Since the looming bird flu pandemic in 2006, governments, hospitals and professional organizations have been preparing for the next big one. New York State has been at the forefront of preparing for a pandemic, having developed its ventilator allocation guidelines in 2007 and updated in 2015. And yet, when the COVID tsunami hit New York City in early 2020 and overwhelmed the healthcare system, New York failed to revise guidelines and officially activate its guidelines, despite pleas from professional and institutional stakeholders, leaving hospital staff without guidance. Without state-approved activation, individual hospitals and their staff have struggled to make difficult triage CPR decisions, in some cases without legal protection. Nevertheless, decisions had to be made at the bedside. Because as Matthew Wynia, MD, MPH, noted early on, “Nobody wants to be held accountable for these decisions. They are tragic decisions, which is why they are rolling downhill. Right? From a powerful person to a less powerful person Person who cannot tell I refuse to make that decision. So they end up on the doctor’s lap at the bedside.”
Across the country, hospitals in both urban and rural areas have also experienced unprecedented COVID spikes and have had to make difficult bedside decisions because they had no other choice. Very little is known about these decisions. In 2022, it’s time to find out.
Crisis standards of care
Crisis Standards of Care (CSC) are officially asserted by state governments when sustained demand far exceeds available hospital staff, equipment and space. Hospitals operating at this level of capacity, i.e. crisis capacity, may be at significantly higher risk of morbidity and mortality for patients. In response, CSC plans typically provide for expansion of hospital capacity and coordinated, if not centrally directed, regional sharing of resources and patient transfers as appropriate. To facilitate staffing, competency and credentials, regulations are relaxed. When these measures are insufficient, CSC facilitates triage—prioritizing access to life-sustaining treatments (e.g., ventilators)—with the goal of saving as many lives as possible. Accordingly, patients who have the greatest chance of surviving with intervention are given a higher priority than both those with the highest probability of surviving without medical intervention and those with the lowest probability of surviving even with medical intervention.
To protect the relationship of trust between treating physicians and nurses, triage decision-making, which is intended to be a transparent process based on publicly available criteria, should be conducted by an independent triage officer or team. In many states, triage is a three-step process:
- Initial screening of patients and possible denial of aggressive treatment based on exclusion criteria (eg, disorders that result in immediate or near-immediate mortality even with aggressive therapy) or simply by positioning such patients low enough on the priority list that it what is clear is that it would never receive scarce resources
- Risk assessment based on the best available objective criteria such as Sequential Organ Failure Assessment (SOFA) score and other physiological data to determine ICU admission priorities
- Periodically reassess progress at regular intervals
In New York City, hospitals have drastically expanded hospital and intensive care unit capacities to meet the continued surge in demand. For example, the Montefiore Health System in the Bronx quadrupled its ICU beds from 120 to 475, an extraordinary increase in capacity. In the hospitals with the most extreme variability, the quality of care was undoubtedly compromised by overworked and, in many cases, undertrained (in critical care) staff. It was clearly an all hands on deck approach. With cases doubling every 3 days, staff getting sick and dying from a lack of PPE, and refrigerated trucks expanding hospital morgues, could it have been any different? The pressure on the staff must have been unimaginable.
Morbidity and Mortality Rounds
A 2022 summary report by HHS Assistant Secretary of Preparedness and Response showed wide disparities in how states and individual hospitals were, or were not, implementing their CSC plans, if they had one. Among key findings: only 9 states declared CSC; 15 states appeared to be providing crisis care but no official statement; and many hospitals declared CSC in the absence of government action. In some states, with or without a declared CSC, executive orders provided for hospital expansion and the relaxation of licensing requirements. John Hick, MD, et al. in their assessment of lessons learned from COVID, found that formal CSC plans often did not meet the needs of the local situation. In addition, healthcare providers often suffered from severe moral burdens associated with bedside rationing decisions.
What was it really like for doctors, nurses and other medical professionals on the front lines? A qualitative study by Elizabeth Chuang, MD, MPH, and colleagues, aimed at identifying potential issues with the implementation of model guidelines based on the National Academies of Medicine’s Crisis Standards of Care and the New York State Ventilation Guidelines, found that Doctors and nurses are at odds over the ethics of triage, raising concerns about their actual performance in a pandemic. Robert Truog, MD, MA, who reviewed the Massachusetts CSC’s soundness, concluded that the basic approach was flawed and impossible to implement and that if time-limited trials of ventilators were used as a precursor to withdrawal, they were likely to be met with backlash would be confronted by politicians. Similar obstacles to implementing CSC protocols were identified in Arizona during a systems simulation exercise (Patricia Mayer, MD, personal communication).
It is time for hospitals to hold the equivalent of morbidity and morbidity rounds to examine the formal (state or hospital) and informal/ad hoc responses to COVID surges with triage.
We need an autopsy, and we need to start with questions.
What do we know about the CSCs and their processes? Were the state CSC triage guidelines or the guidelines adopted by hospitals helpful or too cumbersome to be useful? Were formal triage guidelines used at all? To what extent were triage decisions made in the ED and were CSC exclusion criteria useful, if any? What was the use of SOFA and other rating systems? Who actually oversaw the COVID surge response and triage (e.g., Incident Command System), if anyone, and with what effectiveness? Were records kept at the locations where triage protocols were officially enabled (e.g. some facilities in Alaska, Tennessee and Idaho)? What were their findings, and did they actually save more lives with one protocol?
What do we know about results? To what extent did patients die who would have survived under normal conditions? Have salvageable patients died because intensive care units were already filled with dying patients because staff were unwilling or unable to stop life support treatments to make room for others?
What do we know about staff? To what extent did employees feel legally and ethically supported in their decision-making? Did medical teams even recognize the care provided as triage? Have the teams considered or tried to deal with racial injustice? How many employees have been bullied, threatened, or harassed after the “hero” label went cold? How many quit? committed suicide? What have been the reactions and consequences for teams using formal triage processes versus ad hoc triage processes?
What do we know about patients and families? How much did patients or families know about “equipment, space, and staff” limitations? Now how do families deal with losing loved ones they weren’t allowed to see?
What is the public perception of CSC and triage? How does the public feel about states that haven’t activated CSC (including New York and Texas) when TV footage was filled with dying patients, hearses and body bags and literally everyone assumed it someone made decisions?
And what lessons have been learned? What could you have done differently? Unless we have information about what happened this time, how can we improve next time (and there will be a next time)? Failure to learn from this experience dishonors both those who have died and those who have served. We need answers.
Martin A. Strosberg, PhD, is Professor Emeritus of Health Policy and Bioethics at Union College and Clarkson University in Schenectady, New York. Patricia Mayer, MD, is a palliative care physician and director of clinical ethics at Banner Health in Phoenix. Daniel Teres, MD, is a critical care physician and clinical educator in public health and community medicine at Tufts University School of Medicine in Boston.