POST 199. September 19, 2021. CORONAVIRUS. Crisis Standards of Care. “… to his knowledge, no patient in Idaho has been taken off life-support therapy in order to provide that therapy to another patient who has a better prognosis.” “While that has yet to occur, if we continue on this path, it will,”

“From June through August 2021, preventable COVID-19 hospitalizations among unvaccinated adults cost over $5 Billion.. Over 280,000 COVID-19 hospitalizations could have been prevented by vaccination between June to August 2021.”

for links to POSTS 1-199 in chronological order highlight and click on

“Overwhelmed by a surge in COVID-19 patients, Alaska’s largest hospital on Tuesday implemented crisis standards of care, prioritizing resources and treatments to those patients who have the potential to benefit the most.

“While we are doing our utmost, we are no longer able to provide the standard of care to each and every patient who needs our help,” Dr. Kristen Solana Walkinshaw, chief of staff at Providence Alaska Medical Center, wrote in a letter addressed to Alaskans and distributed Tuesday.

“The acuity and number of patients now exceeds our resources and our ability to staff beds with skilled caregivers, like nurses and respiratory therapists. We have been forced within our hospital to implement crisis standards of care,” Walkinshaw wrote…

Walkinshaw noted that the state’s COVID-19 dashboard, which is routinely updated with numbers related to the virus, “isn’t equipped or designed to demonstrate the intricacies of providing medical care during this unprecedented time.”

At Providence, one of only three hospitals in a city of about 300,000 residents, officials have developed and enacted procedures to ration medical care and treatments, including dialysis and specialized ventilatory support.

The emergency room is overflowing at Providence, and she said patients wait for hours in their cars to see a doctor for emergency care.

Walkinshaw noted that what happens at the Anchorage hospitals affects the entire state since specialty care can often only be provided in the state’s largest city.

“Unfortunately, we are unable to continue to meet this need; we no longer have the staff, the space, or the beds,” Walkinshaw wrote. “Due to this scarcity, we are unable to provide lifesaving care to everyone who needs it.”

That has left patients across the state sitting in local hospitals since Providence can’t accept them for transfer.

“If you or your loved one need specialty care at Providence, such as a cardiologist, trauma surgeon, or a neurosurgeon, we sadly may not have room now. There are no more staffed beds left,” she wrote.” (A)

(Helena, Montana) “St. Peter’s Health has announced they are in “crisis care” as their critical care units reach full capacity.

Crisis Care Standards occur when it is no longer possible to deliver the normal standard of care to all persons in need. The need occurs when health care resources are overwhelmed by a disaster or emergency.

Under crisis care, hospital staff may be forced to evaluate patients in terms of which have a better chance of survival. Medication may be rationed and patients may be sent home for recovery that would normally be kept for observation should their condition worsen. St. Peter’s says crisis standards are not a flipped switch situation, but a stepped approached without official levels and different departments may be at different levels depending on the number and severity of patients they are dealing with.

On Thursday, the regional hospital said their Intensive Care Unit and Advanced Medical Unit are at 100% capacity. Their morgue is also full right now, and they’ve requested a refrigeration truck. Not all the deaths or critical care emergencies are related to COVID-19, but the most recent surge is contributing to the situation at the hospital.

“We are giving our staff permission to not do it all. The hardest thing they will do in their careers is not giving the care they are used to giving, but they simply can’t,” said Chief Medical Officer Dr. Shelly Harkins…

St. Peter’s has requested assistance from the Montana National Guard in responding to the crisis. They are unsure if the request will be granted.

On top of the pandemic, St. Peter’s is facing a staffing shortage and burnout of current employees. The health care organization says they have 200 open positions that aren’t filled.”  (B)

“Idaho’s Department of Health and Welfare this week activated crisis standards of care across the state for the first time as COVID-19 cases and hospitalizations surge.

Other states facing high numbers of COVID-19 cases are considering rationing care, even if not statewide like Idaho…

The largest hospital in Alaska recently adopted crisis standards, and such Western states as Nevada and New Mexico are expected to ration care in the near future. New Mexico had enacted crisis standards last December, but lifted them once hospitalizations subsided.

Intensive care units across the South are also near 100% capacity in several states, including Texas and Florida, according to data from the New York Times.

However, the Idaho Statesman could not find a state besides Idaho that had implemented crisis standards across all its health systems.

Will vaccination status be considered when care is prioritized?

Vaccination status is not listed as part of the considerations for prioritizing care. It is also against the law and against medical ethics for Idaho’s health care system to triage patients based on politics or whether people wore a mask.

“The goal of providing care quickly and efficiently must be guided by fairness, equality and compassion,” according to Idaho’s crisis standards of care plan. “As such, (this) is grounded in ethical obligations that include the duty to care, duty to steward resources, distributive and procedural justice, and transparency. Its guiding principle is that all lives have value and that no patients will be discriminated against on the basis of disability, race, color, national origin, age, sex, gender, or exercise of conscience and religion.”

Under the plan, people who have a higher likelihood of survival will be given care before those who are more likely to die.

Should there not be enough of a certain resource, care could be prioritized in the following order:

1. Children up through 17 years old.

2. Pregnant women with a viable pregnancy, at more than 28 weeks of gestation.

3. Adults by age, from younger to older: age 18-40, age 41-60, age 61-75 and 76 and older.

4. Patients who “perform tasks that are vital to the public health response of the crisis at hand, including, but not limited to, those whose work directly supports the provision of acute care to others.”

5. A lottery, or “random allocation,” if there is still a tie after going through the first four priority criteria.

Dr. Steven Nemerson from Saint Alphonsus Health System said Thursday that so far, he doesn’t know of a single patient who has been taken off a life-support therapy so that therapy could be given to another patient with a better prognosis.

“While that has yet to occur,” he said, “if we continue on this path, it will.”

What is an example of crisis standards of care?

Under crisis standards of care, the focus is on saving as many lives as possible, according to Health and Welfare. So patients who are more likely to survive could be treated first.

According to the standards, patients could be given a priority score based on a number of factors.

For example, if the demand for ventilators is exceeding supply, hospitals could put into place universal “Do Not Resuscitate” orders. That means if an adult patient goes into cardiac arrest, they could “receive NO attempts at resuscitation,” according to Health and Welfare’s strategies for scarce resource situations.

