EXECUTIVE SUMMARY

Throughout the COVID-19 pandemic, healthcare practitioners have observed challenges related to the implementation of crisis standards of care (CSC), a declaration that should be made only when all other options have failed. Experts report there has been a lack of consistency in such decision-making. In some cases, CSC decisions are made unnecessarily, putting patients at risk. They advise re-examining plans for CSC devised before the pandemic to incorporate recent lessons learned.

  • CSC decisions made at the bedside often are happening in an ad hoc manner rather than moving up the chain of command.
  • One area ripe for improvement is the extent to which hospitals collaborate in their response to a crisis.
  • CSC planners believed hospital systems confronting a crisis would enter into a CSC footing across the domains of space, staff, and supplies concurrently. During the pandemic, that did not happen.
  • Noting fairness is an underlying principle of CSC, experts say the pandemic has adversely affected too many urban medical centers caring for communities of color.

With patients overwhelming capacity and resources in short supply, administrators in many regions of the country are implementing crisis standards of care (CSC), an operational change that is necessary when it becomes impossible to meet typical patient-to-staff ratios and other regulatory standards are put in place to optimize care and safety.

However, experts note this transition to CSC has proven to be a bumpy ride for many health systems, with critical decisions made at the bedside in some cases instead of at higher organizational and community levels. They note this ad hoc decision-making has led to a lack of consistency regarding when crisis standards are implemented and placed added pressure on frontline caregivers who already are dealing with unprecedented levels of stress and fatigue.

Leaders are calling for changes to bring more consistency, eliminate overly bureaucratic mechanisms, and place the responsibility for tough decisions up the chain of command where it belongs.

Involve Clinicians

In a CDC Clinician Outreach and Communication Activity (COCA) presentation on the subject on Dec. 17,1 Vikramjit Mukherjee, MD, director of the medical ICU at Bellevue Hospital in New York City, noted that from mid-March to early April 2020, the rapid intake of patients overwhelmed many ICUs and health systems across the city, but these admissions were not evenly distributed across the region.

“The number of patients in Queens and Brooklyn was far [higher] than the number of patients in Manhattan and Staten Island,” he explained. “What COVID-19 uncovered, if not magnified, were already-existing social and economic disparities in healthcare access and healthcare delivery.”

Bellevue serves as the tertiary referral center for New York City’s public hospital system. Most patients admitted to that ICU came from disadvantaged communities with medium to very high poverty levels.

Recognizing that New York City was the epicenter of the COVID-19 epidemic during this period, ICU directors from across the city engaged in a discussion about their CSC experiences. Some observed that crisis standards were implemented in a subjective manner from the frontlines and at the bedside, Mukherjee recalled. Several of those engaged in this discussion, including Mukherjee, contributed to a report on this issue that highlights several of the themes that emerged.2

“Most of the participants expressed some degree of frustration that the pre-pandemic crisis standards of care planning did not align well with the realities as they unfolded,” Mukherjee said. “Going forward, there was a sense that CSC planning needs to be more operational and that clinicians need to be much more involved from the get-go.”

Also apparent to many ICU directors was the reality that supply/demand mismatches were everywhere, involving all three pillars of surge planning: space, staff, and supplies. Further, clinicians often misunderstood CSC to be limited to the use of ventilator triage or to only involve formal triage processes rather than making the best decisions possible in situations that involve risk to the patient or the provider.

Regarding ventilators, the question most clinicians were confronted with was generally not whether a ventilator was available to a patient, but rather what type of ventilator should be used: a traditional, state-of-the-art machine; a retrofitted, bi-level positive airway pressure machine; or one of the smaller, portable ventilators supplied by FEMA.

In their report, Mukherjee and colleagues stressed that CSC is not a choice, but rather a last-case scenario that healthcare systems are forced into when all other options have failed.

Develop a Plan

In New York City’s public hospital system, there were several innovations that helped minimize the harmful effects of supply/demand mismatches. For example, when looking at space, Mukherjee noted that every day, all the system’s ICU directors met to look at surge levels. This helped Bellevue and other facilities anticipate demand and load-balance cases effectively across the system.

