POST 189. August 19,2021. CORONAVIRUS. “There wasn’t a single I.C.U. bed available in Alabama on Wednesday…”…”A triage plan on the Alabama health department’s website suggests that “persons with severe mental retardation” are among those who “may be poor candidates for ventilator support.”

for links to POSTS 1-189 in chronological order highlight and click on

https://doctordidyouwashyourhands.com/2021/08/coronavirus-tracking-links-to-posts-1-189/

“There wasn’t a single I.C.U. bed available in Alabama on Wednesday, a possible sign of what other states may confront soon amid a deadly surge of new infections in parts of the United States with low vaccination rates.

I.C.U. beds are filling up across Southern states, and Alabama is one of the first to run out. The Alabama Hospital Association said on Wednesday night that there were “negative 29” I.C.U. beds available in the state, meaning there were more than two dozen people being forced to wait in emergency rooms for an open I.C.U. bed.

The situation has grown desperate in Alabama, one of several states reporting a wave of cases driven by the highly contagious Delta variant and low vaccination rates….

Gov. Kay Ivey of Alabama said last month that the surge in new cases was attributable to the large number of people who remain unvaccinated. On Friday, she reinstated Alabama’s state of emergency, which had expired in early July, in an effort to expand hospital capacity.” (A)

“The summer surge in coronavirus cases in the United States, led by the domination of the more contagious Delta variant, is well into its second month, and the number of those hospitalized with Covid-19 has reached heights last seen during the overwhelming winter wave.

The number of those patients who are critically ill, requiring treatment in an intensive care unit, has risen, too. Data from the Department of Health and Human Services shows that the number of hospitals with very full I.C.U.s doubled in recent weeks. Now, one in five I.C.U.s have reached or exceeded 95 percent of beds occupied, a level experts say makes it difficult or impossible for health professionals to maintain standards of care for the very sick.” (B)

March 31, 2020

“The New York Times reviewed triage strategy documents from Alabama, Arizona, Kansas, Louisiana, Maryland, Michigan, New York, Pennsylvania, Tennessee, Utah and Washington State to see what factors they propose to use to decide which patients get potentially life-saving treatments….

If a hospital has a shortage of resources, the first thing it may consider is whether to decline admission to an intensive care unit to people who have conditions that will likely result in near-immediate death even if they get that treatment.

One common strategy, including for New York and Maryland, is to exclude patients who may have a cardiac arrest that is unresponsive to standard interventions such as defibrillation. Plans can also exclude those who may have had a major brain injury or severe burns where the likelihood of survival is low.

A triage plan on the Alabama health department’s website suggests that “persons with severe mental retardation” are among those who “may be poor candidates for ventilator support.” Washington State’s guidelines include the consideration of a “baseline functional status” for each patient, considering such factors as declines in energy level, physical ability and cognition.

Federal civil rights officials recently announced they will not allow hospitals to discriminate on the basis of disabilities, race, age or religion.

The plan on Alabama’s website would also use AIDS as a factor in deciding to exclude someone for ventilator support, but Alabama officials said they have replaced the plan with a different set of guidelines. The newer policies do not address questions about ventilator triage.

In Washington State, doctors can also consider withholding advanced care for patients with “severe congestive heart failure,” “severe chronic lung disease” or “severe cirrhotic liver disease with multiorgan dysfunction,” as well as other major problems with a poor prognosis for recovery.

Louisiana may exclude patients with severe dementia….

Some of the states rely at least in part on a score known as the Sequential Organ Failure Assessment (SOFA), which measures the functioning of major body systems, including the heart, lungs, kidneys, liver, blood and neurological system. Patients with high SOFA scores would be less likely to qualify.

The scoring system was never meant for this use, and some experts question how accurate it will be in predicting survival. Some plans use different scoring systems or use a sliding scale so that someone whose score is slightly higher than an arbitrary cutoff does not get automatically excluded if it turns out there are enough ventilators.

The guidelines in Maryland also look at severe pre-existing health problems likely to result in death within a year. But they do not seek to project survivability beyond a year, in part to avoid disadvantaging the poor and people of color.

