What Are 'Crisis Standards of Care'? Experts Explain How Patients Are Prioritized Amid COVID Surges
A dire situation is unfolding in Alaska, where a surge of COVID-19 cases is forcing doctors to prioritize the care of some patients over others, reports the Associated Press. As of October 5, according to data tracked by the New York Times, the state has the highest number of COVID-19 cases per capita in the nation. For people in rural Alaska requiring higher levels of care, it is hit or miss: sometimes they're transferred to hospitals in Anchorage or Fairbanks; other times they must wait hours for a facility or bed to open—or, in a couple of cases, die waiting, per the AP report.
Alaska is not alone in dealing with COVID's chokehold on hospital resources. An Alabama man, Ray DeMonia, died last month after staff at Rush Foundation Hospital in Meridian contacted 43 hospitals in three states in search of a cardiac ICU bed, the man's family wrote in his obituary. The family urged others to honor their loved one (whose death was attributed to a cardiac event) by getting vaccinated against COVID "to free up resources for non COVID related emergencies."
Since the start of the pandemic, hospitals across the country have been strained as they attempt to care for more patients amidst limited resources. Now, as the country approaches the second full year of the pandemic, several states and regions have enacted "crisis standards of care"—or protocols to help full or near-full hospital prioritize certain patients over others, what some would call health care rationing.
So far, parts of Alaska and Montana and the entire state of Idaho have officially deployed crisis standards, per news reports. And experts say other states—especially those with COVID-19 outbreaks—are near the brink as hospitals continue to see an uptick in patients who need critical care. While some hospitals have had to turn away patients, how and when clinicians treat patients can vary widely depending on the severity of the local crisis.
Here's what you need to know about crisis standards of care—and how they could affect you—according to experts.
What are crisis standards of care?
All health care organizations have standards of care, or guidelines they follow to treat patients. Arthur L. Caplan, PhD, a professor of bioethics at NYU Grossman School of Medicine in New York City, says these standards are usually set by medical societies specific to a doctor's specialty, research literature, or common behaviors of other doctors in the same field.
These standard procedures protect health care providers from liability if a patient sues for malpractice. "If a doctor prescribes a medication off-label and something goes wrong, they could be liable if it's out of step with the majority opinion of specialists in the area," Caplan says. In an emergency, like the pandemic, doctors may need to deviate from normal procedures to effectively care for their patients. Caplan says enacting crisis standards of care can protect clinicians from liability when resources are scarce—say, sharing one ventilator between two patients or prioritizing one patient over another.
According to Caplan, crisis standards are usually officially enacted when states get overwhelmed; it doesn't happen in places where hospitals aren't full. A number of factors, such as a state or region's vaccination rate or the number of hospitals in the area, affect hospital capacity. "That tends to be the driver, when hospitals have 'ICU overwhelm,' they want legal relief from their triage decisions," Caplan says.
When hospitals turn people away or delay care
That said, crisis standards aren't always official. Andra Blomkalns, MD, a professor of emergency medicine at Stanford Medicine and an emergency medicine physician with Stanford Health Care in California, says it's fairly rare that true crisis standards of care are deployed. But hospitals make crisis decisions big and small all the time.
On the extreme end, doctors may have to turn away patients. Dr. Blomklans says strained emergency departments may not take stable patients that can get care later—for example, if you have a cut or a break, a hospital in flux would prioritize someone with pneumonia or a heart attack. "We try to defer things that can be cared for later or give people instructions on when to come back," she says.
In less severe cases, hospitals may reuse PPE in a shortage or reschedule elective surgeries to save hospital beds for people in crisis. "It's not that all of a sudden people will be dying in the streets," Dr. Blomkalns says. "If resources aren't there we do our very best, but sometimes we have to breach our existing standards of care."
The difference is that crisis standards are more regulated when they're enacted by the government. For example, Emily C. Cleveland Manchanda, MD, MPH, assistant professor of emergency medicine at Boston University School of Medicine and director for equity initiatives at Boston Medical Center, said the Massachusetts government mandated that hospitals notify it if they were close to enacting crisis standards so they could help identify resources to help more patients.
Plenty of beds—but too few caregivers
Crisis standards of care come into play when the demand for care outpaces resources to provide that care. According to Dr. Blomkalns, the goal is the same as ordinary times: to provide the best care with the resources you have, or to help the most people.
A number of factors play into why crisis standards might be deployed and whether a state or region might face them. At this stage in the pandemic, Dr. Manchanda says surges—and crisis standards—are only happening in places where the population isn't effectively following evidence-based strategies for containing the pandemic.
Hospitals that treat historically marginalized patients; smaller, rural hospitals without critical care resources; and places with lower vaccination rates are more likely to have full ICUs. Delaying preventative care during the pandemic could also result in a higher number of non-COVID emergencies, says Troy Clark, president and CEO at the New Mexico Hospital Association. Beyond rationing physical space and equipment, many hospitals are working with less staff.
