The COVID-19 Pandemic: Are crisis standards of care coming?Nov 1, 2021
The course of Colorado’s pandemic remains alarming with still rising case and hospitalization counts. The Colorado Department of Public Health and Environment website shows disturbing data trends—test positivity has risen to almost 9% and 1,236 patients with confirmed COVID-19 are hospitalized as of today. An alarming 38% of hospital facilities anticipate staff shortages in the next week, and 31% predict ICU bed shortages. A satisfactory explanation for the timing of the surge is elusive, but most convincing is that 78% of inpatients are unvaccinated.
Throughout the pandemic, the “North Star goal” has been to avoid exceeding hospital care capacity, whether for COVID-19 or all the other causes of hospitalization. Now, implementing crisis standards of care (CSC) is under consideration for Colorado. Current CSC guidance originated in a 2009 report from the Institute of Medicine (now the National Academy of Medicine) that was motivated by the 2009 H1N1 influenza pandemic. A seven-volume report in 2012 expanded the 2009 framework. Quoting the 2009 report, CSC is defined as: “A substantial change in usual healthcare operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g., pandemic influenza) or catastrophic (e.g., earthquake, hurricane) disaster.”
In approaching such situations—when triage of scarce resources might be required and some in need might have to go without potentially life-saving services such as dialysis, blood transfusions, or mechanical ventilation—the report emphasized an ethical vision for making the most difficult of triage decisions to include fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. It also called for states to develop crisis standards of care protocols. Colorado did so, and with the advent of the COVID-19 pandemic the state has also developed a set of more specific CSC guidance documents for various types of resource shortages. These include a document for allocation of critical care resources, such as ventilators, which was an early paradigm case for discussions about scarce resource allocation in the pandemic. But there is also a Colorado CSC guidance document for managing extreme staff shortages, one for shortages of Emergency Medical Services resources, one for shortages of palliative care resources, and more.
A recent National Academy of Medicine discussion paper (including Matt Wynia, Director of the CU Center for Bioethics and Humanities, as a co-author) addresses lessons learned about CSC from the COVID-19 pandemic so far, giving emphasis to equity. As with the public health system, the COVID-19 pandemic has stress tested our capacity to deliver health care in the face of an extreme crisis. The discussion paper identifies successes and shortcomings related to hospital care delivery under surging demand and resource constraints during the COVID-19 pandemic, and it proposes some solutions. Its lengthy list of problems points to a needed agenda for action and highlights several issues related to equity, including the differential impact of the pandemic in the United States, the structural nature of inequities inherent to a ‘save the most lives’ approach to resource allocation in crises, and the communications challenges in reaching all populations.
For example, the authors recommend that steps taken under crisis standards of care should not worsen disparities and that equity in resource allocation should be ensured. They admit, however, that using tools for resource allocation, like the Sequential Organ Failure Assessment (SOFA) score, to assess the likelihood of survival (which diverts scarce resources to those most likely to survive if they receive those resources) will inherently privilege those with fewer comorbidities and better underlying health status. Given the distribution of poor health status and comorbid conditions across lines of race and ethnicity in the U.S., explicit steps to counter this underlying dynamic will be required to ensure equity. As a result, the authors recommend caution in using triage algorithms incorporating the SOFA score and suggest that “the triage process should specifically exclude consideration of age, race, gender, disability, and other inappropriate discriminators, and those conducting triage should be trained on implicit bias with the aim of mitigating the inadvertent exacerbation of disparities.”
The course of the pandemic over the next few weeks will be critical in determining if crisis standards of care are needed in Colorado. What we are seeing and hearing from our hospitals today is that Colorado’s CSC guidance for managing extreme staff shortages is already being used, whether formally declared or not. While an executive order to invoke these standards would be a demarcation, the state has been facing a growing crisis for weeks, sliding towards the point of the unthinkable—not meeting its North Star goal. In this current context, mask mandates represent one proven and rapidly realized short-term stop-gap measure while efforts continue to increase vaccination, soon to reach 5- to 11-year-olds. If implementation of CSC guidance becomes necessary, certainly implementing mask mandates merits consideration.
Note: Matt Wynia provided important contributions to this week’s commentary.
Jonathan Samet, MD, MS
Dean, Colorado School of Public Health