“The likelihood of survival after a cardiac arrest is extremely low for adult patients. As well, resuscitation poses significant risk to health care workers due to aerosolization of body fluids and uses large quantities of scarce resources such as staff time, personal protective equipment, and life-saving medications, with minimal opportunity for benefit.” (C)

“The Idaho Crisis Standards of Care Activation Advisory Committee met Wednesday and determined the influx of COVID patients had severely impacted all of the state’s hospitals to the point of asking the director to expand crisis standards statewide.

The move comes as COVID cases and hospitalizations are at their highest point in the pandemic and show no signs of slowing.

“These are uncharted waters,” said Brian Whitlock, president and CEO of the Idaho Hospital Association. “We’ve never been in this situation before as a state.”

Roth said St. Luke’s has done everything possible over the past 20 months to avoid crisis standards of care.

“This is an incredibly sad day for St. Luke’s and for our community,” he said.

Roth said the overwhelming patient volumes are a result of COVID-19 patients and historic levels of traditional patient care, with the latter largely brought on by a pent-up demand from patients delaying care last year because of COVID-19.

“I’ve never seen any volumes even close to what we’re seeing in my history at St. Luke’s of 14 years,” Roth said.

He said St. Luke’s had a record 173 COVID-positive admissions to its hospital at the end of August, breaking the 172-admissions record back in the December surge. It recently broke the record again with 281 COVID-19 admissions.

“If we continue on this course over the next several weeks, St. Luke’s Health System will become a COVID health system,” said Roth, noting it will consume every resource and bed it has with coronavirus patients.

Roth said the vast majority of patients in St. Luke’s ICU are COVID positive, with 98% of them unvaccinated.

He said the health system has hired more staff and is doing everything it can to provide safe and effective care, “but the standard of care is being eroded.”

“We’ve now stopped surgical procedures that can be reasonably expected to be associated with a significant risk of permanent disability or pathology,” said Dr. Jim Souza, chief physician executive at St. Luke’s.

Souza said certain breast cancers, prostate cancers and bladder tumors, for examples, will be managed “medically” until doctors can get to them.

Sandee Gehrke, chief operating officer at St. Luke’s, said the hospital stretched its nurse-ICU patient ratios. She said a registered nurse in the ICU typically took care of one or two patients but is now tending to about three.

Gehrke said the combination of high patient volumes and 400 employees at home because of COVID-19-related illnesses is stretching St. Luke’s staff thin.

“The strain that we are experiencing from a team member standpoint is heartbreaking,” Gehrke said. “To hear our team talk about the stress that they see and experience, when they are working 10 shifts in a row and they don’t get to see their family and they are seeing the death and the despair that COVID is bringing to us, it’s really taking a toll across the board.”

Nemerson said Saint Alphonsus has 135 COVID-positive patients, which is 35% of its total inpatient volume.

He said Saint Alphonsus is experiencing record numbers of non-COVID and COVID inpatients. Nemerson said COVID inpatients could exceed 210 in the next three to four weeks, at the current rate.

“We, too, are at the maximum capability of providing care without stretching our teams further and further and further,” he said.

Nemerson said Saint Alphonsus is able to continue to deliver a reasonable standard of care, but that will decline simply because caregivers cannot care for patients fast enough.

“I’m scared for all of us,” he said.

Still, Nemerson said people should not avoid emergency care, and if they have medically necessary or time-sensitive procedures, Saint Alphonsus will always be there for them. He said, to his knowledge, no patient in Idaho has been taken off life-support therapy in order to provide that therapy to another patient who has a better prognosis.

“While that has yet to occur, if we continue on this path, it will,” Nemerson said.

As of Tuesday, there were more than 600 Idaho residents hospitalized with the virus as federal contract workers are being dispatched to support understaffed hospitals. There were 173 Idaho COVID patients in intensive care units statewide.

Last winter, hospitals statewide saw just more than 400 COVID patients at once before the surge quelled.

“Our hospitals and health care systems need our help. The best way to end crisis standards of care is for more people to get vaccinated. It dramatically reduces your chances of having to go to the hospital if you do get sick from COVID-19. In addition, please wear a mask indoors in public and outdoors when it’s crowded to help slow the spread,” Department of Health and Welfare director Dave Jeppesen said in a news release. “The situation is dire – we don’t have enough resources to adequately treat the patients in our hospitals, whether you are there for COVID-19 or a heart attack or because of a car accident.” (D)



Crisis standards of care give legal and ethical guidelines to health care providers when they have too many patients and not enough resources to care for them all. Essentially, they spell out exactly how health care should be rationed in order to save the most lives possible during a disaster.

Some health care rationing steps have become commonplace during the pandemic, with hospitals postponing elective surgeries and some physicians switching to online visits rather than seeing patients in person. But more serious steps — such as deciding which patients must be treated in a normal hospital room or intensive care unit bed, and which patients can be cared for in a hospital lobby or classroom — have been rare.

At the extreme end of the spectrum, crisis standards of care generally use scoring systems to determine which patients get ventilators or other life-saving medical interventions and which ones are treated with pain medicine and other palliative care until they recover or die.


States may use a combination of factors to come up with patient “priority scores.” Idaho’s and Montana ’s system both consider how well a patient’s major organ systems are functioning. Patients with indications of liver or kidney damage, poor oxygen and blood clotting levels and an inability to respond to pain because they are in a coma have higher scores.

Both states also score people based on saving the highest number of “life-years,” so if a person has cancer or another illness that is likely to impact their future survival, they get a higher score.

The lower a patient’s score, the more likely they are to survive, moving them toward the front of the line for ventilators or other resources.

The plans also have “tie-breakers” that come into play if there aren’t enough resources for all of the folks at the front of the line. Youth is the biggest tie-breaker, with children getting top priority.

In Idaho, pregnant women who are at least 28 weeks along with viable pregnancies come next. Both states also give consideration to younger adults ahead of older adults, and Idaho’s fourth tie-breaker is if the patient performs a task that is vital to the public health crisis response. The final tie-breaker is a lottery system.

If someone at the front of the line is given a ventilator and doesn’t show improvement within a set period of time, Idaho says they should be taken off so someone else can have a chance…



In both Idaho and Montana, the crisis standards of care don’t consider whether a person has been vaccinated against COVID-19. Likewise, patients aren’t denied care if they are injured in a car accident because they failed to wear a seatbelt or drove while intoxicated.

