Altered Standards of Altered Standards of Care:Care:Is that Really the Issue?Is that Really the Issue?

Carl H. Schultz, MDCarl H. Schultz, MDProfessor of Emergency MedicineProfessor of Emergency Medicine

Director, Disaster Medical ServicesDirector, Disaster Medical ServicesUC Irvine School of MedicineUC Irvine School of Medicine

OverviewOverview

What is the standard of care?What is the standard of care?What are altered standards of care?What are altered standards of care?Why does it need to be altered?Why does it need to be altered?

What are you trying to achieve?What are you trying to achieve?What are the consequences?What are the consequences?What do we really need?What do we really need?

Standard of Care fffffStandard of Care fffff What is the standard of care?What is the standard of care?

Definition:Definition:The level at which the average, prudent The level at which the average, prudent

provider in a given community would provider in a given community would practice. It is how similarly qualified practice. It is how similarly qualified practitioners would have managed the practitioners would have managed the patient's care under the same or similar patient's care under the same or similar circumstances. circumstances.

Assumes unlimited resources/normal Assumes unlimited resources/normal conditionsconditions

Somewhat vague Somewhat vague May require interpretationMay require interpretation

Standard of CareStandard of Care

Why do we need a standard of care?Why do we need a standard of care?UtilityUtility

Establish what is acceptable level of Establish what is acceptable level of carecare

Provide standard for liabilityProvide standard for liabilityWas there a breach in theWas there a breach in the

standard of care?standard of care?

Altered Standard of CareAltered Standard of CareWhat are altered standards of care?What are altered standards of care?

Change in the expectations of resource Change in the expectations of resource commitment and skill of providerscommitment and skill of providers

Can be higherCan be higherEveryone gets an organ transplant with Everyone gets an organ transplant with

no restrictionsno restrictionsCan be lowerCan be lower

Victim receives treatment by any Victim receives treatment by any physician with a license regardless of physician with a license regardless of specialtyspecialty

Goals of Altered Goals of Altered StandardsStandards

Why does it need to be altered?Why does it need to be altered? Insufficient resources to meet demand after Insufficient resources to meet demand after

mass casualty disastermass casualty disaster Inability to meet the standard of careInability to meet the standard of care Need to change the standard to justify actionsNeed to change the standard to justify actions

What are you trying to achieve?What are you trying to achieve? Allocation of scarce resourcesAllocation of scarce resources Ethical distribution of careEthical distribution of care Protection from liabilityProtection from liability

But does this really work?But does this really work?

Goals of Altered Goals of Altered StandardsStandards

How does changing the standard How does changing the standard improve outcome?improve outcome?It doesn’tIt doesn’t

Changing what you do improves Changing what you do improves outcomeoutcomeModification of liability during disastersModification of liability during disastersCreation of strategies for allocation of Creation of strategies for allocation of

resourcesresourcesEthical evaluation of processes and public Ethical evaluation of processes and public

supportsupport

ConsequencesConsequencesWhat are the consequences of altered What are the consequences of altered

standards of care?standards of care?Why don’t disaster victims deserve the Why don’t disaster victims deserve the

same standard of care? Are the less same standard of care? Are the less worthy?worthy?

Can you have multiple standards? Can you have multiple standards? If so, which ones apply?If so, which ones apply?IOM: local, state, regionalIOM: local, state, regional

How low can you go?How low can you go?If you violate these standards, If you violate these standards,

still suffer liability still suffer liability

ConsequencesConsequencesWith lower standards, no need to With lower standards, no need to

strive for improving disaster strive for improving disaster protocols.protocols.You have “met the standard of care”.You have “met the standard of care”.Example: ESAR-VHP and hospital-based Example: ESAR-VHP and hospital-based

credentialing modelcredentialing model

What is really neededWhat is really neededOne standard of careOne standard of care

Disaster victims are no less deservingDisaster victims are no less deservingAcknowledge can’t reach standardAcknowledge can’t reach standardEmphasis on all disaster guidelines to Emphasis on all disaster guidelines to

get as close to the standard as possibleget as close to the standard as possibleGuarantees continuous effort to Guarantees continuous effort to

address issuesaddress issuesLiabilityLiabilityAllocation of scarce resourcesAllocation of scarce resourcesRights of individuals/ethical approachesRights of individuals/ethical approaches

ReferencesReferences1.1. Thompson AK, Faith K, Gibson JL, Upshur REG: Pandemic Thompson AK, Faith K, Gibson JL, Upshur REG: Pandemic

influenza preparedness: an ethical framework to guide decision-influenza preparedness: an ethical framework to guide decision-making. BMC Medical Ethicsmaking. BMC Medical Ethics 2006, 7:12.2006, 7:12.

2.2. Altered Standards of Care in Mass Casualty Events. Prepared by Altered Standards of Care in Mass Casualty Events. Prepared by Health Systems Research Inc. under Contract No. 290-04-0010. Health Systems Research Inc. under Contract No. 290-04-0010. AHRQ Publication No. 05-0043. Rockville, MD: Agency for AHRQ Publication No. 05-0043. Rockville, MD: Agency for Healthcare Research and Quality. April 2005.Healthcare Research and Quality. April 2005.

3.3. Draft Guidelines for the Development of Altered Standards of Draft Guidelines for the Development of Altered Standards of Care for Influenza Pandemic. Massachusetts Department of Care for Influenza Pandemic. Massachusetts Department of Public Health and the Harvard School of Public Health. June Public Health and the Harvard School of Public Health. June 2007. 2007.

ReferencesReferences4.4. Schultz CH,Schultz CH, Stratton SJ: Improving Hospital Surge Capacity: A Stratton SJ: Improving Hospital Surge Capacity: A

New Concept for Emergency Credentialing of Volunteers. Ann New Concept for Emergency Credentialing of Volunteers. Ann Emerg Med 2007;49:602-609. Emerg Med 2007;49:602-609.