An interim guideline produced in Pennsylvania in March uses SOFA scoring but also takes into consideration the likelihood of long-term survival, such as for patients with Alzheimer’s disease or those with cancer who have less than 10 years of expected survival….

Here’s an example of how the guidelines could compare patients needing a ventilator in Maryland:

Patient A: 24 years old, with a SOFA score of 13 (indicating signs of failure across multiple organ systems) but no pre-existing conditions that would limit life expectancy to less than a year. The person’s high SOFA score would give them three overall points.

Patient B: 72 years old, with a SOFA score of 10 (indicating significant but less-severe signs of organs failing), and moderate Alzheimer’s disease but no pre-existing conditions that would limit life expectancy to less than a year. This patient would end up with an overall score of two because the SOFA score is lower.

The older person would qualify for care first.

But in Pennsylvania, the person with moderate Alzheimer’s would score additional points, under the guidelines, leading the younger person to qualify for care first.” (C)

JAN. 8, 2021

Stretched to the breaking point by a deluge of COVID-19 patients, Los Angeles County’s four public hospitals are preparing to take the extraordinary step of rationing care, with a team of “triage officers” set to decide which patients can benefit from continued treatment and which are beyond saving and should be allowed to die.

The county’s top health officials have not yet declared a shift to a crisis level of care, which would trigger the rationing system, but the leader of the public hospitals acknowledged in a letter reviewed by The Times this week that “there will likely come a point when we simply don’t have sufficient staffing or critical supplies to care for all our patients in the way we normally would.”

The crisis designation would empower the newly named triage officers — usually critical care and emergency room doctors — to decide which patients at county hospitals would get access to resources such as ventilators, respiratory therapists and critical care nurses when they become too scarce to be provided to every patient.

Hospitals outside the county system will have to decide on their own whether to invoke similar urgency measures, though state officials told them last week that they should have triage plans ready.

Inside many overflowing Southern California hospitals, a form of undeclared rationing appears already to be taking place. Ambulances carrying COVID patients have been diverted from overtaxed medical centers. Critically ill patients sometimes wait days to get intensive care beds.

At one private hospital in Lynwood this week, doctors stood in a hallway, loudly arguing over whether to give one of the few remaining ventilators to an elderly woman. The doctor describing the scene said the hospital had no formal plan to resolve such disputes.

Paramedics having some patients stay home as hospitals struggle with COVID-19 wave

To confront the life-and-death triage choices, the California Department of Public Health and some hospital systems recommend reliance on clinical scoring systems that evaluate patients’ organ functions, generating numerical scores meant to indicate an individual’s survival chances.

County health leaders called the most common scoring system too rigid and imprecise to be used as the lone criterion for making triage decisions.

They have directed triage officers to use a broader “principle-based approach” that seeks to shift care away from patients judged to be terminal to patients judged to have the best chance of survival.

“Our goal as a health system will be to save as many lives as possible,” Dr. Christina Ghaly, who oversees the county’s public hospitals, said in a letter to staff this week. “That means shifting from providing the best care for each individual patient to providing the best care for our whole patient population. It also means possibly reallocating resources from a patient who is not benefiting to a patient who would benefit.”

Physicians, clerics and ethicists have debated for generations how to equitably allocate scarce resources in a time of crisis.

“Now we are on the verge of entering uncharted territory, as we may have to actually make those decisions,” said Dr. Arun Patel, the physician and lawyer overseeing the triage program for L.A. County. “No one in the United States has had to implement guidelines like this, at this scale, or for the duration that we may have to.”

Doctors and ethicists in Los Angeles and across the U.S. have not been able to agree on a single methodology for prioritizing patients, or even concur on the appropriate factors when determining who should get medical care.” (D)

“Due to a rapid increase in patient hospitalizations, both with and without a COVID-19 diagnosis, Kaweah Health called a Code Triage on Monday, August 16, 2021 at approximately 1:30 p.m. A Code Triage is a disaster or problem that may affect the hospital and/or the patients and puts us at a heightened level of crisis preparedness so that we are better positioned to respond to emergencies.

