Crisis Standard of Care Doing the Right Thing When You Must Do Something and You Can’t Do Everything

1. Crisis Standard of CareDoing the Right ThingWhen You Must Do Something and You Can’t Do Everything Kristi L Koenig, MD, FACEP Professor of Emergency Medicine Director of Public Health Preparedness Co-Director, EMS and Disaster Medical Sciences Fellowship University of California at Irvine

2. Case Study • A patient is in cardiopulmonary arrest • Do you do CPR? • What is the “Standard of Care?”

3. Standard of Care • Legal Definition • What would the prudent person do under similar circumstances?

4. Standard of Care • Healthcare Personnel • “Diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance” • New England Journal of Medicine, 2004 • Concerns about medical malpractice

5. Catastrophic Disaster • Scarce resource environment • Difficult to conceptualize in the United States

6. Lack of Resources? • 29 disasters in the United States • 6% supply shortages • 2% personnel shortages • Lack of a management system to organize available resources • Hurricane Katrina • An exception?

7. Catastrophic Event • When needs exceed resources at a given point in time • Allocation of scarce resources

8. Goal in Scarce Resource Environments • Standard of Care • Goal to optimize population medical and health outcomes rather than individual outcomes • You must do something and can’t do everything

9. Standard of CareCatastrophic Disaster • Do not alter the “standard” of care • Change thegoal • Triggers to shift to population management • Triggers to shift back to individual management • May move back and forth several times during a single event

10. Case Study • A patient is in cardiopulmonary arrest • Do you do CPR? • What is the “Standard of Care?” • Answer • It depends on the situation!

11. Crisis Standard of Care • Not an “altered standard” of care • Not “graceful degradation” of care • Not a “diminished” or “lower” standard of care • How would this play out in the media? • How would the public perceive it?

12. Current InitiativesFuture Directions • State of California • Surge Standards and Guidelines Project • Crisis Care Committee • Develop specific protocols for clinicians and emergency managers • Develop benchmarks to determine when to activate and deactivate Crisis Care

13. Current InitiativesFuture Directions • Designate a “Crisis Triage Officer” and include provisions for palliative care in triage models • Respect ethical principals of beneficence, stewardship, equity, and trust • Regulatory relief to provide liability protections in a scarce resource environment • Prioritize population health over individual outcomes

14. Selected Resources • Standards of Care During a Mass Casualty Event-A Series of Regional Workshops, Institute of Medicine Regional Forum Irvine, CA March 12, 2009 http://www.iom.edu/CMS/3740/42532.aspx • American Health Lawyers Association (AHLA) Community pan-flu preparedness: a checklist of key legal issues for healthcare providers 2008 http://www.healthlawyers.org/Resources/PublicInterest/Public%20Information%20Series/Documents/Pan-Flu%20Checklist.pdf Page 20

15. Selected References • Koenig KL, Cone DC, Burstein JL, Camargo CA. Surging to the Right Standard of Care.Acad Emerg Med 2006 Feb;13(2):195-8 • Emile F. Chang MSC, Howard Backer MD, Tareg A. Bey MD, and Kristi L. Koenig MD (2008) "Maximizing Medical and Health Outcomes after a Catastrophic Disaster: Defining a New “Crisis Standard of Care”Western Journal of Emergency Medicine: Vol. 9: No. 3, Article 18 http://repositories.cdlib.org/uciem/westjem/vol9/iss3/art18