Author: Will Humble

Last week the ADHS announced that they’ve authorized “Crisis Standards of Care” within our hospital systems. The declaration allows for statewide triage protocols when the demand for healthcare exceeds the ability to provide care using normal standards of care.

Arizona is the only state to have made such a declaration and this is the first time it has ever been made in Arizona. See last week’s blog post to see how patients will be prioritized when Crisis Standards of Care are being used.

Here’s the document that officially activates the new crisis care standards for patient triage and prioritization. Now that we’re under the crisis standard, there are civil liability protections for healthcare providers and institutions who are following the approved Triage Protocol.

Hospitals are also urged to: 1) activate tactics identified in the Arizona Crisis Standards of Care; 2) prepare for surge; 3) limit surgeries; 4) activate hospital incident command; and 4) establish regular communication with local health jurisdiction.

These measures have become necessary because of the tremendous community spread of the virus in AZ and the resulting surge of patients into AZ hospitals.

Latest analysis shows that city/county face covering requirements may be slowing the acceleration of SARS CoV2 but hospital capacity still in peril

The week ending June 28 recorded 22,388 new Covid-19 cases, which is an 8% increase over last week’s revised tally of 20733 new cases, marking a grim 4-week period with 50–70% increases per week. However, this week’s increase looks to be about 30% from the previous week.

But don’t celebrate too much…  absolute levels of community-driven viral transmission have never been higher as evidenced by frequent daily and weekly record-setting numbers of newly reported cases.

While still reflecting enormous growth, it’s slightly less exponential suggesting that perhaps the local face covering ordinances may be showing a moderating effect on the still steep trajectory.

PCR testing capacity continues to increase but it’s not keeping pace with viral transmission as evidenced by the very high percentage of patients testing positive which was 21.8% this past week.  This figure is the worst in the nation by a wide margin and likely the highest percent positive in the world right now. 

Since the end of the stay at home order, COVID-19 hospitalization has increased 243%. Increases in general ward occupancy have been greater than increases in ICU occupancy (284% versus 140%).

Non-COVID patients are being squeezed our of hospitals as evidenced by the fact that while inpatient COVID hospitalizations are up over 250% all-cause occupancy is up 12% during that time period. This trend could be a result of non-COVID patients being triaged out of the hospital system. Continued increases in case counts are expected to drive additional hospitalizations for the foreseeable future.

Note: COVID patients are more labor intensive than typical ICU patients and therefore pose a more intense drain on provider resources.

The week ending June 21st is now the week with the largest number of reported deaths. Given that case counts are continuing to increase, a larger number of deaths in the coming weeks is expected.

Arizona State University Covid-19 Modeling and Evaluation Team – July 1 Update

The ASU Modeling and Evaluation Team updated their findings last week in their July 1 Update. provided selected findings from their July 1st update.  A pre-print of their work with specific model specifications and additional results is also available.

The team projects Arizona will reach 100% of existing hospital capacity in early-to-mid July absent further reductions in non-Covid hospitalizations or increased bed capacity.

A substantial amount of federal money has been provided to states to help with the public health responses to the pandemic. In addition, the state legislature allocated $50M to the ADHS to assist with the response.  I thought it would be interesting to provide a breakdown of how it’s been spent so far. It’s from a JLBC report. Last week, the ADHS notified the JLBC how it has spent some of that money. Here’s the dollar line item breakdown:

• $71M for medical supplies and PPE; 

• $10M for ventilators;

• $9.2M for COVID-19 testing;

• $8.2M for counties and $1.8M for tribes;

• $8.1M for the St Luke’s surge hospital buildout;

• $5.5M for ADHS overhead, advertising, I.T., and legal services;

• $3.9M to expand childcare options for essential workers;

• $2.2M to the Department of Emergency and Military Affairs;

• $2.1M to operate the Arizona Surge Line;

• $1.5M for serology/antibody testing;

• $986K for lab equipment and supplies for the ADHS Lab; and

• $452K for the Arizona “Testing Blitz”

Last week CMS directed Medicare Administrative Contactors and Medicare advantage plans to cover COVID-19 testing for patients and residents in nursing homes. Hopefully this will improve testing in those facilities.

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.