“Vaccination status is not relevant to us when it comes to taking care of patients. We simply do what they need us to do within the constraints and the resources that we have,” said Dr. Shelly Harkins, chief medical officer at St. Peters hospitals in Helena.


Nearly everything.

People will likely wait longer for care, not just in hospitals but at urgent care centers that will likely be dealing with more patients as well. Nurses will care for more patients than they normally would. Instead of hospital beds, some people might be placed on stretchers and cots. Patients will likely be sent home from the hospital as soon as possible, relying on friends, family and prescriptions for in-home medical equipment during their recovery.

And in some cases, physicians may not attempt to save a patient’s life at all. Idaho’s crisis standards of care plan calls for a “Universal Do Not Resuscitate Order” for all adults once the state has reached the point where there aren’t enough ventilators to go around.

That means if a patient experiences cardiac arrest — where the heart stops suddenly — there will be no chest compressions, no attempts to shock the heart back into a normal rhythm, no chance at hooking them up to life support. That’s partly because resuscitation requires a bunch of hospital staffers, a lot of time, and is frequently unsuccessful. It’s also because if the patient has COVID-19, the process of attempting to revive sends aerosolized virus particles into the air, putting staffers at risk.

Montana’s plan is a bit different, in that it allows individual doctors to decide whether or not to resuscitate patients on a case-by-case basis.” (E)

“As of Monday morning, more than 96,000 hospital beds are filled with Covid-19 patients nationwide — contributing to the 77% of all hospital beds across the country being currently in use, according to data from the US Department of Health and Human Services. About 80% of intensive care unit beds are in use.

Hospitals in some places are closer to capacity than in others.

In Arkansas, Gov. Asa Hutchinson said in a briefing last week that there were only 23 ICU beds available statewide. “That’s closer than we’d like, but it is better than what it has been. And so we continue to monitor that,” Hutchinson said, adding that 27 new ICU beds will be coming online this month.

A heart patient died after he couldn’t get a cardiac ICU bed in 43 hospitals. Now his family is pleading for people to get vaccinated

In Kentucky, Gov. Andy Beshear laid out the severity of the Covid-19 spread in his state on CNN last week, saying that while hospitals are not yet at the point of needing to make tough choices about rationing care, “we are right at” or “quickly approaching that point.”

“We are in a really tough place, Kate,” he told CNN’s Kate Bolduan. “We’ve called in FEMA strike teams, the National Guard, we’ve deployed nursing students all over the state, we’ve taken over testing from hospitals just to free up additional people.”

And In Alabama, a mourning family has issued a plea to others to get vaccinated after Ray DeMonia, a Cullman, Alabama resident​, died ​about 200 miles from his home, in a Mississippi hospital, because there were no cardiac ICU beds nearby. His daughter Raven DeMonia told his story to The Washington Post on Sunday.

‘Rationing health care is not new’

When hospitals run out of beds or when staffing is low, tough decisions must be made on which patients get to be first in line for care. Overall, hospitals and health systems have plans on the table to address an overflow of patients and making such difficult decisions.

Hospitals scrambling for incentives to retain nurses amid shortage

“All hospitals and health systems have plans in place to deal with a surge in patients. These plans can include actions like adding beds, including in non-traditional areas of care in a hospital like a cafeteria or parking lot, shifting patients between hospitals, and working with their local and state health departments to find other sites of care,” Akin Demehin, director of policy at the American Hospital Association (AHA), wrote in an email to CNN on Friday.

“Sometimes this includes sending patients to hospitals in nearby states that may have the capacity to treat them,” Demehin wrote. “One other option that some hospitals have taken is to scale back, or put a pause, on so-called elective procedures that are non-emergent and can be safely delayed for a period of time.”

Yet for the most part, hospital capacity is not only about how many beds are filled — a hospital can usually add beds — but many facilities are much more concerned about enough staffing to care for patients, according to Demehin.

“Hospitals and health systems entered the COVID-19 pandemic already facing a shortage of skilled caregivers, and the last 18 months have exacerbated that,” Demehin wrote, adding that AHA has called on the Biden administration to work as a partner in developing strategies to address the shortage of health care staff.

‘This pandemic is our World War II.’ An up-close look at how a Florida hospital fights to save Covid-19 patients

Overall, decision-making around rationing care can look different depending on the type of medical facility — a hospital or private doctor’s office.

“There are different decisions whether it’s a doctor’s office or an emergency room,” Art Caplan, professor of bioethics at NYU Langone Health in New York, told CNN.

“You have no right to be taken care of by a primary care doctor. There’s still no right to health care that way — the doctor has the ability to decline,” Caplan said, adding for instance, that some doctors might decline to take Medicaid as a patient’s insurance or might decline to treat patients who haven’t received certain vaccines because that patient could pose a risk to the doctor or the health of other patients.

Yet “in the ER, there’s a federal law that says you have to accept anybody, even if they have no money, and stabilize them. It’s called EMTALA, and it’s been around for a while,” Caplan said.

“Rationing health care is not new in the American health care system,” he added. “It’s just Covid that’s new, but not rationing.”

Who receives an ICU bed?

The Emergency Medical Treatment and Labor Act or EMTALA requires hospitals with emergency departments to provide a medical screening exam to any person who comes to the emergency department and requests care. The law also prohibits hospitals with emergency departments from refusing to examine or treat people with emergency medical conditions.

Now, during the pandemic, many of the Covid-19 patients filling hospital beds are unvaccinated. EMTALA obligations remain in place.

As Covid-19 hospitalizations spike, some overwhelmed hospitals are rationing care

“Hospitals generally do not take into account why a gravely ill patient is there,” Caplan said. “The way in which it might become relevant is if you thought it was a predictor of a bad outcome.”

For instance, if a hospital is short on beds or mechanical ventilators, they can prioritize care for patients who are seen as more likely to respond to the care and survive — meaning a 26-year-old Covid-19 patient with no underlying health conditions could be prioritized for care over a 90-year-old patient with lung failure and other medical problems, Caplan said.

“Or, if being unvaccinated and having lung failure puts you at a worse chance of survival versus someone who just comes in with asthma and lung problems but are vaccinated,” Caplan said. “Many places would give priority to the vaccinated asthma patient as opposed to the unvaccinated lung failure patient. What they’re watching is outcome and likelihood of success.”

