As we press through contingency standards of care toward crisis standards of care, I thought it would be good to provide a little summary in plain language about what those words mean.
Hospitals generally operate under conventional standards of care. That just really means that they’re providing patient care without any change in daily practice. Every cold and flu season hospitals face surges in demand (like the week after Christmas and off and on during January and February in Arizona). But hospitals are still operating under conventional care standards.
They will juggle space and staffing and may temporarily ask ambulances to go to alternate facilities or accelerate the discharge of healthy patients. Staff may be asked to work in a different part of the hospital than they’re used to (for example a surgeon might be asked to work in the ER) but everyone is still working in their bounds of expertise and they’re following standard protocols.
As hospitals transition to contingency standards of care (where AZ is operating right now) hospitals change their practices and do everything they can to maintain the standard level of care. For example, under contingency care they will use rooms of the hospital for different kinds of clinical care than usual, like converting surgical rooms for emergency services or using recovery rooms as a makeshift intensive care unit. Doctors, nurses, and respiratory therapists make different decisions about what therapies to use because of resource shortages too. For example, they may not provide oxygen to a patient that would normally receive it because it’s in short supply.
Under contingency standards of care they also change admitting and discharge protocols. Patients that arrive in the ER who might normally be admitted will be observed for awhile and then sent home with a prescription for example.
Practitioners may start conserving supplies by, for example, not providing precautionary oxygen to patients who under normal circumstances would receive it, but who can survive and recover without it.
Patients are transferred between hospitals as they try to level out patient loads when they have periods of time. Some hospital systems like Banner are large enough to do interfacility transfers using their own resources and data. Others will need to contact the ADHS Surge Line, where transfers can be facilitated. I’ve been told that in recent days the Surge Line has been activated to facilitate patient transfers.
Hospitals restrict non emergency procedures. This isn’t something hospitals like to do because patients really need these important procedures and because general surgery and elective procedures contribute much to the financial bottom-line. Nevertheless, these procedures will begin to be postponed or canceled. This is probably already happening.
Hospitals change their admission decisions. For example, persons presenting in the emergency department may be sent home when, under normal circumstances, they would be admitted. Likewise, a patient that would normally be admitted to an Intensive Care Unit (with robust staffing rations) might instead be placed on a general ward bed.
Hospitals change their discharge decisions. People that have been admitted and who would normally stay for a couple more days will be discharged rather than observed. In some cases, persons that are in the ICU may be discharged directly to home rather than admitted to a general ward bed. Others will be discharged to a skilled nursing facility rather than a general ward hospital bed.
When the system becomes totally saturated, as will be the case in the next 2 weeks, hospitals will ask the ADHS to allow them to operate under Crisis Standards of Care.
“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. Ethics panel discussions will be held to make difficult decisions regarding who will get care and who will not.
Under Crisis standards hospitals need to make even more substantial changes to the way they provide care. For example, staff are asked to practice outside of the scope of their usual expertise. Supplies are reused and recycled. In some circumstances, resources may become completely exhausted.
Core strategies that get used under Crisis standards include substitution, adaptation, conservation, reuse, and reallocation in the areas of for oxygen, medication administration, IV fluids, mechanical ventilation, nutrition, and staffing.
The Crisis Standards of Care also provides a protocol to help healthcare providers objectively decide who gets care when resources don’t allow everyone to get treatment. This blog post fleshes it out How Will Patients Be Prioritized Under the New “Crisis Standards of Care”.
Here’s a link to the ADHS Crisis Standards of Care Planning Document. It’s 141 pages, but the real heady stuff is on pages 29 through 38 where it discusses the scoring system to prioritize which patients will get treatment and which will not and how to ration care to all patients when resources are outstripped by demand.
The ADHS also has an Addendum to the report called Allocation of Scarce Resources in Acute Care Facilities Recommended for Approval by State Disaster Medical Advisory Committee.