ICU staffing was a particular challenge during the early days of the pandemic. Even with all the intensivists working, there was a need for added clinical leadership and administration.

“Many of us took a role as a pit boss as we navigated through the pandemic ... and the role of trainees, which was a little bit up in the air for the first phase, ended up playing an extremely important part in our surge response,” Mukherjee said.

To help staff the ICU during this period, Mukherjee maximized the use of existing ICU staff. Critical care staff, recently liberated from closed operating rooms, were called in to help. Other staff who were uptrained to work in the ICU and new workers from other medical centers across the country pitched in.

“Back in April, we were the only [area] that was being [so broadly] affected by the pandemic, and we were lucky to get so much help from our colleagues,” Mukherjee said. “Unfortunately ... there are many, many hot spots [now], and this might not be as easy to arrange ... but there were challenges in making sure there was a uniform approach, and making sure that PPE was standardized.”

In terms of supplies, many shortages were anticipated, but there were some surprises, too. “We didn’t expect the need for deep sedation, and had to be nimble about IV pumps, fentanyl, opiates, and paralytics,” Mukherjee noted.

There also were shortages of cooling blankets, tracheostomy kits, and disposable items such as circuits, filters, and even syringes. Ultimately, the disaster plan Bellevue put in place proved to be less than ideal, but Mukherjee stressed that an imperfect plan is better than no plan.

“We recognized that there is always going to be a supply/demand mismatch,” he said. “Even though it wasn’t a perfect plan, we had something to fall back on.”

Provide Clarity

During their discussions, ICU directors agreed that implementing CSC on the fly is challenging, Mukherjee said. “There needs to be a clear form of declaration that the CSC context exists at the hospital, hospital system, healthcare coalition, and jurisdictional levels,” he stressed. “However, CSC plans must factor in that a formal declaration from the state may not be made in time.”

For example, New York state never made a formal declaration for CSC, but such decisions were made at the bedside. “Institutions need to recognize that whether a formal declaration from the state is made or not, there have to be decisions made in a very sensitive manner at the front lines,” Mukherjee noted.

CSC planning also should factor in the emotional impact on frontline practitioners trying to manage a crisis. “We know that not just the pandemic, but the hard decisions that came with pandemic planning, took a toll on healthcare workers,” Mukherjee said. “This is something that needs to be part of our discussions going forward as we address crisis standards of care.”

Also ripe for improvement is the extent to which hospitals collaborate in their response to a crisis. For example, in New York City, Mukherjee noted collaboration was excellent within health systems, but non-existent between health systems. “All of the systems worked well within their silos, and were able to level-load within their silos, but these major institutions were rarely talking to each other, sharing information with each other, or level-loading between institutions,” he said. “That is a huge vulnerability that needs a lot of work.”

Elevate CSC Decisions

John Hick, MD, a professor of emergency medicine at the University of Minnesota and Hennepin Healthcare in Minneapolis, also spoke during the Dec. 17 COCA presentation.

“In retrospect, when we look back at the work that the Institute of Medicine’s committees on crisis standards of care have done over 2009, 2012, and 2013, certainly we had not had contact with an enemy like this,” Hick said. “We recognize certain shortcomings in the [CSC] framework ... and some of the operational recommendations that were made.”

For instance, before COVID-19, CSC planners thought hospital systems confronting a crisis would enter into a CSC footing across the domains of space, staff, and supplies at the same time. In reality, that did not happen. Instead, Hick pointed out the healthcare system entered into CSC almost immediately from a PPE standpoint, particularly regarding N95 respirators.

“I give the CDC tremendous credit for constructing an extremely rational, well-thought-out sequence of graceful degradation of materials, from conventional to contingency to crisis-relative to N95 respirators,” Hick said.

He explained that when moving from a conventional to a contingency footing, one makes adaptations that enable staff to provide care that is functionally equivalent to conventional care without any added risk to the patient or provider. “It is just done in a somewhat different way,” Hick added.

