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Addressing Challenges Associated with Operationalizing a Crisis Standards of Care Protocol for the Covid-19 Pandemic

ABSTRACT: In a novel pandemic, health care leaders are tasked with designing and implementing Crisis Standards of Care protocols to guide clinicians in the event that a surge of cases outpaces the supply of critical care resources. Leaders need to actively engage communities who will be impacted by these protocols, with particular attention to vulnerable groups, including racial and ethnic minorities, and those with disabilities. Summary The imminent threat of a Covid-19 surge overwhelming available resources for critically ill patients prompted many state-level public health officials to rapidly develop triage protocols for scarce resources, known as Crisis Standards of Care (CSC). It is important, however, for health care organizations to develop their own local CSC plans to address unique staff and community factors. In Massachusetts, a working group of experts at Brigham and Women’s Hospital (BWH) developed a CSC implementation plan by engaging the hospital community, providing support to staff, and responding to changes in state-issued guidance and feedback from the hospital and broader Boston community. This process decreased clinician anxiety and increased hospital-wide understanding of the CSC process. While challenges remain in both the conceptualization and operationalization of these guidelines, health care organizations may adopt elements of the BWH process and incorporate key lessons learned.

SUBMITTER: Milliken A

PROVIDER: S-EPMC7423180 | biostudies-literature | 2020 Aug

REPOSITORIES: biostudies-literature

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Project description:ImportanceSignificant concern has been raised that crisis standards of care policies aimed at guiding resource allocation may be biased against people based on race/ethnicity.ObjectiveTo evaluate whether unanticipated disparities by race or ethnicity arise from a single institution's resource allocation policy.Design, setting, and participantsThis cohort study included adults (aged ≥18 years) who were cared for on a coronavirus disease 2019 (COVID-19) ward or in a monitored unit requiring invasive or noninvasive ventilation or high-flow nasal cannula between May 26 and July 14, 2020, at 2 academic hospitals in Miami, Florida.ExposuresRace (ie, White, Black, Asian, multiracial) and ethnicity (ie, non-Hispanic, Hispanic).Main outcomes and measuresThe primary outcome was based on a resource allocation priority score (range, 1-8, with 1 indicating highest and 8 indicating lowest priority) that was assigned daily based on both estimated short-term (using Sequential Organ Failure Assessment score) and longer-term (using comorbidities) mortality. There were 2 coprimary outcomes: maximum and minimum score for each patient over all eligible patient-days. Standard summary statistics were used to describe the cohort, and multivariable Poisson regression was used to identify associations of race and ethnicity with each outcome.ResultsThe cohort consisted of 5613 patient-days of data from 1127 patients (median [interquartile range {IQR}] age, 62.7 [51.7-73.7]; 607 [53.9%] men). Of these, 711 (63.1%) were White patients, 323 (28.7%) were Black patients, 8 (0.7%) were Asian patients, and 31 (2.8%) were multiracial patients; 480 (42.6%) were non-Hispanic patients, and 611 (54.2%) were Hispanic patients. The median (IQR) maximum priority score for the cohort was 3 (1-4); the median (IQR) minimum score was 2 (1-3). After adjustment, there was no association of race with maximum priority score using White patients as the reference group (Black patients: incidence rate ratio [IRR], 1.00; 95% CI, 0.89-1.12; Asian patients: IRR, 0.95; 95% CI. 0.62-1.45; multiracial patients: IRR, 0.93; 95% CI, 0.72-1.19) or of ethnicity using non-Hispanic patients as the reference group (Hispanic patients: IRR, 0.98; 95% CI, 0.88-1.10); similarly, no association was found with minimum score for race, again with White patients as the reference group (Black patients: IRR, 1.01; 95% CI, 0.90-1.14; Asian patients: IRR, 0.96; 95% CI, 0.62-1.49; multiracial patients: IRR, 0.81; 95% CI, 0.61-1.07) or ethnicity, again with non-Hispanic patients as the reference group (Hispanic patients: IRR, 1.00; 95% CI, 0.89-1.13).Conclusions and relevanceIn this cohort study of adult patients admitted to a COVID-19 unit at 2 US hospitals, there was no association of race or ethnicity with the priority score underpinning the resource allocation policy. Despite this finding, any policy to guide altered standards of care during a crisis should be monitored to ensure equitable distribution of resources.

Project description:Chronic Obstructive Pulmonary Disease (COPD) is a chronic inflammation in the lungs that causes obstruction in the airway, poor airflow, and irreversible loss of lung function. In clinical practice, comprehensive care for COPD patients includes the diagnosis using spirometry, clinical examination and comprehensive pharmacological and non-pharmacological management. The diagnosis is based on symptoms, dyspnea and lung function impairment and can be mild to very severe. Symptoms are examined using the COPD assessment test (CAT) score, and dyspnea grade are examined using a modified MRC from GOLD guidelines. When mild, the care includes self-management education, smoking cessation, lifestyle modifications, vaccination, and short-acting bronchodilators. Self-management education involves inhaler device training, breathing technique, early recognition of acute exacerbations and writing action plans. As the disease progresses, other care measures are added. These measures include the addition of long-acting inhaler therapies, pulmonary rehabilitation, oral therapies, oxygen and lung transplantation. During the final stages of COPD, patients receive end-of-life care (Bourbeau et al., 2019).1 The novel coronavirus disease (COVID-19) is a viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that is spread through respiratory droplets. This infectious disease has led to a pandemic and is affecting the lives of many around the world, including Canadians. During this pandemic, the non-essential health services, including caring for patients with COPD, have been put on hold to reduce the risk of spread. Other implications of this pandemic for COPD patients include the health risk in case of infection. A meta-analysis including studies from January to March 2020 in Wuhan showed that pre-existing COPD worsens the risk of COVID-19 progression and leads to poorer prognostics. The sub-group analysis showed a significantly higher risk of ICU requirements and death in COPD patients who are infected with the SARS-CoV-2 virus. Studies suggest strong efforts to mitigate the risk of infection in this population (Zhao et al., May 2020).2 This makes caring for this population even more critical during the pandemic.

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Addressing Challenges Associated with Operationalizing a Crisis Standards of Care Protocol for the Covid-19 Pandemic

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