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

Crisis Standards of Care: Lessons from New York City Hospitals’ COVID-19 Experience | A Meeting Report
Eric Toner; Vikramjit Mukherjee; Dan Hanfling; John Hick; Lee Daugherty Biddison; Amesh Adalja; Matthew Watson; Laura Evans
Date posted:
November 24, 2020
Publication type:
The Johns Hopkins Center for Health Security
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New York City suffered an unprecedented surge of novel coronavirus disease 2019 (COVID-19) patients from April to June 2020 associated with extraordinary use of critical care resources and high case fatality ratios. Hospitals were overwhelmed and conventional standards of care were unable to be maintained, forcing hospitals and healthcare workers to adjust the way that care was provided in order to do the most good for the greatest number.

The purpose of this project was to convene a forum in which critical care physicians from a number of hospitals across New York City could frankly discuss their experiences with implementation of crisis standards of care (CSC). The Johns Hopkins Center for Health Security, in collaboration with New York City Health + Hospitals, convened a virtual working group in October 2020 consisting of 15 New York City intensive care unit (ICU) directors. The following major themes emerged from the discussion:

  • Prepandemic 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.
  • Interhospital collaboration was an effective adaptive response.
  • Situational awareness, especially related to information about patient load and resource availability, was a challenge for many clinicians.
  • Multiple CSC challenges had to be overcome, especially around decision making for triage or allocation of life-sustaining care.
  • Healthcare workers were profoundly psychologically affected by dealing with CSC issues amid the extraordinary surge.

Looking ahead, the following themes and suggestions were expressed:

  • Going forward, there was a sense that CSC planning needs to be more operational and that 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; such decisions are not limited simply to ventilator triage or other formal triage processes.
  • More research is needed to understand what future guidance for CSC planning is needed. Discussions between clinicians and their legal advisors are needed in the planning process to resolve differences in understanding of what is and is not legal in the CSC context.
  • In a crisis, a clear formal declaration that a CSC context exists at the hospital, hospital system, healthcare coalition, and jurisdictional levels is needed. This should include specific clinical guidance about the scope of the declaration—that is, 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 plans must be made for how to proceed 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 processes must be developed that involve the treating physician as well as other physicians. Education is needed for those clinicians who are making such decisions and a process developed for them to engage another expert rapidly if possible.
  • There needs to be clarity around the kinds of triage and resource allocation decisions that hospital clinicians make frequently on very busy days and the shift in thinking and practice that is involved in a CSC context. There needs to be further education on the spectrum of crisis care—from conventional to contingency to crisis—and this should be practiced in emergency preparedness exercises.
  • Future pandemic planning should be integrated with widely accepted ICU guidance about futility of care.
  • 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 is a high priority.
  • Engagement of families is essential in end-of-life discussions, especially when resource triage issues are involved. This is much more difficult in the setting of a contagious disease that precludes families from being present in the hospital. Innovative solutions, beyond video conferencing, must be found.
  • CSC 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 healthcare workers.



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