My son was lucky to get a pediatric ICU bed when he needed one. He shouldn't have needed luck

In hospitals that are so overwhelmed that they have to ration care, those decisions should not be based on whether or not a person chose to get vaccinated against Covid-19, Dr. Anthony Fauci said Thursday.

“If you’re asking, should you preference it for a vaccinated person versus an unvaccinated person, that is something that is always widely discussed, but in medicine I know that you don’t prejudice against someone because of their behavior,” Fauci, director of the National Institute of Allergy and Infectious Diseases, told CNN’s Anderson Cooper.

“You just don’t do that in medicine,” Fauci said.

Fauci added that the decision about where to direct “scarce resources” must be based on a “medically sound” reason, “not in a punitive way for someone’s behavior.”

‘We’re in a situation of limited resources’

Throughout the pandemic, Covid-19 has strained the US health care system — and hospitals continue to face difficult decisions on which patient takes priority when staffing is low and beds are full.

“We’re already making those choices and they’re very difficult choices. I work in the intensive care unit. Many people have serious illnesses but not illnesses where they’re going to die immediately, but serious illnesses where they need an operation and some of these operations are so serious that after surgery, they need to be in the intensive care unit for a day or two — replacement of a heart valve, surgery for serious cancers like pancreatic cancer,” Dr. Steven Brown, a critical care pulmonologist at Mercy Virtual Care Center in St. Louis, told CNN’s Ana Cabrera on Thursday.

“If the intensive care unit beds are all filled up with patients who are on ventilators because of their pneumonia, surgeries have to be postponed,” Brown said. “We have situations where people may come into the hospital with a heart attack, and they have to stay in the emergency room for extended periods of time while waiting for a bed to open up.”

Unfortunately, in some cases, for a bed to become available means a patient has died.

“It’s a sad situation that we really haven’t seen in American history in a very, very long time.” Brown said. “We’re in a situation of limited resources now, and when you have limited resources, we are in triage situations — and some people may die as a consequence of this.” (F)

“Some hospitals in Central California are still so overwhelmed with COVID-19 patients that some critically ill people are waiting days to be transferred into the intensive care unit from the emergency room, officials said.

One Fresno area hospital had nine critically ill patients who were unable to get into the intensive care unit for more than three days, interim health officer Dr. Rais Vohra said at a news conference this week. This forces emergency room staff to treat patients needing ICU care, disrupting the healthcare of other patients with less severe illness.

“We’re basically really straining what the emergency department has to do,” Vohra said. “We still anticipate at least a few more weeks of thoroughly impacted operations” in ICUs and emergency rooms.

Hospitals in Fresno County are teetering on the need to ration healthcare and implement “crisis standards of care,” Vohra said. In these situations, hospitals conclude that they can no longer provide the same standard of healthcare to everyone, and must choose whose lives to prioritize to keep as many patients alive as possible.

“We’re still just right there where we’re looking at things on a day-by-day — and even hour-by-hour — basis to see how we can match the resources with the needs,” Vohra said.

In Fresno County and the greater San Joaquin Valley, hospitals remain extremely busy, said Dan Lynch, director of the Central California Emergency Medical Services Agency. Most of Fresno County’s hospitals are running at 108% to 110% of standard capacity, while Clovis Community Medical Center near Fresno has been running at 130% of capacity.

“It just means that they’ve got patients in nooks and crannies throughout that hospital. And they’re taking advantage of every, every place they can to place patients safely,” Lynch said of the Clovis hospital. “We’re providing them with as much staff, and they’re finding staff from outside the state and other areas of the state of California to help them staff those beds.”

Officials have been forced to extend the policy by which not all patients calling 911 will be transported to emergency rooms if they don’t meet certain criteria to be transported. EMS officials had been hoping to relax that policy, but emergency rooms remain overwhelmed.

Lynch said he’s been pleading with federal officials to bring in additional staffing to support the hospitals.

Some help has arrived, in the form of several National Guard teams in the region, comprised of nurses and emergency medical technicians who can help aid emergency rooms.

But Lynch is still seeking federal medical teams who can provide the kind of care needed in intensive care units, “which is really what’s needed so we can expand our ICU surge beds. We have the capability of adding ICU beds to some of our hospitals — we just don’t have a staffing to do it. And that’s what those federal teams would do.” “(G)

With COVID cases surging in Idaho’s panhandle and hospitals there exceeding capacity, the state of Idaho recently activated its crisis standards of care. That means care is not guaranteed for everyone. Instead, doctors are advised to treat patients who are most likely to survive — not necessarily those whose conditions are most critical. The goal by doing that is saving as many lives as possible while space is limited.

But in Oregon, such crisis care standards no longer exist.

“A pandemic is the time when you absolutely need crisis standards of care in place,” said Becky Hultberg, president and CEO of the Oregon Association of Hospitals and Health Systems. “So for us to not have them right now is really troubling.”

Hultberg said having a crisis standards of care document is important for healthcare workers in Oregon as well as patients. She believes everyone should understand how care will always be delivered when resources can no longer meet demand.

“We’re not having to allocate a scarce resource like a ventilator at this point, but having the guidance in place gives clinicians the path forward to making these really tough decisions.”

Oregon had a crisis standards of care document with that guidance in 2018. But last year, the state said the document was discriminatory.

In December of 2020, the Oregon Health Authority (OHA) replaced the crisis care standards document with four “crisis care principles,” which they developed with community input. Those principles are non-discrimination, health equity, patient-led decision making and transparent communications.

An Oregon Health Authority spokesperson told KGW that no new crisis guidelines are in development and that they expect health care providers to apply the principles. OHA also shared the following statement:

“Oregon has developed a set of crisis care principles to help guide health care providers in the event that they have to make heart-wrenching, life-and-death decisions if hospitals reach the point where they are overwhelmed with more patients than they can treat. OHA worked closely with community voices from across Oregon to ensure these difficult decisions are made in a way that is transparent, is not discriminatory and fully involves patients and families.

Hospitals can implement crisis care standards on their own — and triage decisions are just one step Oregon empowers hospitals to take to respond to a public health crisis. They can suspend elective procedures, alter staffing and take other steps that can help prevent hospitals from reaching a point where they are forced to ration care. They do not need to rely on a declaration from state health officials.

