Contemplating A Different `Standard of Care'

Triage Tag

#15,141


Although the exact details are scant, it has been pretty much acknowledged that in the hardest hit regions of Northern Italy, the `standard-of-care' being provided by hospitals for many COVID-19 patients is far below what is normally permitted.

Some patients who might benefit from a critical care bed, or a ventilator, are being denied simply because there are more critically ill patients than their overburdened system can handle (see Cold Calculations: The Realities Of Ventilator Triage).

The situation was likely the same in Wuhan City, China and appears similar in Iran, and there are hints that the same may be happening in several other European countries. New York City and Seattle are either there, or on the cusp, and there are genuine concerns that similar scenes are only weeks away for thousands of other hospitals around the world.

Overnight, the Washington Post ran an in-depth article on the hard decisions that doctors, and healthcare institutions, must consider in the days and weeks ahead.  It's a worthwhile read, so follow the link. I'll be here when you return.

Hospitals consider universal do-not-resuscitate orders for coronavirus patients

Worry that ‘all hands’ responses may expose doctors and nurses to infection prompts debate about prioritizing the survival of the many over the one

Anyone who is shocked or surprised by these discussions hasn't been paying attention for the past 15 years, as we've trod this ground many times before.

Twelve years ago, in Triage In A Pandemic, we looked at the media stir following the publication of new guidelines on triage in a pandemic or MCE (Mass Casualty Event) in the May 2008 edition of Chest, the medical journal of the American College of Chest Physicians. 

A list of some of the people they suggested might be denied care in a pandemic or MCE included:

• People older than 85.
• Those with severe trauma, which could include critical injuries from car crashes and shootings.
• Severely burned patients older than 60.
• Those with severe mental impairment, which could include advanced Alzheimer's disease.
• Those with a severe chronic disease, such as advanced heart failure, lung disease or poorly controlled diabetes.   

Today, we appear to be seeing these types of triage decisions being made in some parts of the world, and more will likely follow suit. 

Despite government assurances about increasing supplies of PPEs and improved COVID-19 testing, I'm hearing nearly every day from nurses, doctors, and other healthcare professionals all around the country that - at least for them -  PPEs are either rationed or not available for anything but `high risk' procedures, and testing . . .  well, most of the time testing for HCWs isn't even an option.

And many of these healthcare professionals are in the high risk group of over 60, while others have pre-existing conditions.  Getting infected isn't a trivial matter for them. 

As valiant as it may sound for HCWs sans PPEs to rush to the aid of a potentially dying, highly infectious patient, it is the surest way to ensure faster attrition of vital medical staff and a further degradation of healthcare delivery during this crisis either due to illness, death, or an unwillingness of employees to work without protection.

And so we find ourselves contemplating withholding highly invasive, and risky resucciative care in order to protect HCWS. 

And before anyone utters those damnable words `No one could ever have imagined . . . .', all of this has been discussed ad nauseam for years - and then, after a suitable period of hand wringing - has been shelved for someone else to worry about down the road.

After the 2009 H1N1 pandemic ended, and it turned out to be less deadly than first feared, pandemic preparedness was put on the back burner - both here in the United States - and around the world.  Most of the pre-2009 pandemic guidance was mothballed, preparedness plans shoved in bottom drawers, and the world moved on.

We'd had our `once-in-a-generation' pandemic, and it wasn't so bad, and besides . . . another probably wouldn't happen for decades . . . 

Our Strategic National Stockpile was left to languish with insufficient - and sometimes expired - supplies, and while there were numerous congressional hearings,  bipartisan blue ribbon panels, and Federal agency studies all highlighting major gaps in our pandemic preparedness, very little substantive action was taken.

While the National Strategic Stockpile holds tens of millions of N95 and surgical masks in reserve, the numbers needed as envisioned in 2015's CID Journal report Potential Demand for Respirators and Surgical Masks During a Hypothetical Influenza Pandemic in the United States ran into the billions.

From their Results and Conclusions:

Assuming that 20% to 30% of the population would become ill, 1.7 to 3.5 billion respirators would be needed in the base case scenario, 2.6 to 4.3 billion in the intermediate demand scenario, and up to 7.3 billion in the maximum demand scenario (for all scenarios, between 0.1 and 0.4 billion surgical masks would be required for patients). For pandemics with a lower attack rate and fewer cases (eg, 2009-like pandemic), the number of respirators needed would be higher because the pandemic would have longer duration.

Providing these numbers of respirators and surgical masks represents a logistic challenge for US public health agencies. Public health officials must urgently consider alternative use strategies for respirators and surgical masks during a pandemic that may vary from current practices.

Telling that even 5 years ago, the advice wasn't to acquire sufficient quantities of PPEs, or pre-arrange for emergency production capacity, but to `consider alternative use strategies' for respirators and masks.

And it isn't just PPEs, the ventilator shortage - which was a hot topic in 2006-2008 (see Ventilator Triage During A Pandemic , Triage In A Pandemic , Fear And Loathing Of Pandemic Triage, and The Allocation of Medical Resources) - was raised again in 2015 in a study published in Clinical Infectious Diseases and written by researchers at our own CDC & HHS - which warned:

Estimates of the demand for mechanical ventilation in the United States during an influenza pandemic.

Meltzer MI1, Patel A2, Ajao A3, Nystrom SV4, Koonin LM5.
Author information

Abstract

An outbreak in China in April 2013 of human illnesses due to avian influenza A(H7N9) virus provided reason for US public health officials to revisit existing national pandemic response plans. We built a spreadsheet model to examine the potential demand for invasive mechanical ventilation (excluding "rescue therapy" ventilation).

We considered scenarios of either 20% or 30% gross influenza clinical attack rate (CAR), with a "low severity" scenario with case fatality rates (CFR) of 0.05%-0.1%, or a "high severity" scenario (CFR: 0.25%-0.5%).

We used rates-of-influenza-related illness to calculate the numbers of potential clinical cases, hospitalizations, admissions to intensive care units, and need for mechanical ventilation. We assumed 10 days ventilator use per ventilated patient, 13% of total ventilator demand will occur at peak, and a 33.7% weighted average mortality risk while on a ventilator.

At peak, for a 20% CAR, low severity scenario, an additional 7000 to 11,000 ventilators will be needed, averting a pandemic total of 35,000 to 55,000 deaths.

A 30% CAR, high severity scenario, will need approximately 35,000 to 60,500 additional ventilators, averting a pandemic total 178,000 to 308,000 deaths. 

Estimates of deaths averted may not be realized because successful ventilation also depends on sufficient numbers of suitably trained staff, needed supplies (eg, drugs, reliable oxygen sources, suction apparatus, circuits, and monitoring equipment) and timely ability to match access to ventilators with critically ill cases. There is a clear challenge to plan and prepare to meet demands for mechanical ventilators for a future severe pandemic.

Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Somehow, despite hundreds of warnings, myriad studies, numerous congressional hearings - and a handful of `warning shots across our bow'  (H7N9, H5N1, MERS-CoV) - we've squandered a decade's worth of preparedness time.

Everyone knew we didn't have the PPEs, or the ventilators, or the hospital surge capacity to deal with even a moderate pandemic. And while it has been discussed endlessly, no one did anything about it. As a result, many people - including HCWs - are going to pay the price.

If we get very, very lucky we may see a drop in COVID-19 cases over the summer, and that may provide an opportunity to gear up over the next few months to be better prepared what what comes this fall.  

COVID-19 won't be the last - and perhaps not even the worst - pandemic threat we will face in the years to come.  I can only hope we'll make better choices going forward.