On Monday as of 6:00 p.m., there were 340 inpatients being cared for in the downtown medical center and zero beds available for additional patients needing hospitalization. As of 6:00 p.m., there were 163 patients seeking care in the Emergency Department, 63 of which were awaiting admission. The remaining 100 patients were waiting to be seen by emergency providers or were holding for additional examination.

Patients are being cared for in overflow areas using nursing staff from other clinical and non-clinical teams. Currently, Kaweah Health Medical Center has 89 admitted patients with COVID-19, with six additional COVID-19 positive patients holding in the Emergency Department. More than ninety percent (90%) of all currently admitted patients with COVID-19 are being treated for a primary diagnosis of the virus. The surge of patients began on Saturday, August 14 and has steadily increased since that time.

“We cannot discharge enough patients to handle the number of admissions that are coming in,” said Keri Noeske, Kaweah Health Vice President and Chief Nursing Officer. “We are asking people to please reach out to their primary care doctors, day or night, for medical needs versus using the Emergency Department for non-life threatening issues. Right now, we have 63 patients waiting for beds and only 45 patients ready to be discharged.” (E)

“The goal of triage is to ensure the best outcome for the largest number of patients. COVID-19 has overwhelmed Intensive Care Units in regions around the world so that there are simply not enough resources to provide the highest standard of care to every patient who might possibly survive.

In those cases, triage should select patients who have the best chance of pulling through over those with low odds of survival.

The great difficulty in COVID-19 cases is that not enough is known about the disease for strong evidence-based approaches. Using what is known and being discovered, ICUs should form triage committees to evaluate patients and handle the critical decisions over which patients should receive care and which should be offered only palliative measures when the unit becomes overwhelmed.

Those interprofessional teams should: Ensure standards are developed to account for care equity; Develop and impose ICU admission criteria; Assess currently admitted patients regularly; Handle removal of critical care when warranted; Handle family communication; Document triage decisions; COVID-19 Is Requiring Old Skills To Be Relearned in Some ICUs…

Review The Principles of Triage

The essential principle of triage is straightforward: patients with the best short-term prognosis with the available treatments should be admitted in preference to those who face a poor prognosis even with intensive intervention.

Triage guidelines should also incorporate aspects such as:

Equity of care – Ensuring that patients are treated on a strictly medical basis, without preferential treatment for the wealthy, well-connected, or based on racial or cultural judgements.

Preservation of as many lives as possible – Although triage is based in part on the conditions of an individual patient, the overriding goal should take in the overall community to ensure the maximum benefit is available to the largest number.

Protection of medical staff – There may be circumstances where further treatment not only endangers the community, but also healthcare workers. Preserving the capacity to treat other and future patients takes precedence over individual treatment. This means triage considerations also have to incorporate factors such as current staffing, PPE availability, and staff qualifications.

Develop Allocation Standards

Predetermining as many decision points as possible will help reduce decision fatigue and allow triage committees to make more objective judgements even during periods of high stress.

Each facility will need to determine its own specific criteria for allocating resources based on both availability, local standards of care, and patient status. Those criteria should broadly cover the following elements:

ICU Admission – Strict standards for initial admission should be adopted early on to reduce crowding. Data out of Italy shows that the median time a patient will be in ICU after admission is 15 days for survivors, and 10 days for fatalities. Either way, once they are admitted, they’ll be taking up a bed for a while. Tight criteria should be developed around critical procedures that are only possible in an ICU environment, including: Mechanical ventilation; Advanced hemodynamic care

ICU Exclusions – Beyond determining criteria for initial ICU admission, standards should be determined for specific categories of patient to be excluded from consideration for advanced care, even when current clinical presentation might argue otherwise. These will usually involve comorbid conditions or other factors that make a long-term recovery unlikely, including:Do not resuscitate orders; Trauma or recurrent cardiac events; Life expectancy less than 12 months, or otherwise in end-stages of fatal diseases like: COPD, Heart or severe circulatory failure, Cirrhosis of the liver….” (F)

Alberta Health Services has released a triage plan for determining who will receive critical care in the event that COVID-19 patients outnumber available ICU beds in the province.

