Making really good sausage Evolving standards in public health case reporting.
Altered Standards of Care: Is that Really the Issue?
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Transcript of Altered Standards of Care: Is that Really the Issue?
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.