Covid-19 Crisis Forces California Hospitals To Plan Who Gets Life-Saving Care

Plans for how to make calls about scarce medical resources were published this week. Covid-19 Crisis Forces California Hospitals To Plan Who Gets Life-Saving Care

Overwhelmed California hospitals raced this week to complete crisis-care plans that give priority to which patients get care when there aren’t enough staff, supplies and lifesaving equipment, raising concerns that the inconsistent criteria across hospitals will lead to disparities for patients.

In a prolonged nationwide Covid-19 surge, California leads states in daily new cases and deaths, with about 22,800 hospitalized as of Wednesday, figures from Johns Hopkins University and the Covid Tracking Project show. Four hospitals have approached or hit the crisis point before getting state help, California’s Department of Public Health said.

The state required hospitals to publish crisis plans this week. A review of some plans by The Wall Street Journal found hospitals came up with varied policies for how to decide which patients will receive critical services when demand outstrips available supply. Hospitals must notify public-health agencies as they hit crisis stage, but public officials gave conflicting answers this week on whether they would notify the public.

Hospitals and public officials said they are working to avoid reaching a crisis state by moving people or support where they are needed. But the surge has pushed some hospitals near or to their limits. Shortages of critical supplies are acute; Los Angeles County, for example, told ambulance crews on Monday to conserve oxygen given to patients.

Methodist Hospital of Southern California is using its crisis policies to review patients daily but hasn’t yet been forced to ration care, said Dr. Bala Chandrasekhar, Methodist Hospital’s chief medical officer.

“We are getting into the habit of streamlining the process so that if at some point we need to do something we are a well-oiled machine,” said Dr. Chandrasekhar. “We’re doing this day to day, we’re looking at what resources are available on a daily basis, what our needs are, and we’re trying to match it as best as we can.”

Dr. Chandrasekhar meets each morning with other members of the hospital’s triage team to review patients in the hospital’s intensive-care units and emergency-room beds who require critical care. Each patient is scored on the basis of their predicted mortality using the sequential organ failure assessment, known as the SOFA score, he said.

Crisis policies seek to maximize the lives saved with limited resources, but putting the policy into practice is agonizing and contentious among doctors, ethicists and advocates. California and other states have issued guidelines to hospitals, but hospital policies don’t always follow California’s recommendations and can vary widely, a review of some policies by The Journal found.

“It has the potential to create big and unexpected disparities,” said William Parker, a critical-care doctor at the University of Chicago who studies health-care rationing. Wealthy and well-connected patients can more easily identify and travel to hospitals with the most available resources, he said. Others cannot.

Also, some California hospitals use prioritizing algorithms that may disadvantage people of color, who have been disproportionately hit hard by the pandemic, doctors said. S

ome hospitals consider chronic conditions, which are more prevalent among people of color as a result of longstanding inequities, said Emily Cleveland Manchanda, director of equity initiatives for the Boston Medical Center emergency-management department, who has studied state crisis-care policies.

Officials at Scripps Health in San Diego said the five-hospital system uses the same prioritization criteria as other San Diego County hospitals for patients who need extracorporeal membrane oxygenation machines, which are extremely limited and are used when ventilators fail. Scripps made the change early in the pandemic to ensure equitable access, said Juliann Eigner, the cardiac critical care nurse who manages the program.

Crisis plans can use different methods to decide which patient is most likely to live and should receive scarce resources, how to break ties among patients and whether there are patients who should be categorically excluded from critical ICU or ventilator care under crisis conditions.

California and many other states use the SOFA scoring system for organ dysfunction to decide who is least likely to survive. Patients who are worse off have more points under the SOFA system.

Physicians said the score works well, but isn’t perfect. Prior health problems can push up scores. Some patients with similar laboratory test results will inevitably fall on either side of point cutoffs.

“The nature of this exercise, unfortunately, is it ends up drawing these boundaries that can end up being excruciating,” said William Feldman, a critical-care doctor at Brigham and Women’s Hospital in Boston who helped develop the hospital’s crisis plans.

California tiebreakers allow hospitals to consider some severe and advanced health problems that limit near-term survival. But the state policy says no patient should be categorically excluded.

Prominent California-based hospital systems and national chains with hospitals in the state said they would follow state scoring guidelines, including Kaiser Permanente, based in Oakland, Calif., and HCA Healthcare Inc., based in Nashville, Tenn.

Others drafted their own crisis policies. University of California Los Angeles and San Diego hospitals combine the SOFA score with information on severe comorbidities that limit near-term survival—but also use information about moderately severe chronic comorbidities that could impact outcomes, such information on patients with end-stage renal disease who are on dialysis or on those with chronic lung disease.

Dr. Cleveland Manchanda said such chronic comorbidities are more prevalent among people of color and called the criteria “very problematic.”

“The plan was developed with broad input and granular detail that would guide decision-making for a number of scenarios,” a UCSD Health spokeswoman said. State guidelines allow underlying comorbidities for tiebreakers, she said. She cited universitywide crisis guidelines that said addressing inequities would require “controversial and pragmatically impossible value judgments.”

UCLA Health said no one was immediately available for comment as staff responded to the coronavirus surge.

California doesn’t explicitly exclude anyone from scoring, which its guidelines say would “raise fundamental questions of fairness.” Some hospital policies rule out ICU care or ventilator use for some patients during crisis mode. Riverside University Health System’s policy said patients who suffer catastrophic heart attacks, burns and some other traumas “will not be eligible” for the critical services.

“Patients with these types of medical conditions are routinely treated in our facility and may receive ICU or ventilator support if in the judgment of the treating physicians they may benefit from it,” said Raul Coimbra, surgeon-in-chief for Riverside University Health System-Medical Center.

“In a mass-casualty situation with multiple victims presenting emergently the medical and trauma literature shows that those with these types of traumatic injuries are the least likely to benefit from ICU care or ventilator use.”

At Methodist Hospital, Dr. Chandrasekhar said that while the hospital ran low at some points on supplies of epinephrine and propofol, they were restocked and the triage team hasn’t, to date, had any close calls with care rationing.

But he could see that happening if the surge continues, and he urged the public to heed orders to stay home and avoid gatherings.

In the past few days, he said, the hospital has acquired about 50 additional nurses, at least a dozen through assistance from the California Department of Public Health after it reported going into crisis standards of care.

The resources helped, Dr. Chandrasekhar said. But as of Thursday morning, 18 emergency-room patients were waiting for a hospital bed, with 11 of those needing an ICU bed.

“It is the complete antithesis for doctors to talk about even rationing care,” he said. “We are not trained to do that; we have never been trained to do that.”

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