The 50-page Critical Care Triage plan, unveiled Friday, would not be activated until the health authority has exhausted all other options, such as transferring patients, health-care staff, equipment and medication between different hospitals in the same health zone or across the province. It would be implemented based on direction from the AHS CEO, in consultation with the executive leadership team.

“When activated the triage protocol will be utilized in all health-care facilities and critical care units in Alberta to prioritize patients who have the greatest likelihood of overall survival,” the report states.

The plan lays out four “pandemic or disaster” stages, which would determine whether triaging is necessary.

In a “minor surge,” the number of patients requiring critical care would exceed resources. As a result, staff may be pulled from other critical care units to help with care and patients may be moved into recovery rooms.

A “moderate surge” would see staff brought in from other areas of hospitals and patients moved to recovery rooms or subspecialty ICUs. Transfers for patients in emergency departments would be delayed.

Triaging may be required in a “major surge,” which would occur when 90 per cent or more of available ICU beds in the province are occupied. The first phase of triaging would only allow patients who are predicted to have more than 20 per cent likelihood of surviving one year to enter the ICU.

A “large-scale surge” would see 95 per cent or more of available ICUs in the province occupied and could see the second phase of triaging activated. Under that scenario, those with a 50 per cent chance of surviving one year would be admitted to the ICU. Pediatric triaging will be considered.” (G)

“Surging COVID-19 cases in recent weeks have led to intensive care units across the country nearing capacity. In turn, this has prompted governments and health systems to review their existing ICU triage protocols for allocation of scarce ventilators and critical care resources.

Douglas White, MD, MAS and Bernard Lo, MD argue in the American Journal of Respiratory and Critical Care Medicine for the adoption of three strategies to mitigate health inequities during ICU triage. Their paper, ‘Mitigating Inequities and Saving Lives with ICU Triage During the COVID-19 Pandemic,’ provides a practical triage framework that incorporates the three strategies and attends to the twin public health goals of promoting population health and social justice.

“The pandemic has laid bare the deep inequities in society and disproportionately disadvantaged the poor and Black, Latinx, and Indigenous communities,” said Dr. White, who is the UPMC Endowed Chair for Ethics in Critical Care Medicine. “If we don’t factor health inequities into revised policies for ICU triage, we’ll simply be compounding these inequities.”

Three strategies to mitigate health inequities during ICU triage

Introducing a correction factor into patients’ triage scores to reduce the impact of baseline structural inequities

Giving heightened priority to individuals in essential, high-risk occupations

Rejecting use of longer-term life expectancy and categorical exclusions as allocation criteria. (H)

“How are my obligations different under triage protocols?

Be aware that triage protocols focus on maximizing benefits for the public at large and may override the duty of care to individual patients.

Follow any applicable and relevant triage protocols established by your healthcare institution, health authority, public health agency, or government. In some jurisdictions, such protocols have the force of law if ordered under emergency management legislation.

Thoroughly document your understanding of the triage protocols being applied, as well as your rationale for deviating from or deciding not to apply an established protocol if this is necessary for a specific patient.

Proactively communicate with patients, substitute-decisions makers, and families (where appropriate) how triage protocols might affect patient care and how they might impact the application of any advance care directives and other end-of-life wishes.

Apply triage protocols fairly and consistently across all patients with similar prognoses. While the primary purpose is to prioritize certain patients over others, patients cannot be discriminated against based on a prohibited ground of discrimination. Some protocols include guiding principles for triage, which specifically reference non-discrimination and protection of individual human rights.” (I)

“Science alone cannot tell us how to allocate ICU beds. Should they go to the sickest patients? Should they go to those who are most likely to benefit from treatment? Should we use a lottery system? Should we withdraw treatment from patients if they are not going to have a meaningful recovery to give the bed to someone who will? And what constitutes a meaningful recovery? These are ethical questions requiring value judgements.

