POST 197. September 12, 2021. CORONAVIRUS. Idaho officials have instituted “crisis standards of care” to help 10 hospitals and health care systems decide how to allocate personnel and resources to deal with a crush of COVID-19 patients.”… “The Washington Medical Coordination Center oversees facilitating transfers in the state, and it’s warning we could be nearing the point of “Crisis Standards of Care,” just like Idaho.” .. “These crisis models don’t actually save more lives, they just save different lives..”

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“Idaho officials have instituted “crisis standards of care” to help 10 hospitals and health care systems decide how to allocate personnel and resources to deal with a crush of COVID-19 patients.

The crisis standards are for the hospitals in two health districts in the state’s panhandle and north central areas.

“When crisis standards of care are in effect, people who need medical care may experience care that is different from what they expect,” the news release said. “For example, patients admitted to the hospital may find that hospital beds are not available or are in repurposed rooms (such as a conference room) or that needed equipment is not available.”

Idaho has a low vaccination rate and health experts fear that the state could be dealing with up to 30,000 new COVID cases per week by mid-September if current trends continue, The Associated Press reported…

Hospitals report severe staff shortages in nursing, housekeeping, and other positions because workers are burned out or affected by the pandemic, The Associated Press said.

The governor recently tried to fill the staffing gap by calling in 220 medical workers through federal programs and mobilizing 150 Idaho National Guard soldiers.” (A)

“Crisis standards of care is a last resort. It means we have exhausted our resources to the point that our healthcare systems are unable to provide the treatment and care we expect,” said DHW Director Dave Jeppesen. “This is a decision I was fervently hoping to avoid. The best tools we have to turn this around is for more people to get vaccinated and to wear masks indoors and in outdoor crowded public places. Please choose to get vaccinated as soon as possible – it is your very best protection against being hospitalized from COVID-19.”

The process to initiate crisis standards of care began when resources were limited to the point of affecting medical care. The director of DHW convened the Crisis Standards of Care Activation Advisory Committee on Sept. 6, 2021, to review all the measures that were taken to address the staffing and bed shortages. The committee determined that the ability of northern Idaho hospitals and healthcare systems to deliver the usual standard of care has been severely affected by the staffing shortages, and all contingency measures to address these shortages had been exhausted. The committee recommended to the director that crisis standards of care be activated. Director Jeppesen issued his decision on Sept. 6, 2021, under the authority vested in him through the temporary rule.

Efforts will continue with earnest to alleviate the staffing and any other resource constraints in North Idaho. The crisis standards of care will remain in effect until there are sufficient resources to provide the usual standard of care to all patients.” (B)

“The move came as the state’s confirmed coronavirus cases skyrocketed in recent weeks. Idaho has one of the lowest vaccination rates in the U.S.

The state health agency cited “a severe shortage of staffing and available beds in the northern area of the state caused by a massive increase in patients with COVID-19 who require hospitalization.”

The designation includes 10 hospitals and healthcare systems in the Idaho panhandle and in north-central Idaho. The agency said its goal is to extend care to as many patients as possible and to save as many lives as possible.

The move allows hospitals to allot scarce resources like intensive care unit rooms to patients most likely to survive and make other dramatic changes to the way they treat patients. Other patients will still receive care, but they may be placed in hospital classrooms or conference rooms rather than traditional hospital rooms or go without some life-saving medical equipment.

At Kootenai Health — the largest hospital in northern Idaho — some patients are waiting for long periods for beds to open up in the full intensive care unit, said Dr. Robert Scoggins, the chief of staff. Inside the ICU, one critical care nurse might be supervising up to six patients with the help of two other non-critical care nurses. That’s a big departure from the usual one ICU nurse for one ICU patient ratio, he said.

On Monday, the Coeur d’Alene hospital started moving some coronavirus patients into its nearby conference center. A large classroom in the center was converted into a COVID-19 ward, with temporary dividers separating the beds. Some emergency room patients are being treated in a converted portion of the emergency room lobby, and the hospital’s entire third floor has also been designated for coronavirus patients.

Urgent and elective surgeries are on hold, Scoggins said, and Kootenai Health is struggling to accept any of the high-level trauma patients that would normally be transferred from the smaller hospitals in the region.

