Planning for the Unthinkable – Again

On April 16, I wrote about the need for hospitals to plan for the potential of invoking crisis standards of care. Put another way: rationing of care. Eight months later, that frightening and tragic possibility has returned to the forefront.

Hospital leaders must act now as some areas of the country are running out of ICU capacity. We are experiencing record-setting numbers of cases and hospitalizations nearly every day, with no end in sight. “Informal rationing of care” has been noted in Utah, and the possibility of “thresholds for admitting patients to hospitals” shifting was recently raised by Melanie Evans in The Wall Street Journal. Other states, including New Mexico and my own state of Idaho, are close to the edge.

Despite loud warnings, there’s no indication that the growing spread is causing alarm or inducing Americans to dramatically alter their plans – including holiday travels. Yet based on what we know about the virus and what we observed following Canada’s Thanksgiving in mid-October, there’s every reason to expect the surge to grow over the next couple of weeks.

As if this weren’t enough, we’re also bracing for the annual influenza epidemic. CDC numbers show 140,000 to 810,000 influenza hospitalizations each year in the past decade. This year, we also have the specter of co-infection with influenza and COVID-19, resulting in more severe disease and poorer outcomes.

All of this could serve as the tipping point for many hospitals currently strained by large numbers of staff in isolation or quarantined due to the virus. And, unlike in April when COVID-19 flare-ups were regionalized and resources could be redistributed, there are fewer options for moving healthcare workers into or patients out of hard-hit areas at a neighboring hospital or state.

In short, we must mobilize now. Here are seven points to consider:

  1. Know your state’s crisis standards of care. Ensure that your physicians and staff are familiar with your state’s standards and are prepared to implement them should the time come.
  2. Keep your board up to speed. Ensure they understand how dire the situation is becoming and what the implementation of crisis standards of care will mean for the hospital and your community.
  3. Communicate with your community. The public may not understand exactly what rationing of care means or its full implications. People probably aren’t aware, for example, that your bed capacity is not your number of beds but the number of beds you can staff. They likely think that hospitals can simply hire more staff, open more beds or create field hospitals. And, critically, your community may not realize that capacity constraints don’t just apply to COVID-19 patients – the lack of staffing and bed capacity can affect availability of beds for patients with heart attacks, strokes or trauma injuries. Without proactive education, you face the strong likelihood that the public will react negatively to hospitals for failing to warn them and for failing to take steps to prevent this.
  4. Arm your clinicians with messaging. Make sure that you have specific doctors and nurses prepared to carry the message on media and press interviews. Your communications staff should also be prepared to respond quickly to social media.
  5. Clarify who will make triage decisions. It’s wise that this is a team effort, not an individual. Placing responsibility on a single person comes with risk. First, that person could become ill and unavailable. Second, one person should not bear the weight of care rationing decisions. A team can provide support and lessen the burden. Finally, you could be operating under the crisis standards of care for a while. Even if your state were to implement mandates at that time or other public health orders, it likely would take weeks before the pressures on hospitals was relieved.
  6. Stay in touch with your insurer. Be sure that your general counsel reaches out to your liability carrier to notify them of this impending event given the potential for lawsuits. Hopefully, your state has enacted liability protections in association with a declaration from the governor that crisis standards of care are in effect.
  7. Be empathic. Have a game plan to provide emotional, spiritual and psychological support to families, staff and physicians during the time of these decisions. Families of patients who will not receive every intervention possible will no doubt be angry. Staff and physicians who have to make these wrenching decisions or who will be providing comfort care to patients who would in other circumstances would have received aggressive treatment may suffer tremendous discomfort and discord in not being able to do everything possible for every patient.

I hope this can be averted and that your preparations for crisis standards of care will not be needed. However, with each day, I grow increasingly concerned. This will be a dire time and the most challenging of the entire pandemic. This time will test your leadership like no other. I am praying for you, your physicians, your staff and your communities.

David Pate, MD, JD
dpate@jarrardinc.com