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New Report: Crisis Standards of Care: Lessons from New York City Hospitals’ Covid-19 Experience

Tuesday, November 24, 2020 - The Johns Hopkins Center for Health Security released a new report about the lessons from New York City hospitals’ unprecedented surge of COVID-19 patients in April through June 2020. Many hospitals were overwhelmed and found it challenging to maintain conventional standards of care, forcing hospital administrators and healthcare workers to adjust the way in which care was provided to focus on doing the most good for the greatest number of patients.

Based on the convening of a working group consisting of 15 NYC hospital intensive care unit (ICU) directors in October, the new report, Crisis Standards of Care: Lessons from New York City Hospitals’ Covid-19 Experience, identifies what went well and what needs to be addressed to prepare better for future health crises. These initial lessons are important for hospital systems around the country right now as COVID-19 hospitalizations are rapidly increasing in most states.  

According to the report, the COVID-19 pandemic in New York City was the first time in the United States that a transition to so-called “crisis standards of care” (CSC) was implemented by hospitals on a large and prolonged scale, 11 years after the National Academy of Medicine had released the first in a series of reports on the subject of CSC in the wake of the 9/11 terrorist attacks, Hurricane Katrina, as well as the SARS and the H5N1 influenza outbreaks.

This new report found the following:

  • Pre-pandemic CSC planning did not always align with the realities and clinical needs of the pandemic as it unfolded.
  • The COVID-19 surge response was effective but often chaotic.
  • Inter-hospital collaboration was an effective adaptive response.
  • Situational awareness, especially related to information about patient load and resource availability, was a challenge for many clinicians.
  • There were multiple CSC challenges, especially around decision-making for triage or allocation of life-sustaining care.
  • Health care workers were profoundly psychologically affected by dealing with CSC issues amid the extraordinary surge.

Looking ahead, the following themes and suggestions are outlined in this report:

  • Crisis standards of care planning needs to be more operational, and clinicians need to be more involved.
  • Clinicians must be taught that CSC fundamentally involves making the best decision one can when in an unfamiliar situation that involves risk to the patient or provider and is not limited simply to ventilator triage or other formal triage processes.
  • In a crisis, there needs to be a clear formal declaration that a CSC context exists at the hospital, hospital system, healthcare coalition, and jurisdictional levels. This should include specific clinical guidance about the scope of the declaration—which resources or processes it applies to and which it does not. CSC plans must factor in that a formal declaration from the state may not be made in time and plan for how to proceed to prepare without it.
  • Physician leaders need better situational awareness of patient load, resources, and changing guidance and policies, and they need to find effective ways to keep their staffs informed. This includes both clinical and operational information sharing among hospitals, across hospital systems, and across the city or state.
  • Triage decisions must be made quickly and cannot wait for a cumbersome committee structure. Rapid decision-making processes must be developed that involve the treating physician but also other physicians.
  • Staffing was a great challenge even before COVID-19, and the pandemic has made it an even greater challenge. It likely will continue to be the greatest challenge in the foreseeable future. Planning for critical staff shortages: ICU doctors, critical care nurses, and respiratory therapists are a high priority.
  • These situations impose a heavy emotional toll on healthcare workers. The incredible stress of the magnitude and pace of the patient surge intertwines with the moral burden of making life and death decisions. Ways must be found to alleviate some of this burden and to provide emotional support to the healthcare workers.

Read the new report.

 

 

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