However, when contingency moves to crisis, that is a threshold where the clinician, hospital, and health system determine they need to allocate resources in a way that increases the risk of a bad outcome to the patient. While it is not uncommon for individual providers to essentially move to a crisis mode by making certain implicit triage decisions, such decisions should be made at the systems level.

“If you are making a decision that is not in the bounds of ‘usual,’ or it puts a patient at significant risk, that is really a marker that it needs to be kicked up to a systems level,” Hick explained.

Many health systems have set up special triage teams to engage in this type of decision-making, but Hick noted such decisions have revolved around life-support interventions, such as the use of ventilators. However, what the pandemic has made clear is clinicians need access to much more immediate counsel on a range of potential CSC concerns.

“Whether this is a medical director on call or a critical care physician on call, [they need] someone they can touch base with when they are bordering into a crisis phase,” Hick said.

The key is moving the decision up the chain to the hospital level, the systems level, and then to the regional and state levels. “It is very possible that, just like ripples across a pond, you can diffuse the impact across other institutions,” Hick said. “It is important that we try to avoid CSC as much as possible, not only for the patient’s benefit but also from an equity lens.”

Hick noted many urban level I trauma centers that serve communities of color have been much more adversely affected by the pandemic than other hospitals.

“Making sure that impact is diffused so that we can provide the best care possible to a patient regardless of what their community situation may be is so important to making sure that this system is fair,” he said. “Fairness is ultimately the underlying the principle of CSC, along with consistency.”

Avoid Ad Hoc Decisions

Investigators have found that when individual providers have the power to make CSC declarations, they may not be aware there are resources at the hospital, system, or regional levels that may negate their need to make such a declaration. “However, CSC exists any time that a provider is having to make decisions that put patients at risk,” Hick noted.

Particularly when providers are under stress, they want bright lines and firm answers, and there often are not many of those. However, Hick noted that when providers are in question, they should consult with a senior provider who is up the chain. The issue likely is not that provider’s alone.

“It is probably a systems issue, and you are probably not the only provider or hospital experiencing it,” Hick offered. “It needs to be raised up, and it demands and deserves standard work, a standard approach.”

The goal is to avoid ad hoc decisions whenever possible. “If it is not a decision that you normally make, and you feel like you are in a resource-constrained situation, you should validate that up the chain,” Hick observed. “You don’t want to make assumptions at the provider level, and to be doing triage that doesn’t necessarily need to be done. Knowing what resources are available to you is incredibly important, and staying within the scope of practice to the degree possible.”

Hick acknowledged decisions often need to be made quickly. Consequently, he urged administrators to ensure they are providing policy support, procedural support, and clinical decision support to bedside providers so they have an action plan from which to work.

“When they have clinical decisions they feel are out of bounds or novel, they can reach up and make sure to integrate a senior clinician, office medical director, or incident command consultation into that decision,” Hick explained.

Ultimately, CSC conditions in any domain should last for as short a period as possible. “We should be striving to get back to contingency as quickly as possible, using regional mechanisms, standard work, and standardized approaches,” Hick said.

Health systems should rethink how they train and use their workforce, providing them with added flexibility to respond to crises and other adverse events. Still, Hick also voiced concern healthcare leaders have short-term memories.

“I just think it is incumbent on all of us to channel the frustration and some of the pain to make sure that ... when we face this challenge again that we don’t make the same mistakes,” Hick stressed. “We forgot about the 2009 H1N1 [pandemic] too quickly because it didn’t have the impact we anticipated. We cannot afford as healthcare providers or healthcare systems to not learn the lessons from COVID-19.”

More information on the planning and implementation of CSC is available from the Health and Human Services Assistant Secretary for Preparedness and Response here.

REFERENCES

  1. Centers for Disease Control and Prevention. Making practical decisions for crisis standards of care at the bedside during the COVID-19 pandemic. Dec. 17, 2020.
  2. Toner E, Mukherjee V, Hanfling D, et al. Crisis Standards of Care: Lessons from New York City Hospitals’ COVID-19 Experience. A Meeting Report. Baltimore, MD: Johns Hopkins Center for Health Security; 2020.