Other states are preparing to take similar measures if needed. Hawaii Gov. David Ige quietly signed an order last week releasing hospitals and health care workers from liability if they have to ration health care…

The designation will remain in effect until there are enough resources — including staffing, hospital beds and equipment or a drop in the number of patients — to provide normal levels of treatment to all…

The state’s crisis guidelines are complex, and give hospitals a legal and ethical template to use while rationing care.

Under the guidelines, patients are given priority scores based on a number of factors that impact their likelihood of surviving a health crisis.

Those deemed in most in need of care and most likely to benefit from it are put on priority lists for scarce resources like ICU beds.

Others in dire need but with lower chances of surviving will be given “comfort care” to help keep them pain-free whether they succumb to their illnesses or recover.

Other patients with serious but not life-threatening medical problems will face delays in receiving care until resources are available.” (C)

IDAHOCRISIS STANDARDS OF CARE – highlight and click on

Click to access Crisis-Standards-of-Care-Plan_Final_Posted_Signed.pdf

“Idaho adopted the standards by applying elements from the Institute of Medicine (IOM) Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response, published in 2012. “The plan is based on the five key elements of CSC planning identified by the IOM. They include Emergency Management and Public Safety, EMS, Hospital, Public Health, and Out of Hospital Care,” the Idaho CSC document states.

So what does that mean for healthcare professionals working at the ten centers in Idaho’s Panhandle and the city of Coeur d’Alene? MedPage Today examined the CSC document, as well as other recently updated guidelines.

The standards were designed to maximize care at the population health level, and it is recommended that medical centers use them as guideposts to help devise their own game plans, though they stop short of making many detailed stipulations. “The goal of [the] crisis standards of care is to extend care to as many patients as possible and save as many lives as possible,” the DHW news release stated. “Hospitals will implement as needed and according to their own [crisis] policies.”

But the CSC document does offer several specific suggestions, including:

“Continue efforts to increase surge capacity through changes in care practices, e.g., further changes in documentation, nurse-patient ratios, [and] active recruitment for alternative care providers”

“Defer non-life-sustaining outpatient services, including physical and occupational therapy”

“Adapt services and venue for cardiac/stroke rehab and cancer therapy (in pandemic setting) to minimize risk of exposure to severe transmissible illness and free staff for other duties”

“Cancel all job duties considered non-essential and reassign personnel as appropriate”

“Move patients who cannot be discharged but who are stable to alternate facilities experiencing less surge”

“Defer surgeries not essential to preserve life and limb or not needed to facilitate discharge from hospital”

“In mass trauma settings, pull staff with surgical experience from other areas of hospital to support trauma response capacity”

In addition, the document notes that “the EMS Physician Commission will need to create specific guidance for EMS providers that corresponds with the care continuum … In the case of COVID-19 … EMS staff must stringently adhere to infection control and decontamination procedures.”

EMS dispatchers should “utilize non-certified dispatch personnel to handle incoming emergent calls … [and] decline response to calls without evident potential threat to life.” The document also suggests “allowing an experienced critical care Paramedic or RN be the sole provider versus a three-person team if they are comfortable providing that care based on patient needs.”…

Idaho does not appear to be triaging care based on specific COVID-19 criteria — including vaccination status — and MedPage Today could not find any mention of the impact of the dire situation on malpractice, among other issues that concern clinicians during hospital surges. It is also unclear if other states have yet adopted crisis or similar guidelines in any of their hot spots.

In Idaho, the standards “will remain in effect until there are sufficient resources to provide the usual standard of care to all patients.”…

The standards are not likely to be very effective, said Joel Zivot, MD, of Emory University School of Medicine in Atlanta. “These crisis models don’t actually save more lives, they just save different lives,” he noted. “The only way to really do this is first-come, first-serve.”

Zivot is “troubled” by the idea that a healthcare workforce can consistently decide which patients to treat and when in an ethical manner. “We are talking about letting people die; let’s not be so quick to decide,” he said. “All patients — COVID, non-COVID — are equally valuable and they’re due equal access to care.” (D)

“Idaho’s crisis standards of care plan is 48 pages long, with an additional 41-page guide and a 42-page set of checklists. You can download them by visiting the Idaho Department of Health and Welfare’s Emergency Preparedness page.

