Implementing Altered Standards of Care - The VA s Approach

Transcription

1 Implementing Altered Standards of Care - The VA s Approach James Geiling, MD, FACP, FCCM Chief, Medical Service VA Medical Center, White River Jct. VT Associate Professor of Medicine New England Center for Emergency Preparedness Dartmouth Medical School, Hanover NH

2 National Center for Ethics in Health Care VHA s primary office for addressing complex ethical issues Patient care Health care management Research

3 Rationing Should Occur After State of declared emergency Surge capacity is exceeded - Modular Emergency Medical System (MEMS) at max capacity Implementation of Emergency Mass Critical Care (EMCC) measures Leadership authorizes altered standards of care

4 Tertiary Triage A process of sorting HOSPITAL patients into treatment groups Continues while demand exceeds surge capacity Ends when resources again meet demand

5 Scarce Resource Allocation Team (SRA) An advisory committee that: Works within the Incident Command System structure Oversees and guides rationing Ensures primacy given to maximizing survivability Addresses ethical concerns

6 SRA Team Membership Scarce Resource Allocation Team Leader - Normally physician Ethics Committee representative Nursing representative Logistics or Management Representative

7 Additional Optional SRA Team Membership Representatives from: Emergency Department Infectious Diseases/Infection Control Palliative Care Service Social Work Service Chaplain Service Engineering Veteran Service Organization

8 Triage Team A front line team that: Takes direction from the SRA Reviews clinical data for triage scoring Conducts tertiary triage

9 Triage Team Recommended membership includes: - Intensivist - Nursing representative - Logistics/management representative

10 Triage Criteria Decisions Based on: Survival potential (survivability) First-come, first-served (for equally prioritized persons)

11 Exclusion Criteria for Access to Scarce Life-Saving Resources 1. Confirmed presence of any advanced disease with average life expectancy of 6 months or less. 2. Recent cardiac arrest 3. Confirmed severe irreversible cognitive impairment

12 Sequential Organ Failure Assessment (SOFA) Score Variable SOFA Score PaO2/FiO2 mmhg > < 100 Platelets, x 103/µL or x 106/L Bilirubin, mg/dl (µmol/l) > < 20 <1.2 (<20) (20 32) Hypotension None MABP < 70 mmhg Glasgow Coma Score Creatinine, mg/dl (µmol/l) (33 100) ( ) Dop < 5 Dop 6 15 or Epi < 0.1 or Norepi < < 6 < 1.2 (<106) ( ) ( ) ( ) >12 (> 203) Dop >15 or Epi > 0.1 or Norepi > 0.1 > 5 (> 434) or anuric

13 Life-Saving Resources Triage Tool for Initial Assessment Initial Criteria Priority Action Exclusion Criteria or SOFA > 11 SOFA < 7 or Single Organ Failure SOFA 8-11 No requirement for life-saving resources None Highest Interme diate None Do not use life-saving resources Use other resources including palliative measures Use lifesaving resources, as available, per the direction of the Triage team Use life-saving resources, as available, per the direction of the Triage team Use other medical management Reassess as needed

14 Review and Clinical Appeals Process for Triage Decisions During a Pandemic: Daily retrospective by SRA team. Real-time clinical appeals process to consider only whether applicable standards are being followed consistently and correctly.

15 Palliative Care for Those Not Expected to Survive The need for hospice and palliative care is expected to increase dramatically Non abandonment

16 VHA Pandemic Influenza Ethics Initiative VHA National Center for Ethics in Health Care (10E) VHA Office of Public Health and Environmental Hazards VHA National Exercise Planning Group Ethics Resources, Emergency Management Strategic Health Care Group (13C) www1.va.gov/emshg/page.cfm?pg=148 VA Office of Human Resource Management Pandemic Resource Center www1.va.gov/ohrm//worklife/pandemic/hrtemplates_resour ces.htm