Two days ago, in Contemplating A Different `Standard of Care', we looked at some of the difficult triage decisions that some hospitals may face if they are overrun by more severe COVID-19 cases than they can handle.
We've already seen anecdotal reports of rationed ICU beds and ventilators in places like Italy, Iran, and Madrid, and two days ago the Washington Post ran a stark piece entitled Hospitals consider universal do-not-resuscitate orders for coronavirus patients.While government agencies and hospitals are working to avoid a similar scenario here in the United States, ultimately it will depend on how well we `flatten the curve'. ICU beds, ventilators, and trained medical staff are a finite resource, and no one can say with certainty how many severe cases our healthcare system may end up dealing with.
The HHS's office for ASPR (Assistant Secretary for Preparedness and Response) is charged with preparing for Public Health and Medical Emergency Support during any crisis or disaster. Among the many documents on ASPR's TRACIE website (Technical Resources, Assistance Center, and Information Exchange), are a number that deal with Crisis Standards of Care due to COVID-19.
This Topic Collection focuses on plans, tools, templates, and other immediately implementable resources to help with COVID-19 preparedness, response, recovery, and mitigation efforts, focusing on crisis standards of care (CSC). Implementing CSC in a hospital setting should be a last resort when all other surge strategies have failed and no other regional resources are available. Planners need to account for three domains:
The following are selected best practices designed for quick reference and application. Please refer to CDC’s Coronavirus Disease 2019 webpage for the most up-to-date clinical guidance on COVID19 outbreak management.
- Concept of operations – What is the process for making decisions? Who makes the decisions? How is this integrated with the incident command system?
- Criteria – What will the decisions be based upon? Using the best evidence available, primarily prioritizing interventions on the basis of prognosis and duration of use.
- Coordination – How does the facility coordinate with others in the area through healthcare coalition/ other constructs to assure consistency of care and decision making?
If you have COVID-19 best or promising practices, plans, tools, or templates to share with your peers, please visit the ASPR TRACIE Information Exchange COVID-19 Information Sharing Page (registration required) and place your resources under the relevant topic area. Resources specific to CSC can be placed under the COVID-19 Crisis Standards of Care Resources Topic.
ASPR TRACIE. (2017). SOFA Score: What it is and How to Use it in Triage.The Sequential Organ Failure Assessment (SOFA) score was designed as a research tool so that groups of patients could be categorized based on their risk of death. This fact sheet includes an overview of the score, how it is calculated, and how it can be used in triage situations.
ASPR TRACIE. (2020). Crisis Standards of Care and Infectious Disease Planning.This ASPR TRACIE Technical Assistance response covers Crisis Standards of Care (CSC) for infectious diseases.
Biddison, E., Gwon, H., Schoch-Spana, M. et al. (2018). Scarce Resource Allocation During Disasters: A Mixed-Method Community Engagement Study. Chest. 153(1):187-195.
The authors conducted a series of 15 discussions with 324 members of the public and health-related professionals to characterize the public's values regarding how scarce mechanical ventilators should be allocated during an influenza pandemic, and to inform a statewide scare resource allocation framework. They concluded that awareness of how “the values expressed by the public and front-line clinicians sometimes diverge from expert guidance in important ways,” should inform policy making.
Christian, M., Sprung, C., King, M., et al. (2014). Triage: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement.
The 11 suggestions highlighted in this article can help those involved in large-scale pandemics or disasters with multiple critically ill or injured patients (e.g., front-line clinicians and hospital administrators) make more informed decisions about critical care triage.
Colorado Department of Public Health and Environment. (2018). Annex B: Colorado Crisis Standards of Care Plan. CDPHE All Hazards Internal Emergency Response and Recovery Plan.
This comprehensive crisis standards of care plan outlines state-level process and decision making and resource allocation during events that surpass available capacities and capabilities and provides a structure for clinical decisions (though some of the triage decision tools are not the most current). The plan also details a robust engagement and development process.
Devereaux, A., Tosh, P., Hick, J., et al. (2014). Engagement and Education. Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement. Chest. 146(4 Suppl):e 118S–e133S.
