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Updated 6/29/20

arizona is now officially under

“crisis standards of care”

This document outlines the allocation of scarce healthcare resources using crisis Standards of Care

As of this evening, Arizona has officially entered the world of “Crisis Standards of Care”. It’s a term that has been around most of my career, but this is the first time I can remember it being implemented in Arizona.

“Crisis Standards of Care” is basically a protocol for making healthcare decisions when the system can’t provide all of the care that everybody needs because the needs outstrip the resources. In other words, it’s a protocol to help healthcare providers objectively decide who gets care when resources don’t allow everyone to get treatment.

This very important new document outlines how it’ll work over the coming weeks/months. The report specifies statewide triage protocols for hospitals to use when demand outstrips supply. It has a section on “Stabilization of Patients Awaiting Triage” and “Triage Protocols for Scarce Resource Allocation”.  The triage protocols go into effect when a facility moves from normal care to Contingency or Crisis Levels of Care. 

From a big picture point of view, all patients who can potentially benefit from therapies are offered treatment when resources are sufficient, but when resources aren’t, then all patients get assessed to determine how best to allocate care. The new triage protocol provides a way to make those decisions.

The standards thankfully state that nobody is supposed to be “… categorically denied care based on stereotypes, assumptions about any person’s quality of life, or judgement about a person’s “worth” based on the presence or absence of disabilities“. So that’s a good thing.

The Crisis Standards of Care protocol uses a 4-step process to determine how to prioritize patients. It’s a point-based system, and the people with lower scores would be a higher priority for treatment.

In Step 1, providers assign points to set priorities according to the patient’s “Sequential Organ Failure Assessment” (SOFA) score (a range between 1 to 4 points). In Step 1, a person with a low risk of multi-organ failure might get a score of 0 while a person with a high assessment for organ failure might get 4 points.

In Step 2, providers assign additional points based on “… the individual evaluation of the patient and consideration of 1 year or 5 year mortality” (an additional 4 points are possible).  In this step, a person that would be expected to live at least another 5 years if they recover from COVID would get 0 points. Someone that would be expected to live a short time (a year or two) even if they recover would get 4 points.

In Step 3, you add the points from Step 1 and Step 2 and create a total triage score.

In Step 4, a person is given a color grouping based on the score. The people with lower scores have a “higher likelihood of benefiting from critical care” and scarce healthcare resources would be prioritized toward those with lower scores.

As I mentioned, patients with lower scores would be given priority for care. But sometimes, several people might have the same score (color coding).  If that happens, the protocol says that additional factors may be considered as priorities. Those priorities include:

1. Pediatric patients < 18 years of age;

2. First responders or front-line healthcare workers;

3. Single caretakers for minors or dependent adults;

4. Pregnant patients; and 

5. Opportunity to experience life stages (childhood, young adulthood, middle years, and older years).

As a patient’s condition changes over time, they can be reclassified into a different “color” reflecting a different priority for usage of scarce resources. 

You can go to the COVID addendum document to dive into the details is here.

Now that Crisis Standards of Care have been declared, healthcare institutions and providers have additional liability protections recognizing the fact that they are unable to provide normal standards of care.

This is our new reality folks.

In early June the ADHS discussed modifying 2 important documents to further guide contingency and crisis standards of care for when we move into surge status: 1) Remdesivir Allocation Guidance; and 2) Allocation of Scarce Resources in Acute Care Facilities. They’ll post the final guidance documents here.

A recent randomized trial tested to see whether dexamethasone (a steroid treatment) is useful for folks hospitalized with COVID. They found that it reduced deaths by 33% in ventilated patients and by 20% in patients receiving oxygen only.  There was no benefit among those patients who did not require respiratory support.

Here’s the media release that describes the findings.  The results haven’t yet been published in a peer reviewed journal, so beware, these are just preliminary results and not peer reviewed.

The FDA has revoked the Emergency Use Authorization for hydroxychloroquine and chloroquine as treatments for COVID-19 due to new evidence that demonstrates the treatments don’t work for COVID-19 and have serious side effects.

CDC updated their guidelines for COVID-19 testing in nursing homes, clarifying testing recommendations for residents and staff, testing procedures in response to an outbreak, and new recommendations for testing for other pathogens like influenza.

They also updated their web page with information on how COVID-19 spreads, providing more detail on person-to-person transmission through respiratory droplets. Respiratory droplet exposure has been established as the dominant mode of transmission of the virus- reinforcing the importance of face coverings as the single highest return on investment intervention that we have.