The state also created guidelines for nursing homes, should they need crisis standards of care.

Crisis standards won’t just apply to people with COVID-19. They will apply to patients who need medical care for any reason, such as car crashes, heart attacks, strokes and influenza.

Hospitals likely won’t get to that point. Hospital officials have maintained that they would provide as much care as they can and provide treatments to keep patients comfortable, even if they’re denied a resource. Health care providers would also maintain contact with the patients, who could be brought back even if they can’t be treated immediately.

Activating the Crisis Standards of Care Plan may not mean shutting down a certain kind of treatment or service. Depending on the situation, the standards may apply to just one health care resource — such as oxygen or ventilators once hospitals begin to run short — or one region. But if the situation doesn’t improve, these standards likely would be activated statewide after hospitals ran out of resources they could share, Jeppesen has said.

Patients, regardless of diagnosis, would likely face significantly longer wait times for care. Smaller health care centers will have even more challenges. They may not be able to accept transfers from outside hospitals, according to the Department of Health and Welfare. Rural hospitals especially would suffer, the department said.

“Rural hospitals would likely need to care for higher complexity patients than they are used to during crisis standards of care and would likely struggle to even transfer traumas, strokes, or heart attacks,” DHW said.

WILL PEOPLE WHO DIDN’T FOLLOW COVID-19 GUIDELINES BE DENIED?

No, they will be prioritized the same way as people who faithfully followed the guidelines.

It is against the law and against medical ethics for Idaho’s health care system to triage patients based on things like politics, where they live or whether they obeyed mask mandates.” (E)

“After a request from overfilled and understaffed hospitals in the panhandle, Idaho has activated “Crisis Standards of Care.”

Under crisis standards, hospital beds, medicine, and equipment like ventilators may be given to those considered most likely to survive, not the most critical.

The goal is to save as many lives as possible while space is limited. Care is not guaranteed for everyone.

“They have over 200 national support personnel coming in to help them. Their hospital is 50% full of COVID-positive patients,” said Cassie Sauer, president of the Washington State Hospital Association (WSHA). “It is an absolute gut-wrenching decision for anyone who works in health care to have to make. It is terrible. We do not want that to happen here.”

Hospitals are filling up in Washington state as well.

“I think it’d be really hard for the hospitals in Spokane, even as full as they are, who have very strong relationships with the hospitals in Idaho, to say no,” said Sauer. “This feels like an incredible ethical conundrum.”

As Washington hospitals approach capacity, some patients from Idaho could be transferred to Washington state. But Washington is under no obligation to take them, according to the WSHA.

“It is each individual hospital’s decision whether or not they take an out-of-state patient,” explained Sauer. “But we have some special processes of the Washington Medical Coordination Center, and those only apply to patients… that are in a Washington state hospital. So that we are not… guaranteeing the help to anyone that’s outside of Washington state.”

The Washington Medical Coordination Center at Harborview Medical Center oversees facilitating transfers in the state, and it’s warning we could be nearing the point of “Crisis Standards of Care,” just like Idaho.”  (F)

“A major epidemic or pandemic can overwhelm the capacity of outpatient facilities, emergency departments (EDs), hospitals, and intensive care units, leading to critical shortages of staff, space, and supplies with serious implications for patient outcomes.

In the late summer of 2009, with an H1N1 pandemic looming, the Institute of Medicine (IOM, and as of 2015, the National Academy of Medicine), at the request of the Office of the Assistant Secretary for Preparedness and Response (ASPR) at the U.S. Department of Health and Human Services (HHS), convened an ad hoc committee to generate a letter report addressing how resource allocation and triage decisions could be fairly made under crisis conditions [1]. The 2009 IOM letter report Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report was followed by a more thorough exploration of these concepts in 2012 and the creation of a toolkit for planners focused on specific disaster event indicators and triggers in 2013 [2,3].

