bottom line is, NPs are prepared [educationally] the same way across the board, and being tied to a physician in some states, while in other states they are not, is really limiting.”
Towers says it would have been “very helpful” if the UEVHPA had included language that expressly gave states the right to lift supervision or collaboration requirements. “There are some states that have actually passed regulations and statutes that speak to this by saying, ‘If there is a disaster, then the need to be tied to a physician is lifted, for the period of time of the disaster,’” she points out.
But, as with the PAs’ supervision requirements, “that’s happening state by state, and it’s something we’re going to have to work on,” according to Towers.
Wanted: Team Players
One thing that everyone seems to agree on is that preregistration, precredentialing, and involvement in emergency or disaster response teams should be encouraged. To this end, the UEVHPA requires that volunteer health care providers be registered with a system that can confirm their licenses and credentials before they are deployed in response to a disaster.
“The use of registration systems is intended to (1) discourage the uncoordinated use of ‘spontaneous volunteers’ who may independently travel to the scene of a disaster without the support of public or private emergency response agencies,” the preface to the draft legislation reads, “and (2) promote the recruitment and training of volunteers in advance of emergency declarations, while also allowing and facilitating additional registrations at the time of an emergency.”
The increased emphasis on teams, from the community level on up, has been one of the biggest lessons acted on since Katrina. “The amount of planning that’s gone on post-Katrina is incredible,” MTI’s Bollinger says. “A lot of states are looking at creating medical volunteer corps, looking at PAs, NPs, physicians, and paramedical personnel, and gathering them into a database that they can tap into. You know, ‘OK, we need four PAs to go to this clinic, or this displaced persons site, and provide care.’ Boom, that’s in the database; we can launch those folks.”
So-called spontaneous volunteers, though well intentioned, “can put burdens on a fragile infrastructure,” observes Bollinger. “In some ways, you’re relocating the disaster.”
That’s why PAs and NPs are encouraged to join a medical response team—whether a Red Cross unit, a Disaster Medical Assistance Team, or a private agency like MTI. “The best help is not the person who grabs their medical bag and goes down alone,” Davis says. “It’s folks who are part of an organized system that are the most helpful. They show up with their own water and tools and people that they know how to work with.”
Organized units will often handle credentialing and registration, but clinicians can also register on their own so that their licensing information can be verified in advance, allowing them to be mobilized quickly in the event of an emergency. “Having to do any kind of registration once a disaster happens, of course, slows down the process,” Towers observes.
Keeping documentation up to date—including passports if you’ll be responding overseas—is important. And while Davis strongly advocates for advance registration and credential verification “so you don’t show up someplace with a handful of papers,” she also suggests that “there should be a place where you keep all of your core licensing documents, CPR certification, graduation records from school, those things, so that if you’re in a spot where you need to leave quickly, you can.”
There is a touch of irony to the fact that the obstacles to international disaster response often relate to travel and access to remote sites, while within the US the obstacles have more to do with regulatory issues. “That’s the big hiccup, I think, of responding within the US,” says Bollinger, whose vast experience includes working on the MTI team that went to Indonesia in response to the tsunami in 2006. “We have all these laws in place: You must have medical direction, you must have signatures on this, this, and this. And that, I think, is going to become the albatross around our neck in domestic response, particularly for medical personnel.”
The difference? “National scope of practice,” Bollinger says. “The Ministry of Health in most of the countries we respond to, they’re the ones that call the shots.” Within the US, he adds, “We’re looking at significant health system change to make that a reality.”
It’s a reality (however unlikely) that not everyone would want anyway. After observing that most of the countries Bollinger refers to “are about the size of each of our states,” Towers notes that NPs “already have a national scope of practice. The states have set limits on that.” (This may or may not reinforce Bollinger’s point about bureaucracy.) Furthermore, Towers says, “I don’t think that we’re going to be able to create national practice acts. I don’t know that we even want to, for other reasons.”
When asked about national scope of practice, Davis responds, “My joke about that is, ‘I’m a young woman with good health habits, but I’m not going to live that long.’” She provides a brief history lesson for context, citing a 19th-century court case in which “we decided, at the Supreme Court level, that states would regulate health professionals as part of their duty to protect their citizens. People could make a very good case for this being something that the federal government should do, but that’s a big debate.”
On whatever level changes are made, the true test of how well the US has learned the lessons imparted by Hurricane Katrina will come only in the wake of another large-scale disaster—something no one wants to happen. Yet, with two international natural disasters (in Myanmar and China) occurring within a week, and tornadoes inflicting destruction on a smaller but still devastating scale in the US, it seems likely that the nation will eventually have extensive need of emergency responders again. In that case, it seems appropriate to fall back on the traditional Boy Scout maxim, Be prepared.
“If we can raise awareness of how to respond to disasters on the clinician level, I think it makes us a stronger country,” Bollinger says. “If we’re better prepared, we’re better able to respond, and I think a lot of these other issues will kind of go by the wayside. Hopefully.”