Ever since the threat of an avian flu pandemic in 2006, governments, hospitals, and professional associations have been preparing for the next “big one.” New York State was a leader in pandemic preparation, having developed its Ventilator Allocation Guidelines in 2007, with updates in 2015. And yet, when the COVID tsunami hit New York City in early 2020, overwhelming the healthcare system, New York failed to revise and officially activate its guidelines, despite pleas from professional and institutional stakeholders, leaving hospital staff without guidance. Without state sanctioned activation, individual hospitals and their staff struggled to make difficult triage resuscitation decisions, in some instances without benefit of legal protection. Nevertheless, decisions at the bedside had to be made. Because as Matthew Wynia, MD, MPH, noted early on: “No one would want to be accountable for making these decisions. They’re tragic decisions, which is why they roll downhill. Right? From powerful person to less powerful person to the person who can’t say I refuse to make that decision. That’s how they end up in the lap of the bedside doctor.”
Throughout the nation, hospitals in urban and rural areas also experienced unprecedented surges in COVID and had to make difficult decisions at the bedside because they had no choice. Very little is known about these decisions. In 2022, it is time to find out.
Crisis Standards of Care
Crisis standards of care (CSC) are officially invoked 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 patient morbidity and mortality. In response, CSC plans typically call for expansion of hospital capacity and for coordinated, if not centrally directed, regional sharing of resources and transfer of patients if necessary. To facilitate staffing, competency, and credentialing, regulations are relaxed. If these measures fall short, CSC allows for triage — the prioritization of access to life-sustaining treatments (e.g., ventilators) — aimed at saving the most lives possible. Accordingly, patients who have the greatest chance of survival with intervention receive higher priority than both those with the highest likelihood of survival without medical intervention and those with the smallest likelihood of survival even with medical intervention.
To protect the fiduciary relationship of the physicians and nurses treating the patient, triage decision making, which is supposed to be a transparent process based on publicly available criteria, should be carried out by an independent triage officer or triage team. In many states, triage is a three-step process:
- Initial screening of patients and possible denial of aggressive treatment based on exclusion criteria (e.g., medical conditions that result in immediate or near-immediate mortality even with aggressive therapy) or simply by positioning such patients so low on the priority list it is clear they would never receive scarce resources
- Risk assessment based on best available objective criteria, such as the Sequential Organ Failure Assessment (SOFA) score, and other physiological data to determine ICU admission priorities
- Periodic reassessment of progress at regular intervals
In New York City, hospitals dramatically expanded hospital and ICU capacity to meet the sustained surge in demand. For example, Montefiore Health System in the Bronx quadrupled its ICU beds from 120 to 475, an extraordinary expansion in capacity. In those hospitals experiencing the most extreme surges, the quality of care no doubt was diluted by an overstretched and, in many instances, inadequately trained (in critical care) staff. Decidedly, it was an “all hands on deck” approach. Could it have been any other way with cases doubling every 3 days, staff getting sick and dying because of lack of PPE, and refrigeration trucks augmenting hospital morgues? The pressure on the staff must have been unimaginable.
Morbidity and Mortality Rounds
A 2022 summary report from the Assistant Secretary for Preparedness and Response of HHS showed wide variation in the ways states and individual hospitals implemented or failed to implement their CSC plans, if they had one. Among the key findings: only 9 states declared CSC; in 15 states, crisis care apparently occurred but no official declaration was made; and many hospitals declared CSC in the absence of state action. In some states, with or without a declared CSC, executive orders provided for hospital expansion and the relaxation of credentialing requirements. John Hick, MD, et al. in their assessment of lessons learned from COVID, found that the formal CSC plans often failed to meet the needs of the situation on the ground. Also, healthcare providers often suffered from severe moral distress related to bedside rationing decisions.
What was it really like for doctors, nurses, and other healthcare professionals on the front lines? A qualitative study from Elizabeth Chuang, MD, MPH, and colleagues designed to identify potential problems in implementing model guidelines, based on the National Academies of Medicine Crisis Standards of Care and the New York State Ventilator Guidelines, found doctors and nurses to be conflicted over the ethics of triage, raising concerns about their actual performance in a pandemic. Robert Truog, MD, MA, reconsidering the soundness of the Massachusetts CSC, 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 would likely face backlash from politicians. Similar obstacles with regard to the implementation of CSC protocols were found in Arizona as part of a system 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 involving triage.
We need a postmortem, 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 ones 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 ER and were CSC exclusion criteria useful, if they existed? What was the utility of SOFA and other scoring systems? Who actually oversaw the response to the COVID surge and triage (e.g., Incident Command System), if anyone, and with what effectiveness? In the places that formally activated triage protocols (some facilities in Alaska, Tennessee, and Idaho for instance) did they keep records? What were their results, and did they indeed save more lives using a protocol?
What do we know about outcomes? To what extent did patients die who would have survived under normal conditions? Did salvageable patients die because ICUs were already filled with dying patients because staff were unwilling or unable to withdraw life-sustaining treatment to make way for others?
What do we know about staff? To what extent did staff feel their decision making was supported legally and ethically? Did medical teams even recognize the care being provided as triage? Did teams consider or try to deal with racial inequities? How many staff were bullied, threatened, or harassed after the “heroes” label went cold? How many quit? Committed suicide? What were the reactions and consequences to teams using formal triage processes versus those triaging ad hoc?
What do we know about patients and families? How much did patients or families know about the limitations in “stuff, space, and staff”? How are families coping now when they lost 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 did not activate CSC (including New York and Texas) when TV footage was filled with dying patients, morgue trucks and body bags, and literally everybody assumed somebody was making decisions?
And what lessons were learned? Specifically, what could have been done differently? How can we improve next time (and there will be a next time) — unless we have information about what happened this time? Failure to learn from this experience dishonors those who died as well as those who served. We need answers.
Martin A. Strosberg, PhD, is emeritus professor of healthcare policy, and bioethics at Union College and Clarkson University in Schenectady, New York. Patricia Mayer, MD, is a palliative care physician and the director of clinical ethics at Banner Health based in Phoenix. Daniel Teres, MD, is a critical care physician and clinical instructor in public health and community medicine at Tufts University School of Medicine in Boston.