This panel of experts reviewed the literature and developed 23 suggestions into four categories related to clinician engagement and education: situational awareness, clinician roles and responsibilities, education, and community engagement.
Emanuel, E., Persad, G., Upshur, R., et al. (2020). Fair Allocation of Scarce Medical Resources in the Time of COVID-19. The New England Journal of Medicine.
The authors review health impacts of moderate to severe pandemics, health system capacity, and ethical values for rationing health resources in a pandemic. They offer six recommendations to address the question of who should get health resources during the COVID-19 pandemic: 1) maximizing benefits, 2) targeting critical interventions to those caring for ill patients and operating critical infrastructure first, 3) randomizing allocation for those with similar prognoses, 4) differing prioritization guidelines by intervention and altering those guidelines based on changing scientific evidence, 5) prioritizing interventions to reward those willing to assume personal risk by participating in safety and effectiveness research, and 6) allocating scarce resources to patients with COVID-19 and those with other conditions in the same way.
Hanfling, D., Hick, J., and Stroud, C. (2013). Crisis Standards of Care: A Toolkit for Indicators and Triggers. Institute of Medicine, Washington, DC: National Academies Press.
This toolkit contains key concepts, guidance, and practical resources to help individuals across the emergency response system develop plans for crisis standards of care and respond to a catastrophic disaster. It includes sample indicators, triggers, and sample tactics for use in the transition from conventional surge to contingency surge to crisis surge, and a return from crisis response to conventional response including templates for no-notice and prolonged incidents.
Hanfling, D., Hick, J., and Stroud, C. (2013). Crisis Standards of Care: A Toolkit for Indicators and Triggers – Table 8-1. (Free registration required.) Institute of Medicine, Washington, DC: National Academies Press.
Table 8.1 provides specific indicators, triggers, and tactics for hospitals to use along the continuum of care during the COVID-19 pandemic.
Hick, J., Hanfling, D., Wynia, M., and Pavia, A. (2020). Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2. National Academy of Medicine .
This discussion paper describes the application of crisis standards of care principles to clinical care challenges posed by a coronavirus or other epidemic or pandemic. The authors encourage healthcare facilities to develop a process for decision making based on the best available clinical information and built upon existing surge capacity plans.
Minnesota Department of Health. (n.d.). Health Care Considerations – Crisis Standards of Care. (Accessed 3/24/2020.)
This web page includes several resources that healthcare facilities may use to plan for medical surge caused by COVID-19.
Minnesota Department of Health. (n.d.). Health Care Considerations – Crisis Standards of Care – Health Care Facility Scarce Resource Decision-Making Tree. (Accessed 3/24/2020.)
This decision tree is intended for use by healthcare facilities to guide triage planning during a CSC situation.
Minnesota Department of Health. (n.d.). Health Care Considerations – Crisis Standards of Care – Template: Facility Crisis Standard of Care Plan. (Accessed 3/24/2020.)
This Word template may be used by healthcare facilities to develop a CSC plan.
Minnesota Department of Health, Center for Emergency Preparedness and Response, Minnesota Healthcare Preparedness Program. (2014). Patient Care Strategies for Scarce Resource Situations.
This card set can help facilitate an orderly approach to resource shortfalls at a healthcare facility. It is a decision support tool to be used by key personnel, along with incident management, who are familiar with ethical frameworks and processes that underlie these decisions. Note that the card set does NOT include COVID-19 specific predictors of mortality that must be considered in the triage process.
Truog, R., Mitchell, C., and Daley, G. (2020). The Toughest Triage – Allocating Ventilators in a Pandemic. The New England Journal of Medicine.
Based on the currently available number of ventilators in the US in acute care hospitals and the Strategic National Stockpile, the authors of this perspective article estimate that each ventilator may be needed for a range of 1.4 to 31 patients during the COVID-19 pandemic. To prepare for the potential need to ration ventilators, the authors suggest establishing a committee excluding clinicians providing patient care to set the triage criteria and adjust those criteria as the overall situation changes. Additionally, they recommend proactive engagement with high-risk patients and their families about “do not intubate” orders and establishing a voluntary team with palliative care and emotional support expertise to withdraw mechanical ventilation rather than those clinicians caring for patients.