• Ensure your schedule allows for a 5-8 hour commitment for at least 8 weeks (12 weeks is ideal).

• Complete the ASTHO Making Contact: A Training for COVID-19 Contact Tracers

• Register with the Arizona Emergency System for the Advance Registration of Volunteer Health Professionals  

In early June the ADHS discussed modifying 2 important documents to further guide contingency and crisis standards of care for when we move into surge status: 1) Remdesivir Allocation Guidance; and 2) Allocation of Scarce Resources in Acute Care Facilities. They’ll post the final guidance documents here.

An experienced AzPHA member working in state government recently developed the action plan below to more effectively respond to the COVID situation in Arizona. Because of the nature of the person’s they wish to remain anonymous.  I’m posting the person’s ideas here in hopes that it builds the inventory of ideas to enhance Arizona’s response.

Create clear criteria for discharge from an inpatient setting and leverage alternate care sites for Persons Under Investigation or asymptomatic/low symptom burden cases who require support to effectively isolate. quarantine. While such alternate care sites (e.g. “quarantine hotels”) have developed, their clinical oversight is variable, and they are not being utilized in a systematic or organized manner at present. When utilized with appropriate clinical oversight and proper technical assistance and support, they can be an effective tool in bending the curve.

ALL congregate settings, including non-healthcare settings – such as prisons and detention centers –  should have – a)routine screening and periodic testing procedures in place for all personnel working in the facility, b) strict standards for infection control c) guaranteed supply and use of appropriate PPE, d) personnel and pay policies that support those who are exposed or infected to stay home. Home care/ direct care workers, who serve vulnerable populations, should receive similar support from county/state agencies. One-time testing drives are insufficient.

The governor’s office should ensure more robust inter-agency collaboration in directing the response to COVID-19. ADHS should better leverage the academic workgroups that they have convened for modeling to help inform solutions. The modeling effort and disease response effort, clinical and operational functions should not remain as silos.

All counties should transparently state their contact tracing process. ADHS should set up clear standards for contact tracing, isolation/quarantine, case management and follow up by counties to include close contacts, primary AND secondary contacts beginning from 48-72 hours prior to onset of symptoms of the index case and through the infectious period.   Because of the significant impact of pre-symptomatic spread, merely tracing close contacts would be an insufficient response. 

Designate healthcare facilities  as Covid versus non-Covid. Concentrate testing, PPE, training/technical assistance, manpower, funding and monitoring into the Covid accepting facilities. This will allay anxiety among the public and allow people to seek the routine care that is so desperately needed, including childhood immunization.

Create a plan to ensure the control of vaccine preventable infections: including flu/ pneumonia, measles, newborn and childhood vaccines. Participation in the VFC program needs to be encouraged. Flexibilities for this program administration should be sought from the CDC to ensure the infrastructure for vaccine distribution is sustained through the emergency. This infrastructure will be essential should a COVID vaccine emerge.

Most important: ensure CLEAR, CONSISTENT, PROACTIVE messaging at each stage of the pandemic across state agencies. This has been a gap that leadership can correct.

Here’s a link to Dr. Gerald’s latest analysis. As expected given the numbers and trends on the various data dashboards, the trends aren’t encouraging. At least we now have some new interventions underway (view next blog post).

Reported cases and hospitalizations, but not deaths, continue to increase at a rapid pace signaling increasing community spread. While these trends differ by geographic region, Covid-19 is widespread in Arizona (see Appendix for county data).

Absolute levels of community-driven viral transmission have never been higher as evidenced by frequent daily and weekly record-setting levels of newly reported cases.

For most locales, additional government-mandated social distancing restrictions and/or mask-wearing are urgently needed to reduce the pace of community transmission.

The nature of the outbreak is changing such that new infections are shifting towards younger, working-age adults which has important implications for hospital utilization and deaths.

Covid-related hospital utilization continues to increase while excess capacity is declining. Adequate capacity currently exists, but excess capacity could be depleted by early-to-mid July.

Some hospitals are already near or at capacity for ICU care; therefore, local conditions will provide a better indicator of capacity than state-wide trends. Stated capacity may over-estimate actual capacity for structural reasons; therefore, surge beds may be need sooner than expected.

The number of Covid-19 tests is not keeping pace with rising case counts as evidenced by increasing PCR test positive rates. Positivity rates remain >3% indicating capacity is likely inadequate to meet clinical and public health demands. Test reporting lags appear to be about the same.