We can save lives and we can stem the crisis facing hospitals if more Oregonians get vaccinated against COVID-19 and wear masks when they’re in public places. However, if any Oregon hospitals have to make these difficult decisions, state health officials will work with providers to keep the public informed. We want patients and families to be fully informed about the principles health care providers are expected to apply, the rights of patients and the avenues families can use to report their concerns to state regulators and independent advocacy organizations.”

While Hultberg agrees that the 2018 guidance needed revision, she believes the state still needs actual crisis care standards both for now and in the future. She does not believe the list of principles on its own, provides the kind of detailed information that would help clinicians during a crisis.

“These are wrenching choices to make but avoiding the conversation does not solve the problem,” said Hultberg. “We have to be prepared for our hospitals to respond if we see another surge or if we see an earthquake or some other kind of natural disaster.”” (H)

“The state’s plan on how to allocate medical care during times of a crisis was made available for the public to read on Wednesday, Sept. 15.

The Hawaii Department of Health (DOH) said its Crisis Standards of Care Triage Allocation Framework was created in 2020. It included input from healthcare providers across the state, and it was done in preparation for if the state ever found itself in a serious COVID situation.

“It’s something that I reject out of hand, the process to discuss and think about is ok, but Hawaii should never ration care, and of course it created a lot of fear,” said Lt. Gov. Josh Green, who is also an emergency room physician.

“So I thought that someone had to speak up. It created fear amongst our kupuna because in the plan, there was consideration for rationing care under certain circumstances, severe shortages to the elderly, and that’s not anything we could accept,” he continued.

The 36-page public document laid out a scoring system that healthcare facilities would use if they were ever faced with a triage situation.

According to the document:

Advanced age was rejected as a primary triage criterion because it discriminates against the elderly. Age already factors indirectly into any criteria that assess the overall health of an individual because the likelihood of having chronic medical conditions increases with age and there are many instances where an older person could have a better clinical outlook than a younger person. Thus, clinical factors (with the exception of the COVID-19 disease-specific age criterion based upon the known poor prognosis with older age) will be used to evaluate a patient’s likelihood of survival and to determine the patient’s triage priority unless there is a case of equal priority and can be a factor in as a “tie-breaker.”

The document also added that age would only be used if a situation resulted in the need for a tie-breaker.

“Age is used only in a tie-breaking situation. Evidence from multiple countries including the U.S. shows that age >65 yo is an indicator for poor prognosis in COVID-19 patients. If the triage score is equal between two individuals, the Triage Officer/Review Committee should use the consideration that a patient >65 yo who is also COVID-positive is less likely to benefit from the scarce resource.”

Green said he received dozens of phone calls from kupuna after the document was released.

“When a 75-year-old woman reaches out to you, and she’s afraid that if she gets sick, she won’t be able to go to the hospital for life-saving care, that’s when you know you’ve made a mistake,” Green said of the document’s release.

Two weeks ago, Oahu hospitals were at a critical state when there were nearly 450 COVID-patients hospitalized, and triage tents were set up at most major hospitals to handle any overflow.

Hawaii reports 569 COVID cases, 8 new deaths

Hospitalizations have dropped 30% since then.

“I think that it’s important that everyone realizes we will not need to ration care, I will fight against it,” Green said. “It was terrible, it’s a terrible idea in Hawaii to ever rationed care because, as I said several times, we should move heaven and earth before we ever tell someone they can’t get care.”

Green suggested using other facilities by bringing in hundreds of additional federal care nurses and physicians, using monoclonal antibody treatment and utilizing long-term care facilities before considering rationing care.

“All of those are possible solutions before we’d ever tell someone your mom or dad, or your elderly grandfather, does not qualify for care, we should never do that,” he continued. “ (I)

“During the current delta-driven Covid-19 wave, Americans are being transported hundreds of miles from their homes because no nearby hospital has room for them. Some of them have even died waiting for medical attention.

In other words, US hospitals are being forced — in the middle of a public health emergency — to ration health care for their patients.

Rationing has long been a dirty word in US health policy, used as an attack on any socialized health program that more centrally determines which medical services will be covered and for whom. The US health system has always rationed care through cost: It’s de facto rationing when a patient doesn’t get the medical care they need because they can’t pay out-of-pocket costs or because they live in a rural community without a facility nearby.

“We’re so used to rationing by ability-to-pay in this country that classic capacity rationing feels a bit foreign,” Hannah Neprash, a health economist at the University of Minnesota, said in an email.

The delta variant, more contagious and virulent than its predecessors, and America’s lagging vaccination rates are driving the current crisis.

The states with the worst outbreaks in confirmed cases per capita right now — Tennessee, Kentucky, Alaska, Wyoming, and West Virginia, according to the New York Times’s tracker — have either set new hospitalization records in the last several weeks or are near their previous highs from the winter wave. All of them have vaccination rates below the national average. Throughout the South, hospitals are reporting they have more patients in need of ICU care than ICU beds available, as the Times reported on Tuesday.

America, the richest country in the world, is not supposed to be a place where patients are left at the door to die. Yet that is exactly what’s happening now — 18 months into the pandemic.

The US health system wasn’t built to withstand a pandemic

Many parts of the American health system have struggled to handle the pandemic. The current hospitalization crisis is just the latest iteration of an institutional failure.

The United States still has a lot of unvaccinated people who are fully vulnerable to the delta variant of the novel coronavirus, which is more transmissible and may cause more virulent disease. One in four people over 18 still haven’t received any dose of a Covid-19 vaccine, and younger age cohorts have lower vaccination rates than their elders. As a result, there has been a shift in who’s being hospitalized: People over 65 made up more than half of hospitalizations in December and January; now they are about a third. Children under 12 still are not eligible for the vaccines, and pediatric hospitals are seeing their highest number of Covid-19 patients ever.

But while the demographics of the people being hospitalized may have shifted, the sheer number of people getting severely ill with Covid-19 and ending up in the hospital is almost as high as it has ever been.

Texas, to give one example, has nearly matched its winter peak with more than 14,200 people currently hospitalized with Covid-19. More than 90 percent of the state’s ICU beds are occupied, according to Covid Act Now. In Idaho, with about 88 percent of ICU beds in use, hospitals had to activate what is known as “crisis” standards of care. That gives them more discretion to prioritize the patients most likely to survive for ICU beds and other treatment.

