Altered Standards of Care: Is that Really the Issue?

1. Altered Standards of Care:Is that Really the Issue? Carl H. Schultz, MD Professor of Emergency Medicine Director, Disaster Medical Services UC Irvine School of Medicine

2. Overview • What is the standard of care? • What are altered standards of care? • Why does it need to be altered? • What are you trying to achieve? • What are the consequences? • What do we really need?

3. Standard of Care fffff • What is the standard of care? • Definition: • The level at which the average, prudent provider in a given community would practice. It is how similarly qualified practitioners would have managed the patient's care under the same or similar circumstances. • Assumes unlimited resources/normal conditions • Somewhat vague • May require interpretation

4. Standard of Care • Why do we need a standard of care? • Utility • Establish what is acceptable level of care • Provide standard for liability • Was there a breach in thestandard of care?

5. Altered Standard of Care • What are altered standards of care? • Change in the expectations of resource commitment and skill of providers • Can be higher • Everyone gets an organ transplant with no restrictions • Can be lower • Victim receives treatment by any physician with a license regardless of specialty

6. Goals of Altered Standards • Why does it need to be altered? • Insufficient resources to meet demand after mass casualty disaster • Inability to meet the standard of care • Need to change the standard to justify actions • What are you trying to achieve? • Allocation of scarce resources • Ethical distribution of care • Protection from liability • But does this really work?

7. Goals of Altered Standards • How does changing the standard improve outcome? • It doesn’t • Changing what you do improves outcome • Modification of liability during disasters • Creation of strategies for allocation of resources • Ethical evaluation of processes and public support

8. Consequences • What are the consequences of altered standards of care? • Why don’t disaster victims deserve the same standard of care? Are the less worthy? • Can you have multiple standards? • If so, which ones apply? • IOM: local, state, regional • How low can you go? • If you violate these standards, still suffer liability

9. Consequences • With lower standards, no need to strive for improving disaster protocols. • You have “met the standard of care”. • Example: ESAR-VHP and hospital-based credentialing model

10. What is really needed • One standard of care • Disaster victims are no less deserving • Acknowledge can’t reach standard • Emphasis on all disaster guidelines to get as close to the standard as possible • Guarantees continuous effort to address issues • Liability • Allocation of scarce resources • Rights of individuals/ethical approaches

11. References • Thompson AK, Faith K, Gibson JL, Upshur REG: Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Medical Ethics2006, 7:12. • Altered Standards of Care in Mass Casualty Events. Prepared by Health Systems Research Inc. under Contract No. 290-04-0010. AHRQ Publication No. 05-0043. Rockville, MD: Agency for Healthcare Research and Quality. April 2005. • Draft Guidelines for the Development of Altered Standards of Care for Influenza Pandemic. Massachusetts Department of Public Health and the Harvard School of Public Health. June 2007.

12. References • Schultz CH,Stratton SJ: Improving Hospital Surge Capacity: A New Concept for Emergency Credentialing of Volunteers. Ann Emerg Med 2007;49:602-609.