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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.

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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

case study
Case Study
  • A patient is in cardiopulmonary arrest
    • Do you do CPR?
    • What is the “Standard of Care?”
standard of care
Standard of Care
  • Legal Definition
    • What would the prudent person do under similar circumstances?
standard of care4
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
catastrophic disaster
Catastrophic Disaster
  • Scarce resource environment
  • Difficult to conceptualize in the United States
lack of resources
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?
catastrophic event
Catastrophic Event
  • When needs exceed resources at a given point in time
  • Allocation of scarce resources
goal in scarce resource environments
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
standard of care catastrophic disaster
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
case study10
Case Study
  • A patient is in cardiopulmonary arrest
    • Do you do CPR?
    • What is the “Standard of Care?”
  • Answer
    • It depends on the situation!
crisis standard of care
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?
current initiatives future directions
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
current initiatives future directions13
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
selected resources
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

selected references
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