In Bellville, Texas, 46-year-old military veteran Daniel Wilkinson was rushed to the emergency room. He was diagnosed with gallstone pancreatitis, which is treatable but which his local hospital was not equipped to treat, according to KPRC. The doctor called all over the region — to hospitals in Texas, Oklahoma, and Arkansas, among others — but could not find a hospital that would take him. Those states currently have some of the highest Covid-19 hospitalization rates in the country.

An ICU bed was eventually located at a Houston Veterans Administration hospital, more than an hour away from Bellville. But Wilkinson’s organs started failing on the helicopter ride there and he died. It had been more than seven hours since his mother first brought him to the local ER.

There are more stories like Wilkinson’s across the United States. On Monday, the Washington Post reported that a 73-year-old Alabama man died of a cardiac emergency after being turned away from more than 40 hospitals. The closest hospital that would take him was 200 miles away in Mississippi. Alabama is currently experiencing the second-most Covid-19 hospitalizations per capita in the nation.

Hospitals are trying to balance handling a new Covid-19 surge with providing medical care to all of the other patients who need their attention. But that has required them to make some hard choices.

Karen Joynt Maddox, a practicing physician and health policy researcher at Washington University in St. Louis, said her local hospital was instructed during the pandemic not to take patients from small rural facilities unless absolutely medically necessary, which at times has meant rejecting transfer requests made by family members.

The US does not have a lot of hospital beds compared to many other wealthy countries; about 2.9 per 1,000 people compared to the average of 4.6, according to the Peterson-Kaiser Health System Tracker.

There are some good reasons for that: Over the decades, more medical services have been shifted from inpatient to outpatient settings in order to save costs. But that still ended up shrinking the number of hospital beds available in a once-in-a-lifetime emergency.

We wouldn’t necessarily want the US health system to always be flush with excess hospital capacity, some experts contend. It would cost substantial funding to maintain. But even in normal times, urban hospitals will operate at near 100 percent capacity while rural hospitals sit with half their beds open.

“We have beds, just not in the right places,” Joynt Maddox said, “and with no system to try to use the available beds as rationally as possible.”

The current crisis has revealed how disorganized the US health system truly is. American hospitals don’t have a reliable revenue stream, as hospitals do in countries with budgets that pay providers a predictable amount of money every year.

And there is no central authority to help manage the patient load when US hospitals are overwhelmed; Daniel Wilkinson’s doctor made those calls on his own. As NPR reported, local hospital leaders across the country have been left making desperate pleas to other facilities hundreds of miles away.

Other wealthy nations were better equipped to handle their Covid-19 surges

That disorganization is what distinguishes the US from other wealthy countries with different health systems — and arguably contributed to some of these terrible outcomes.

America is not alone in being tested by the coronavirus. Other wealthy nations saw their hospitals strained in the pandemic, especially early on, when countries like Italy endured some of the worst initial coronavirus outbreaks.

But a year and a half into the pandemic, those other countries appear better equipped to handle the load, aided by both higher vaccination rates and more cohesive health systems.

The US is mediocre in terms of hospital capacity, but it’s not at the bottom among its economic peers. Both Canada and the United Kingdom, with government-run health programs for every citizen, actually have slightly fewer hospital beds per capita.

And they neared their limits during the worst waves of the pandemic. The UK’s National Health Service was forced to transfer ICU patients to less congested areas during the fall and winter surges. In Ontario, more than 2,500 patients have been moved to other cities in order to receive lifesaving care. Even in France, which has significantly more hospital beds per capita than the US, more than 100 Covid-19 patients had to be evacuated as Paris hospitals ran low on beds.

These are not quite the same horror stories as we are seeing in the US, however, because there was a stronger level of coordination among the hospitals. In all of these international cases, either the national or local government managed the movement of patients.

No such system exists in the US; it is largely done informally. I spoke with a California hospital executive last summer who had to call a nearby hospital himself, looking for a ventilator when his facility was running low on those lifesaving machines.

Other countries appear to have avoided unnecessary deaths because they have a real system to coordinate care. In Britain, hospitals are currently able to handle more emergency care than the average volume prior to the pandemic, according to recent research by the Nuffield Trust, though elective surgeries are still sometimes being canceled.

“Hospitals have been incredibly stretched but have always been able to offer urgent and emergency care,” Nick Scriven, a UK doctor and past president of the Society of Acute Medicine, told me. “People were not turned away if they needed a hospital bed.”

The pandemic laid bare how disastrously disorganized the US health system is. But that’s always been true. It just usually reveals itself in more subtle ways.

An overwhelmed ER in a downtown urban setting might lead to some patients leaving without being seen. Low staffing at certain times — US hospitals stand out from their international peers because they have more administrative staff and less medical staff — appears to lead to worse outcomes. And then you have the higher out-of-pocket costs borne by Americans, which have been shown to lead to people skipping or postponing necessary medical care.

As Ezra Klein wrote for Vox last year, in covering the UK’s National Health Service, every health system rations care. There are not unlimited resources. But while in the US that rationing occurs in subtle and haphazard ways, other countries have tried to build a more rational system for managing their medical capacity.

That left them better positioned to handle surges of sick patients during the pandemic. America is paying the price for its failure to do the same thing.” (J)

“On Sept. 7, the country’s leading COVID-19 doctor issued a dire warning about the growing number of pandemic cases in the country, and the shrinking number of ICU beds available to care for the sickest people. Speaking on CNN, Dr. Anthony Fauci, the chief White House medical advisor, said we are “perilously close in certain areas of the country of getting so close to having full occupancy that you’re going to be in a situation where you’re going to have to make some tough choices.”

Those tough choices, he admitted, include discussions about whether scarce resources should go to people who haven’t been vaccinated, and the difficult ethical questions about personal choice that rationing crises raise. Doctors and hospital administrators are making heart-breaking decisions about who gets access to the increasingly few ICU beds. Should vaccinated people take precedence? Should people who followed mask and social distancing recommendations be prioritized over people who flouted these public health guidelines? While Fauci said such factors should not factor into a person’s care, he acknowledged that faced with such difficult choices, inevitably, “there’s talk of that.”

In some states, hospitals have already descended into the negative numbers for ICU beds, meaning they have more patients than beds available. In the U.S., as of Sept. 9, 80% of ICU beds are occupied, with 31% of them filled by patients with COVID-19, according to data collected by the Department of Health and Human Services. Those data also show that 100% of ICU beds in Alabama are occupied, but Dr. Karen Landers, assistant state health officer at the Alabama Department of Public Health, said to TIME in an email that the situation is actually worse. The state “reports that Alabama hospitals are in the negative zone in terms of ICU beds,” she writes. “Alabama hospitals have more ICU patients than ICU beds. Alabama has asked for and received Federal assets for care teams in Southwest and Southeast Alabama in the last two weeks.”

