Crisis Standards of Care: Should They be the Standard?

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Original story posted on: September 27, 2021

Sadly, this is a crisis of our own making.

Remember early on in the pandemic, when we used the expression “flatten the curve” when referring to mitigation tactics like masking, social distancing, and handwashing?

See the graphic below. If you have ever seen this in a video, it is often depicted as the area under the flattened curve being equal in volume to the much steeper curve. It indicates that the same number of people contract the virus, but they do it over a much longer period of time, in order to not overwhelm the healthcare system. The intent was to tread water until we had an effective vaccine that could prevent us from getting the disease altogether.

It worked…in the beginning.

But if you have been following the news lately, you know that this ship has sailed, and we blew it. Politics seems to have usurped the primacy of the virus, and people are refusing to get vaccinated or to reinstate mitigation protocols.

In addition, after 18 months of being battered and bruised, the healthcare system has lost myriad nurses and other staff. Surveys show that 40 percent of all nurses and 66 percent of critical care nurses are considering leaving their profession, although I can’t find solid numbers on how many have actually left in the past year and a half. Some leave due to stress, exhaustion, and burnout, and some are leaving because they themselves do not want to get mandatorily vaccinated. Many have converted to becoming a travel nurse, whereby they make considerably more than in their previous position.

When I worked in the ED eons ago, if a nurse called out, a colleague stepped up and endured a double shift to take one for the team. Those days are gone – it is just too much. They rightfully feel underappreciated, undervalued, and overburdened. The attending buying them a pizza lunch just ain’t gonna cut it!

Across the country, our healthcare systems are inundated and overwhelmed by the volume of primarily unvaccinated COVID-19 patients, compounded by understaffing. Patients who have non-COVID-19-related illness and injury are receiving delayed and substandard care. Since the virus is still widespread, transfers to another facility where care is available can be difficult or impossible to arrange. One patient’s provider had to contact more than 40 hospitals in multiple states to find an accepting institution, but the patient died anyway.

The state of Idaho, which not coincidentally has the lowest rate of vaccination in the U.S., activated Crisis Standards of Care (CSC) on Sept. 6. Alaska started prioritizing care the following weekend. Other states may follow suit soon. CSC is a substantial change in usual healthcare operations due to pervasive or catastrophic disaster, such as pandemic, hurricane, or earthquake. Idaho’s layperson explanation of CSC is “people who need medical care may get care that is different from what they expect. For example, patients admitted to the hospital may find that hospital beds are not available or are in repurposed rooms (such as a conference room) or that needed equipment is not available. They may have to wait for a bed to open, or be moved to another hospital in or out of state that has the resources they need. Or they might not be prioritized for the limited resources that are available. In other words, 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.”

This reminds me of mass casualty disaster drills conducted when I was a resident. Mock patients were triaged using a color-coding system: green is for walking wounded who can wait, while yellow is for stable patients who need hospital care and would normally be treated immediately, but initially they will be observed, reassessed, and recategorized. Red tags label folks who need immediate treatment but have a chance of survival, and black tags are for deceased patients and those whose injuries are so extensive that they are not felt to be survivable. It was a formidable responsibility to decide who would essentially be relegated to die.

The American Medical Association (AMA) provides foundational guidance for developing ethically sound CSC:

  • Triage decisions must be based on criteria related to medical need, not on non-medical criteria, such as a patient’s social worth.
  • Limited resources should be allocated first based on likelihood of benefit, and then to promote greatest duration of benefit after recovery.
  • If there are no distinguishing criteria of medical need, an objective and transparent mechanism, such as random choice or lottery, must be applied to minimize potential bias. First-come, first-serve care favors the economically advantaged.
  • Periodically reassess and withdraw care if it is unlikely to achieve the intended goal.
  • Palliative comfort care must be provided when lifesaving treatment is not possible.

When resources are scarce, decisions must be made. Remember the use of the term “death panels,” which opponents to the Patient Protection and Affordable Care Act used?

The decision of approximately 20 percent of our population to refuse to get vaccinated is causing healthcare providers to decide who gets ventilators and who doesn’t; who gets a bed upstairs and who gets transferred to another state; who has a chance to recuperate and who will die. Sadly, this is a crisis of our own making. #getvaccinated

Programming Note: Listen to Dr. Erica Remer Tuesdays on Talk Ten Tuesdays, 10 Eastern, when she co-hosts with Chuck Buck.

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Erica E. Remer, MD, CCDS

Erica Remer, MD, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. She was a physician advisor of a large multi-hospital system for four years before transitioning to independent consulting in July 2016. Her passion is educating CDI specialists, coders, and healthcare providers with engaging, case-based presentations on documentation, CDI, and denials management topics. She has written numerous articles and serves as the co-host of Talk Ten Tuesdays, a weekly national podcast. Dr. Remer is a member of the ICD10monitor editorial board, a former member of the ACDIS Advisory Board, and the board of directors of the American College of Physician Advisors.

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