Ten years later, in the early months of 2020, another potential pandemic looms. This time it is due to the emergence of a novel coronavirus (SARS-CoV-2, causing COronaVIrus Disease 2019 or COVID-19), a beta coronavirus similar to the severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) coronaviruses. The principles of Crisis Standards of Care (CSC) are as relevant now as they were a decade ago. It is simply too early to say, at the time of this writing, what the course of the COVID-19 epidemic will be, although its rapid geographic spread within China, the concomitant meteoric rise in the number of persons affected, along with the detection of the virus in more than two dozen countries, raises the specter of a global pandemic. More people were reported dead in the first month after the SARS-CoV-2 virus was recognized than died during the 8 months that SARS circumnavigated the globe [4].

Proactive planning, in which leaders anticipate and take steps to address worst-case scenarios, is the first link in the chain to reducing morbidity, mortality, and other undesirable effects of an emerging disaster. It is vital that the principles and practices of crisis care planning guide public health and health care system preparations. This discussion paper summarizes some key areas in which CSC principles should be applied to COVID- 19 planning, with an emphasis on health care for a large number of patients. Hospitals routinely utilize selected principles of CSC to deal with seasonal outbreaks, lack of bed availability, and drug shortages, but a potential pandemic requires a deeper understanding and application of CSC.

Reduced to its fundamental elements, CSC describe a planning framework based on strong ethical principles, the rule of law, the importance of provider and community engagement, and steps that permit the equitable and fair delivery of medical services to those who need them under resource-constrained conditions. CSC are based on the following key principles [1]:

Fairness

Duty to Care

Duty to Steward Resources

Transparency

Consistency

Proportionality

Accountability

Since the release of the 2009 IOM letter report, a “duty to plan” has been espoused by leaders in the disaster preparedness and response community and recognized in legal decisions in the setting of hurricane evacuation and sheltering [5,6,7]. This duty is worth highlighting, as a failure to plan for scarce resource situations may lead to the inappropriate application of CSC, wasted resources, inadvertent loss of life, loss of trust, and triage/rationing decisions being made unnecessarily. This will force poor choices on health care providers who will already be markedly limited in their ability to deliver care.” (G)

“I’m going to come right out and say it: In situations where hospitals are overwhelmed and resources such as intensive care beds or ventilators are scarce, vaccinated patients should be given priority over those who have refused vaccination without a legitimate medical or religious reason.

This conflicts radically with accepted medical ethics, I recognize. And under ordinary circumstances, I agree with those rules. The lung cancer patient who’s been smoking two packs a day for decades is entitled to the same treatment as the one who never took a puff. The drunk driver who kills a family gets a team doing its utmost to save him — although, not perhaps, a liver transplant if he needs one. Doctors are healers, not judges.

But the coronavirus pandemic, the development of a highly effective vaccine, and the emergence of a core of vaccine resisters along with an infectious new variant have combined to change the ethical calculus. Those who insist on refusing the vaccine for no reason are not in the same moral position of the smoker with lung cancer or the drunk driver. In situations where resources are scarce and hard choices must be made, they are not entitled to the same no-questions-asked, no-holds-barred medical care as others who behaved more responsibly.

There are a number of reasons. It’s hard to quit smoking, stop drinking, lose weight or even take up exercise. So even those whose health problems can reasonably be blamed on their own lapses deserve the best care possible. After all, for the most part, they are their own victims.

Vaccine resisters are different. Their refusal to take the shot doesn’t just affect their own health — it poses a known risk to the health of others, especially now, with the spread of the delta variant. To decline to be vaccinated is to fail to live up to your duty to your community. And it should mean that you forfeit — if necessary — your claim to equal medical treatment….

Emergency physician Dan Hanfling has written extensively about how to triage care, and he agrees. “If you believe there’s a certain degree of accountability that we as citizens have to take for each other to protect our community, then that group of individuals who have willingly chosen not to vaccinate, for illegitimate reasons, it would be fair to place them at the back of the line. Not kick them out of line, just move them back,” he told me. “At the end of the day, if you have willingly chosen not to do something that benefits the public good in the setting of a national crisis, then there are certain consequences.”

This is an uncomfortable conversation. The irresponsibly unvaccinated have made it a necessary one.” (H)