Many pandemic response plans focus on maximizing the benefit of scarce resources to save the most lives. Allocating ICU beds to people who are unlikely to benefit from them is often considered unethical and inefficient. Clinicians who work in the ICU often talk about the moral difficulty of providing treatments that sometimes do more harm than good. The moral burden of care in these circumstances weighs heavily on ICU clinicians when left to make these decisions alone and without ethical guidance…

Human rights advocates, disability rights advocates, Indigenous health partners and members of the Black community have voiced concerns about the potential for discrimination when triage does not take stock of societal factors and when they are not involved in the process of developing triage criteria. Meaningful inclusion of these communities and their perspectives is essential for the ethical legitimacy of ICU triage frameworks to balance utility with equity.

The public needs to join the conversation on an ethical approach to triage

Consensus on a proposed ethical framework for pandemic triage, even just among bioethicists, is unrealistic. Nor is it necessarily desirable. In fact, the role of dissensus in bioethics is crucial to avoiding the narrowing of possible policy avenues and avoiding presumptive constructions of various stakeholders.

As bioethicists, our expertise is in sketching the moral landscape, providing options and framing ethical debate. Our job is to propose a possible approach to intensive care triage that the public and stakeholders can then weigh and deliberate. It is also to propose and promote accessible and ethically defensible processes for doing so.

Bioethicists are not moral authorities, and governments ought not decide on an approach to intensive care triage without engaging in broader moral deliberation with the public and with those who will be most affected.

To be sure, public deliberation will not make the decisions about how to prioritize patients for intensive care any easier, nor will it necessarily make it easier to live with the consequences. But it would ensure that all voices have been heard, innovative approaches have been considered, and that new ethical considerations can come to light. It is a distinctly political obligation to ensure that the triage protocol is grounded in an ethical, democratic process and that it is based on values that have been justified through stated public reasons.” (J)

(A)Alabama has no more I.C.U. beds available, the state authorities said., by Alyssa Lukpat, https://www.nytimes.com/2021/08/19/us/alabama-icu-shortage.html

(B)American Hospitals Buckle Under Delta, With I.C.U.s Filling Up, By Albert Sun and Giulia Heyward, https://www.nytimes.com/interactive/2021/08/17/us/covid-delta-hospitalizations.html?referringSource=articleShare

(C) At the Top of the Covid-19 Curve, How Do Hospitals Decide Who Gets Treatment?, By Mike Baker and Sheri Fink, https://www.nytimes.com/2020/03/31/us/coronavirus-covid-triage-rationing-ventilators.html?referringSource=articleShare

(D) ‘Triage officers’ would decide who gets care and who doesn’t if COVID-19 crushes L.A. hospitals, BY JAMES RAINEY, SOUMYA KARLAMANGLA, JACK DOLAN, https://www.latimes.com/california/story/2021-01-08/la-county-covid-rationing-triage

(E) Kaweah Health Calls Code Triage for COVID-19, https://www.kaweahhealth.org/articles/2021/august/kaweah-health-calls-code-triage-for-covid-19/

(F) What’s Involved in Triaging COVID-19 Patients When The ICU is Beyond Capacity?, https://www.doctorofnursingpracticednp.org/whats-involved-in-triaging-covid-19-patients-when-the-icu-is-beyond-capacity/

(G)AHS releases triage protocol outlining which patients would receive care if ICUs become overwhelmed by COVID-19, by Anna Junker; https://edmontonjournal.com/news/local-news/ahs-releases-triage-protocol-outlining-which-patients-would-receive-care-if-icus-become-overwhelmed-by-covid-19

(H)ICU TRIAGE PROTOCOLS: AN EQUITABLE SOLUTION, https://www.ccm.pitt.edu/node/1291

(I) Navigating triage protocols amid COVID-19, https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2020/navigating-triage-protocols-amid-covid-19

(J) Public conversation on the ethics of intensive care triage during pandemic is overdue, https://healthydebate.ca/2021/04/topic/icu-triage/