In the vast majority of states, at least 60% or more of those beds are filled with patients, most of them battling COVID-19. As of Sept. 9, more than half a dozen states reported that 90% or more of its ICU beds were occupied.

The strain pushes hospital directors into an ethical corner: how to decide which of the extremely limited beds and staff should go to which patients. In Idaho, where 90% of ICU beds in the state are full, the governor on Sept. 7 declared, for the first time in the state’s history, that the northern regions would now operate under “crisis standards of care,” which means normal standards of care that hospitals provide are preempted by other pressing factors, most notably the scarcity of equipment, beds, and health care staff. The declaration minimizes liability for doctors, nurses, health care workers and hospitals if they can’t respond with the same level of care and resources as they normally would. “Crisis standards of care is a last resort,” said Dave Jeppesen, director of the Idaho Department of Health and Welfare, which made the decision, in a statement.

Because it’s the first time that the emergency standard is being applied, “things are pretty fluid as we are still figuring out what it all means for us,” says Kimberly Johnson, director of communications and marketing for St. Mary’s Health, a 23-bed community hospital in Cottonwood, Idaho. Any decision about allocating limited medical equipment or services to patients goes to the hospital’s triage team, which involves an ethics committee that applies an intricate algorithm that takes into account the patient’s age, health status, family situation and more. It’s not perfect by any means, but gives doctors some foundation on which they can make those seemingly impossible decisions about who receives care and when.

“We are robbing Peter to pay Paul,” says Johnson. “We are wheeling and dealing to find beds, asking other hospitals to take our very acute patients if we can take their less acute ones.” Johnson says doctors have called facilities as far as Utah and San Francisco to find beds for their critical care patients when none were available in the northern part of Idaho last week.

Meanwhile, hospitals need to find ways to free up room for those less acute cases. At Kootenai Health, one of the Idaho hospitals affected by the new standards, officials turned the hospital’s health resource center into a temporary patient care unit to absorb those with less urgent needs. Hospitals in Florida were forced to do the same, converting cafeterias into patient wards to accommodate less urgent cases.

But what if there are no such valves to reduce the pressure on the critical care system? In those situations, says David Magnus, director of the Center for Biomedical Ethics at Stanford University, long-standing principles of utilitarianism, prioritization and egalitarianism apply. Different institutes may come up with varying algorithms that balance these concepts in different ways, with some preferring to focus on addressing social and cultural discrimination while others prioritize life years that a younger, healthy person may have yet to live over absolute number of lives saved. These principles have guided medical decision making of scarce resources, most notably in distributing organs for transplantation, for decades. That doesn’t make allocation decisions any easier, he notes, and rationing may grow more necessary in coming weeks and months as COVID-19 continues to spread.

Should vaccinated patients get priority?

The shadow that hovers over the current threat of rationing is the fact that this blow to the health care system was essentially avoidable and solvable. “We are having the same conversation that we had in April 2020. It’s disheartening; we are back where we were a year and a half ago,” says Jeffrey Kahn, director of the Johns Hopkins Berman Institute of Bioethics. “It didn’t have to be this way.”

Unlike during the previous crush on the health care system during the first and second COVID-19 waves, one of the factors driving the flood of ICU cases this time around are people who have not been vaccinated against COVID-19. It’s no coincidence that the states with the highest ICU bed occupancies are also those with relatively low vaccination coverage; in Georgia, where 99% of ICU beds are now full, 42% of the population is fully vaccinated, and in Alabama, where hospitals can no longer find beds for patients who need ICU care, 39% of the residents are vaccinated; Wyoming has a similar vaccination rate, which is the lowest in the country. In a plea on the state’s department of public health website, Alabama’s Landers noted that “given the shortage of ICU beds in Alabama, Alabama Department of Public Health continues to remind the general public of mitigation standards to reduce COVID-19 as well as the need for all persons ages 12 and above to be vaccinated.”

Still, ethicists and medical professionals agree that people’s behavior is not an acceptable factor to consider in making rationing decisions, as emotionally difficult as that may be to implement. “It’s understandable why physicians, nurses, respiratory therapists, social workers, food service and environmental workers and everybody who works in a health system are frustrated and angry toward the unvaccinated,” says Magnus. “They are facing another surge, and have had a miserable year and a half. And instead of being over, we’re back to square one. There is a sense that this time, we didn’t have to have this, and yet here we are again. So, the emotions are very understandable. But the mere fact that their behavior may have contributed to why people are sick and needing access to critical care resources is not a reason to discriminate [against] them by itself.”

Inevitably, patients who flouted public health guidelines to wear masks, avoid indoor public gatherings, and maintain social distancing will be vying for the same ICU beds as patients who followed them faithfully; but adherence to these guidelines should not play any role in determining who gets care. “The truth is that we provide care to diabetics who are non-compliant [with their dietary advice] and medication, and we provide critical care to smokers who develop heart disease,” says Johnson from St. Mary’s in Idaho. “Not having a vaccination is not a reason to not provide care; it’s not a consideration in our algorithms for how we provide care.”

The chokepoints on the horizon

Those algorithms will be tested to their limits in coming weeks. Even more urgent than the dwindling number of ICU beds is the shortage of ECMO units. For patients who can’t breathe well, extracorporeal membrane oxygen machines act as a mechanical set of heart and lungs to pump oxygenated blood through the body, similar to the heart-lung bypass machines surgeons use during heart bypass surgery. Many of the younger patients now affected by COVID-19 aren’t improving on ventilators—which only provide mechanical breathing assistance but still rely on patients’ lungs to do most of the work—and often require an ECMO. But even before the pandemic, ECMO machines were not widely available. In northern California, where about 7 million people live, there are 40 ECMO beds; Kaiser Permanente’s six beds are already full, and Stanford receives four to five requests for ECMO daily. “There is just not anywhere near enough of this resource to go around,” Magnus says.

