Putting Spectrum of Care Into Practice

Participants

• Beth Venit, VMD, MPH, DACVPM, American Association of Veterinary State Boards, Washington, District of Colombia

• Kate Boatright, VMD, Write the Boat, Grove City, Pennsylvania

• Sarah L. Babcock, DVM, JD, Animal & Veterinary Legal Services, Boca Grande, Florida

Moderator

Katie Berlin, DVM, Instinct Science

Defining Spectrum of Care

Dr. Katie Berlin: How is spectrum of care defined, and how is it related to or different from the terms access to care, contextualized care, and gold standard?

Dr. Kate Boatright: Spectrum of care is, for me, a subset of the bigger access to care conversation. Access to care is a client’s ability to obtain veterinary care, whether at a financial or geographic level.

Spectrum of care and contextualized care, however, are essentially the same. The term contextualized care was coined in the United Kingdom, and I love it because it reminds us to put everything in the context of the individual client and patient; however, spectrum of care is more recognized in the United States, and I think it will be the term we stick with. The updated principles of veterinary medical ethics now include offering contextualized care/spectrum of care as part of the ethical responsibilities of veterinarians.

Dr. Berlin: I also love the term contextualized care because spectrum of care is sometimes seen as offering the best care all the way down to the least acceptable level of care; however, it's more about what is the best care in the context of the patient and client situation. Removal of judgment and acceptance of the client’s circumstances are central to this conversation.

Dr. Sarah Babcock: Sometimes the gold standard gleaned from textbooks has limited practical application to patients, clients, and the care provided. For me, the gold standard is meeting a client where they are and providing adequate patient care. I don't like being compared to a standard that is not practically applicable in the field. I feel the term implies judgment, so I tend to use best practices or guidelines to remove that judgment.

Practicing Spectrum of Care

Dr. Berlin: Dr. Boatright, could you give us an idea of your considerations regarding practicing spectrum of care? Say, for example, you are presented with a blocked cat. The owner brings the cat in, and it's like a little wet blanket on the table. Where does your brain go in terms of spectrum of care?

Dr. Boatright: The first thing I think about in any case is the importance of signalment, history, and physical examination. Blocked cats are a great example because they can be diagnosed on physical examination. The minute you feel a rock-hard bladder, you know what you’re dealing with. On physical examination, I'm looking for things to give me an idea of the patient’s stability (eg, heart rate, mentation, hydration status) and the clinical history (how long has this been going on?).

For a blocked cat, my best practice would be to give some pain medication, run some initial diagnostics (eg, nitrogen and potassium levels), and relieve the obstruction. Ideally, I’d like to hospitalize the patient for a couple of days for diuresis and try to use an indwelling catheter to reduce the risk for recurrent obstruction. This treatment level, however, costs thousands of dollars and is not feasible for many clients. The priority is to relieve the obstruction and manage pain, so the options I offer may range from multiday hospitalization with a full diagnostic workup to reduced time in the hospital (maybe just 24 hours) and limited diagnostics.

I think about what information I care about the most, like kidney values and potassium levels. Do I really need to run a full CBC on this cat? I can't think of a time CBC results changed how I approached a blocked cat. I start to narrow down the diagnostics and think about the most essential treatment.

Some clients, however, may not be able to afford any hospitalization. When I was a recent graduate, if a client said they couldn’t afford any level of hospitalization, I would recommend euthanasia because the gold standard I was taught was that blocked cats needed hospitalization. However, with clinical experience, support of mentors, and reading the literature, I’ve learned some cats can be unblocked and treated as outpatients.

The options I now offer depend on patient stability, the most essential information needed from diagnostics, and the most essential treatment options—what will make that patient feel better.