Five patients in your hospital will die unless they are aggressively treated by a physician in the next hour. You have staff to treat only three of them, there is no other hospital available to accept patient transfers, there is no more staff to call in, and it will be a couple of days before the National Guard arrives to help. Which two patients will die from lack of care? Over the next few weeks we may get the answers to hypotheticals like this.
Welcome to “Crisis Standards of Care,” (CSCs) which are the protocols a hospital deploys in a disaster situation in which the hospital, after doing everything it can, has insufficient resources to provide standard health care to all those who need it. Depending on the situation, CSCs may include:
- Not providing health care to some people who need it, even if that may result in their further injury or death.
- Rationing scarce resources such that patients receive less care or resources than they normally would, even if this exposes patients to harm they would not face under normal circumstances.
- Providing health care in a way that is less safe than normal, because that is the only way there will be sufficient resources available. An example would be allowing COVID-infected health care providers who are exhibiting symptoms to treat patients, “as a last resort” according to new CDC guidance just issued.
There is typically a lot of detail about how CSCs will apply to each scarce resource. For example, last Thursday Minnesota updated its guidance for who gets monoclonal antibodies to treat COVID when there are not enough antibodies to treat everyone. In that state, the approach is basically to (1) identify the sickest patients; and (2) if there are not enough antibodies for all of these sickest patients, the state runs a “lottery” and the “winners” get the antibodies. Those who don’t win this particular lottery are out of luck.
As the COVID caseload increases in some areas of the country, we’re seeing hospitals begin moving to CSCs. Typically this happens in two steps: (1) ceasing all non-emergent activity; and (2) declaring a disaster. Over the last week this has happened at University of Maryland — Upper Chesapeake, an unnamed hospital in Illinois, eight hospitals in Arizona, and it is effectively the case at the largest hospital in Rhode Island, even though the state has not officially activated them:
“The bottom line is that although we may not have a formal declaration from the state (yet) regarding crisis levels of care, in our ED and ICUs we are already there,” Dr. Stephen Traub, a top doctor at the independent emergency physician group that works at Lifespan hospitals, wrote in a Wednesday letter to colleagues. “This has led to several discussions about how to care for patients in an era of scarcity, and we are working with ICU leadership to identify patients who under normal circumstances would go to the ICU who we can manage in the RICU or the floor. This is terrible. But it is necessary.”
In Arizona the hospitals are not quite there yet, but they’re getting ready, and Washington State hospitals worry that CSCs are coming soon.
And we’re still weeks away from the expected mid-January peak of cases from the holidays and from Omicron.
If hospitals in your area move to crisis standards, that means they may not be available if you or someone in your family has an emergency. The emergency does not need to be COVID, it could be a heart attack or stroke.
We’re in the middle of a slow-moving, tragic and avoidable disaster. I’m not a clinical health care provider, so I cannot imagine the heartbreak that comes from not being able to help someone because the resources simply are not available. Many of our front-line providers are already burned out or close to it, and now face the additional stress that comes from simply not being able to care for all those who need it. I wish there was more cheerful news on Christmas.