Beth Feldpush, senior VP of policy and advocacy at the American Hospital Association, says many health care professionals are quitting or retiring due to burnout at the same time as a patient influx. "We've heard from hospitals that they've had to take beds offline, so while there's space for patients, there aren't enough caregivers to accept patients in," she says.
In light of heightened clinician burnout, some hospitals are trying to balance the current, ongoing demand with a long-term perspective. "So many people are exiting the medical workforce, and we have to ration their energy so we can still take care of people in five years," says Dr. Blomkalns.
How hospitals respond to crisis situations depends on what patients need and which resources are scarce. In states with formal crisis standards, clinicians may have to turn away patients altogether. "Someone who is otherwise healthy and would recover more rapidly may get treated or have access to a ventilator before someone who is not likely to recover," Idaho's Department of Health and Welfare recently told residents in a news release.
'These are super messy decisions'
In the rare event a hospital has to ration care, Dr. Manchanda says doctors usually rely on formal crisis policies created at the state level with input from hospital associations, emergency preparedness experts, frontline physicians, and ethicists. In ICUs, rationing decisions are often made based on a score called SOFA, or sequential organ failure assessment, which aims to predict patient mortality.
But the scoring system isn't perfect or necessarily applicable in all scenarios. Dr. Manchanda says it was created to assess people's likelihood of surviving an infection. "We don't have any data that SOFA scores accurately predict survival for people who had a stroke or were in a car accident," she says.
The scoring system also overestimates the survival of white people, so it could be inherently racially biased, says Dr. Manchanda. "It's probably the best tool we have for predicting survival in a viral pandemic, but we don't know how it applies to other forms of critical illness and who's at an advantage or disadvantage," she says.
In many cases, external boards help physicians decide who gets care so patients aren't at the mercy of one clinician's emotions. If two COVID-19 patients need an ICU bed, Caplan says a doctor could theoretically deprioritize a patient who hasn't been vaccinated. According to Dr. Manchanda, external boards help prevent decisions driven by personal bias.
Leslie Scheunemann, MD, assistant professor of geriatrics and pulmonary and critical care at the University of Pittsburgh School of Medicine, says many clinicians are aware of systemic factors contributing to people's vaccination status, and that while it may be frustrating, most clinicians are doing their best to care for patients objectively.
"These are super messy decisions," says" Dr. Scheunemann.
'If you don't have an ICU with beds in the area, you're kind of stuck'
Federal law requires level-one trauma centers to stabilize people in the emergency department, but Caplan says there's no law about admitting people to the hospital or ICU. "If someone's having a heart attack and they're stable, you could kick them out," he says.
States aren't under any obligation to take spillover patients from hospitals across state lines, either. An Idaho patient could drive to a hospital in Washington but would have to pay to get there or foot the bill for an ambulance, says Caplan. "If you don't have an ICU with beds in your area, you're kind of stuck," he explains. "That's just part of the health care system you and I have created."
That said, some states and individual hospitals are working together to ensure patients can get the care they need, when they need it, during times of strained resources. Dr. Manchanda says her hospital, Boston Medical Center—a safety-net hospital that typically cares for marginalized patients, avoided enacting crisis standards of care by collaborating with other area hospitals that had more free ICU beds due to the wealthier population they serve. "We had a voluntary agreement with other hospitals that we could transfer out ICU patients to institutions that had more capacity so we could care for patients who came to ours," she says.
In New Mexico, Clark says hospitals across the state are collaborating to free up ICU beds by transferring lower-acuity patients to smaller hospitals and patients in smaller hospitals to larger ones with more resources. And smaller hospitals can also work remotely to stabilize critical patients in place when there aren't any ICU beds available for transfer. "If you're an ED physician at a smaller hospital, you might be able to call an ICU service center and have an ICU doctor work with you to set up and manage a ventilator," Dr. Scheunemann says.
Averting crisis in your community
Since the start of the pandemic, public health leaders have worried about hospitals becoming overwhelmed, and so the response was to encourage masking and social distancing to slow the spread of COVID-19. Today, those evidence-based mitigation measures, along with vaccination to prevent serious infections from occurring in the first place, remain the best tools for quelling COVID case counts and freeing up hospital resources.
"When people are vaccinated, even if they get COVID-19, they don't need ICU beds," Dr. Manchanda says. "It's the most effective strategy for ensuring when you have a heart attack or get into a bad car accident that you will have the resources you need at your hospital."
The information in this story is accurate as of press time. However, as the situation surrounding COVID-19 continues to evolve, it's possible that some data have changed since publication. While Health is trying to keep our stories as up-to-date as possible, we also encourage readers to stay informed on news and recommendations for their own communities by using the CDC, WHO, and their local public health department as resources.
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