How Will Patients Be Prioritized Under the New “Crisis Standards of Care”

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.

Unpublished Study Shows dexamethasone Reduces Death by up 30% 

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.

CDC Updates Testing Guidelines for Nursing Homes & COVID Transmission

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.

Dear Arizona Public Health Worker,

June 23, 2020

The Arizona Public Health Association (AzPHA) staff and Board of Directors thank you for your dedication, passion, and diligence as you work to save lives by slowing the spread of the SARS CoV2 in Arizona.

We see you—the extra hours worked, the weekends spent reviewing data, the countless small tasks you’re tackling that add up to a coordinated effort to stop this virus. Your dedication to the public health includes changing emergency medical service protocols; conducting case investigations and examining infection control in assisted living and skilled nursing facilities; performing contact tracing; collecting and analyzing epidemiological data; developing a surge line and its protocols; preparing crisis standards of care criteria and guidance, and much more. 

Arizona’s public health workforce is dedicated to keeping us safe. You make a difference. You are brainstorming creative solutions and making recommendations to improve system effectiveness. Your work is establishing new evidence-based public health policy interventions and pitching them to decision makers in your agency.

As Arizona’s independent voice for public health, the AzPHA is doing our part by encouraging our elected and appointed officials to implement evidence-based public health policy measures that will slow the spread of the virus. At times, this means taking positions on public health policy at odds with those officials.

For example, AzPHA has been publicly advocating for mandatory mask wearing in public indoor spaces, increased testing of staff and improved infection control in long-term care facilities, authority for cities to implement mitigation measures within their own jurisdiction, and mandatory mitigation compliance expectations for businesses.

Our work, along with the advocacy of many other organizations such as AARP, ArMA, AzHHA, and hospital systems was ultimately successful in driving important policy and resource allocation changes, as evidenced by last week’s policy decisions by the governor and local leaders.

The objective of our advocacy work is to enhance the work of Arizona’s public health workforce by persuading elected and appointed officials to make evidence-based policy choices that will help the entire public health system more effectively respond to the pandemic . As an independent voice for public health, we can take policy positions that you may not be able to take because of the nature of your employment.

You can become more involved in our public policy efforts by joining our Public Health Policy Committee which is comprised of members who are committed to improving the health of every Arizonan through engaging our members, partners, policymakers and the public to bring strong public health policies to the forefront.

If you’re interested in participating in that committee you can contact Zaida Dedolph, our Director for Public Health Policy and she can get you set up on our Policy Committee Basecamp.

We know you probably don’t hear this enough, but your work is heroic. Thank you for your continued efforts on behalf of the people of Arizona!

Sincerely,

Arizona Public Health Association Board of Directors and Staff

AzPHA Member Whitepaper on COVID Interventions

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.

Dr. Gerald’s Latest AZ Specific COVID-19 Trend Analysis & Discussion

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.

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