In addition, ECMO was first used primarily in treating pediatric patients, and only recently became an option for adults, which means that fewer machines calibrated for adults, as well as fewer specially trained nurses, are available to treat adult ECMO patients—a single patient on ECMO requires a team of three specially trained nurses on duty 24 hours a day. That means that guidelines for helping doctors navigate who should receive ECMO when supply is scarce aren’t as robust as they are for rationing ventilators or ICU beds. “We have similar principles, but I don’t think the processes are as well developed for making decisions in a transparent way and with any type of community engagement,” says Magnus.

Staffing in ICU units is becoming another choke point on the already strained critical care system. Even if ICUs beds are available, the trained staff to care for patients occupying them may not be.

In Florida, when hospitalizations during this latest surge hit their peak in late August, hospitals scrambled to find doctors and nurses to staff the overflowing ICUs. It’s a catch-as-catch-can system that needs better coordination, says Mary Mayhew, president and CEO of the Florida Hospital Association. Having a database of health care professionals from neighboring states who are licensed and ready to fill in during emergency shortages would be a useful lesson learned from the pandemic experience. Already, many states participate in nursing compacts that enable nurses to work outside of the state in which they’re licensed. “We need better information about the number of individuals who have those compact licenses, and a repository that is regularly updated of individuals who have indicated an interest or willingness to support whatever current or future needs may be,” Mayhew says. “It points to an opportunity post-pandemic to evaluate where there are still unnecessary barriers to timely access to staff.”

In the meantime, Fauci stressed that getting vaccinated could help to alleviate some of the burden on ICU wards, as well as avoid those wrenching rationing decisions, as we enter the fall and winter, when students are back in school and colder weather means more people will be spending time indoors where not just SARS-CoV-2, but other respiratory viruses like influenza can take hold and spread. Studies show that fully vaccinated people are better protected against COVID-19, and far less likely than unvaccinated people to develop severe disease that requires ICU or even hospital care. But if the numbers of unvaccinated people remain high, the reality is that the fast-spreading Delta variant will find a way to bury deeper in communities not just in the U.S. but around the world. And with finite medical resources available to care for the sickest patients, rationing will become a hard truth. “Everybody who talks about this really hopes we never have to do this,” says Kahn.” (K)

“From April through June 2020, New York City hospitals were overwhelmed by COVID-19 patients, and now, a working group of 15 hospital intensive care unit directors and the Johns Hopkins Center for Health Security have reported on the successes and failures of that time.

“Crisis Standards of Care: Lessons from New York City Hospitals’ COVID-19 Experience” determined that crisis standards of care (CSC) planning did not always match actual clinical needs during the pandemic, and though the response to surging COVID-19 cases was effective, it was often chaotic. Notably, this was the first time CSC measures were implemented by hospitals on a large and prolonged scale since their development by the National Academy of Medicine 11 years ago.

As hospitals shifted from conventional standards of care, inter-hospital collaboration proved successful even as situational awareness stumbled. Decision-making for triage and allocation of life-sustaining care proved difficult for many to process, and healthcare workers themselves proved very susceptible to and affected by the psychological strain of dealing with CSC issues as the surge continued.

The researchers determined that the lessons from this time could help other hospital systems, however, as COVID-19 hospitalizations rapidly rise again across the country. They believe that CSC planning needs to be more operational, with greater involvement from clinicians, who need to be shown that the process is not limited to things like ventilator triage. The researchers stated that it is essentially about making the best decision when in an unfamiliar situation involving risk to a patient or provider.

A formal declaration is needed for crises — one that clearly lays out guidance about the scope of the declaration and the researchers or processes to which it applies. Better situational awareness of patient load, resources, and changing guidance is necessary, and so are ways of inter-staff communication. Speed is key, and as such, triage decisions should be taken out of committee hands and instead involve the treating physician and others. Emotional support for healthcare workers is needed, but so is planning for staff shortages as the pandemic wreaks its toll.” (L)

“Our analysis of HHS and CDC data indicates there were 32,000 preventable COVID-19 hospitalizations in June, 68,000 preventable COVID-19 hospitalizations in July, and another 187,000 preventable COVID-19 hospitalizations among unvaccinated adults in the U.S. in August, for a total of 287,000 across the three months. We explain more on how we arrived at these numbers below.

If each of these preventable hospitalizations cost roughly $20,000, on average, that would mean these largely avoidable hospitalizations have already cost billions of dollars since the beginning of June.

From June through August 2021, preventable COVID-19 hospitalizations among unvaccinated adults cost over $5 Billion

Based on our estimates, described below, we find preventable COVID-19 hospitalizations cost $5.7 billion from June to August in 2021.

We used counts of adult hospitalizations with confirmed COVID-19 in recent months reported to HHS to estimate preventable hospitalization costs for unvaccinated adults. We focus on hospitalizations of adults (ages 18+) with COVID-19 because many children are still ineligible for the COVID-19 vaccine, and even those minors who are eligible may need parental consent to get the vaccine. We made assumptions that result in a conservative estimate of costs attributable to preventable, unvaccinated hospitalizations.

Over 280,000 COVID-19 hospitalizations could have been prevented by vaccination between June to August 2021…” (M)


POST 187. August 11, 2021. CORONAVIRUS. “As a result of the increase in COVID-19 cases and hospitalizations, the state of Florida requested 300 ventilators from the federal government.”… “An 11-month-old girl with Covid-19 is stable and no longer intubated one day after she was airlifted to a Texas hospital 150 miles away because of a shortage of pediatric beds in the Houston area.”

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.”

POST 190, August 21, 2021. CORONAVIRUS. “We’re looking, in essence, at running two systems — a COVID system and a non-COVID system of care,”..“Emergency medical technicians (EMTs) and certified paramedics can now care for patients in Mississippi hospitals and emergency rooms under a new health office order issued by the Mississippi State Department of Health on Wednesday.”

POST 195. September 6, 2021. CORONAVIRUS. “…there are “zero ICU beds left for children in Dallas County, Texas,”.,..”That means if your child’s in a car wreck, if your child has a congenital heart defect or something and needs an ICU bed, or more likely if they have Covid and need an ICU bed, we don’t have one. Your child will wait for another child to die… (county judge Clay Jenkins)

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..”


  1. Wm May

    Who else thinks that the information reported in the article is a bit out of date? Don’t we have absolutely different figures now? I googled several comparing sites and all of them provided different details. Best of all was COMPACOM review. Only verified information, references to trusted sources, examples, and case studies really attracted my attention.

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