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Crisis Standards of Care Lessons from COVID-19

05/19/2022

By John L. Hick, MD and Matthew Wynia, MD, MPH

Not enough personal protective equipment (PPE), not enough staff, not enough space, nowhere to transfer patients, difficult decisions about dialysis and other treatments. Most hospitals experienced crisis conditions during surges of COVID-19 over the past two years which posed a substantial risk to patients and providers – necessitating difficult choices. 

State and hospital responses to these situations were often ad hoc and did not follow existing crisis standards of care (CSC) plans that were primarily designed for ventilator triage and other situations that did not systematically occur. 

In our open access article, “Hospital Planning for Contingency and Crisis Conditions: Crisis Standards of Care Lessons from COVID-19,” in the upcoming June/July issue of The Joint Commission Journal on Quality and Patient Safety (JQPS), Dan Hanfling, MD, and I try to offer hospitals a roadmap to plan for these situations. 

Crisis and Contingency Situations

Crisis situations are not rare, and contingency situations (which require adaptive strategies to address a resource shortfall) are even more common. An example of a contingency situation which could progress to a crisis – depending on how long and severe the shortage – is our current shortage of a radiologic non-iodinated contrast agent. This and many other shortages and incidents can help us prepare for the worst by being proactive and doing our best to stay out of crisis. Better strategies keep us in contingency – where our adaptations pose minimal risk of poor outcomes.

Crisis conditions exist at hospitals regardless of what the state or other entities do or don’t do. Therefore, we need to plan and be ready for when a shortage or disaster strikes. Most CSC plans involve triage teams and scoring systems for situations that rarely occur. We refocused planning to help make sure that the provider, facility and regional systems are all prepared for allocation decisions related to: 

  • communication
  • information sharing
  • consultation when decisions are needed that fall outside a provider’s usual scope
  • regional patient transfer/load-balancing agreements 

Supporting Providers During Crisis
Plans, education and pre-existing systems and policies help greatly in a crisis to assure that providers:

  • feel supported
  • are able to pivot to non-traditional roles knowing that it is the correct ‘next step’
  • know that the region as a whole is working to assure that hospital resources in the region are leveraged to provide the best, most consistent level of care possible to its communities

Bedside providers should know who to call and what to do when faced with triage decisions that they do not normally make. Hospitals need to understand the importance of this planning and support their providers so that they are not alone in their decision making. Ad hoc decisions breed inconsistency, moral distress, and do not engage the hospital and regional systems in recognizing the problem and developing best practice strategies to address the issue. 

COVID-19 reinforced that during a disaster, hospitals must coordinate to use their resources effectively – including across healthcare systems. We have learned that surge conditions may have contributed to as many as 25% of hospitalized deaths in the United States. This is sobering, and a call to action to make our care during surge conditions safer and more coordinated. 

We are grateful to all healthcare providers for their sacrifice, tenacity and knowledge through this grueling two-year pandemic. We have done so much and can now begin to focus on improving our systems and supporting our providers and hospitals. We hope that our article can empower needed discussions and planning for whatever comes next. 

John L. Hick, MD, is a Faculty Emergency Physician at Hennepin Healthcare in Minneapolis. Dr. Hick also is a Professor of Emergency Medicine at the University of Minnesota in Minneapolis. Matthew Wynia, MD, MPH, is Professor at the University of Colorado School of Medicine and the Colorado School of Public Health in Aurora, Colorado. Dr. Wynia also is Director of the University of Colorado Center for Bioethics and Humanities in Aurora.