Crisis Standard of Care Doing the Right Thing

Crisis Standard of Care Doing the Right Thing When 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

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

Standard of Care F Legal Definition – What would the prudent person do under similar circumstances?

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

Catastrophic Disaster F Scarce resource environment F Difficult to conceptualize in the United States

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

Catastrophic Event F F When needs exceed resources at a given point in time Allocation of scarce resources

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

Standard of Care Catastrophic Disaster F Do not alter the “standard” of care F Change the goal – Triggers to shift to population management – Triggers to shift back to individual management – May move back and forth several times during a single event

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

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

Current Initiatives Future Directions F State of California – Surge Standards and Guidelines Project – Crisis Care Committee u Develop specific protocols for clinicians and emergency managers F Develop benchmarks to determine when to activate and deactivate Crisis Care

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

Selected Resources F 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 F American Health Lawyers Association (AHLA) Community panflu preparedness: a checklist of key legal issues for healthcare providers 2008 http: //www. healthlawyers. org/Resources/Public. Interest/Public%20 Infor mation%20 Series/Documents/Pan-Flu%20 Checklist. pdf Page 20

Selected References F Koenig KL, Cone DC, Burstein JL, Camargo CA. Surging to the Right Standard of Care. Acad Emerg Med 2006 Feb; 13(2): 195 -8 F 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/vol 9/iss 3/art 18