The Oregon Health Authority on Friday issued interim guidelines on how hospitals should equitably prioritize access to potentially life-saving treatments should the health care system become overwhelmed by the ongoing pandemic or a future natural disaster.
It’s hardly an academic question, as daily cases of the highly contagious omicron variant public have set records all week and topped 10,000 cases Friday, roughly triple the late summer high point in the delta wave.
While omicron appears to cause less serious illness, Oregon hospitals are already operating on very thin margins in terms of available beds, and public health officials predict the sheer size of the omicron surge will drive a major wave of hospitalizations, as it has in other states. In the coming weeks, they predict that will strain and potentially swamp available staffing, bed capacity and vital equipment necessary to deliver normal standards of care – although the state managed to make it through the earlier delta surge when infections spurred record hospitalizations and deaths.
In a worst-case scenario, a new wave could leave hospitals making life or death decisions on how to allocate scarce resources among competing patients.
Area hospitals are already beginning to feel the pinch in emergency rooms. COVID-19 hospitalizations have been rising steadily and spiked 12% Thursday, though intensive care units have not seen the same uptick and the supply of ventilators remains plentiful.
Dr. Dana Hargunani, OHA’s chief medical officer, said the interim tool issued Friday is based on standards used in Arizona, Washington and Massachusetts. Hospitals can use their own standards if consistent with the state’s or adopt the interim tool.
In the event multiple patients are competing for the same scarce resource, the state tool provides a scoring system hospitals can use to rank patients based on their likelihood of surviving to hospital discharge. It takes into account how many of their bodily functions are compromised, and to what extent. The protocols stress that an individual’s use of medical or social resources in the past or the future should not be a factor in care decisions.
If two patients need the same scarce treatment, say a ventilator, and present with tie scores, the interim tool says the choice of who gets the treatment should be randomized. It also describes the triage teams that hospitals should set up – independent of the primary caregiver – to make the ultimate triage decisions.
Hargunani says the tool provides an objective way for hospitals to manage difficult triage decisions that’s in line with the state’s equity principles and avoids perpetuating historical inequities in health care access and outcomes among the disabled and various minority groups.
“We hope this doesn’t need to occur,” she said of the crisis standards, “but we believe the risk is in front of us.”
The tool does not speak to the allocation of new pharmaceutical treatments for patients infected with the coronavirus, such as monoclonal antibodies, which are in short supply. Hospital officials said Friday that the same equity principles apply, but the calculation of which patients are likely to benefit from such treatments, versus survive to hospital discharge, is different, so standards may need to be modified to deal with those situations.
Hospitals and health care organizations have spent months asking the OHA for such “crisis standard of care,” arguing that they needed consistent, statewide guidelines on how rationing decisions should be made, as well as state-defined trigger points for when a crisis will be declared and the standards kick in, whether statewide or in specific regions.
Yet the OHA has remained largely silent since the state scrapped previous crisis care guidelines that were developed by 42 health care and community groups statewide. That happened in 2020 after disability groups launched a civil rights challenge to the standards, arguing that they were discriminatory to those with disabilities and minority groups historically disadvantaged by the health care system.
In their place, the OHA issued a statement of equity principles that hospitals should adhere to in rationing care: non-discrimination, health equity, patient-led decision making and transparency. But the statement provided no triage standards, and some health care experts said it actually tied providers’ hands by telling hospitals to exclude a number of clinical indicators from their decision making, including underlying conditions, life expectancy and quality of life.
Then they heard nothing from OHA until mid-December, when the prospect of a massive new wave of COVID-19 driven by the omicron variant lit a fire under the agency and it promised to deliver an “interim crisis care tool.” That was what arrived Friday and OHA said it is seeking applicants for a new advisory committee to review and amend the interim tool and develop any additional resources required.
Crisis standards are a morally and competitively fraught subject. In a normal environment, with unconstrained resources, health care providers typically seek to treat patients with whatever intervention necessary unless directed otherwise. Meanwhile, in a competitive health care market, no individual hospital or health system wants to be the first to declare a crisis while other health care systems hold off on similar declarations. And from a patient standpoint, no one wants to believe such decisions are being made on an ad hoc basis in a back room.
Many experts believe it’s a system that calls out for state leadership and coordination, for establishing standards, coordinating interhospital transfers and allocating emergency resources.
“It’s human nature that people don’t want to acknowledge that terrible things are happening,” said Dr. Matthew Wynia, director of the Center for Bioethics and Humanities at the University of Colorado. “Particularly in a competitive system, you’re not going to have one of them say, ‘Look we’re harming patients right now because we’re overwhelmed.’ Everyone ends up saying we’re close but we’re not hurting anyone yet, when in fact patients are being hurt right now.”
Hargunani said that she’s not concerned about that conflict, as the state and health care organizations across the state have been successfully coordinating responses to multiple disasters – wildfires, ice storms, the pandemic – for the last two years, and that crisis conditions descend on individual institutions quickly, and can be resolved quickly with that cooperation.
But Dr. Robert Macauley, a medical ethicist at Oregon Health & Science University and pediatric doctor who specializes in palliative care, said in an interview Friday that it would be useful for the state to step into that role and make the crisis declarations on a broader basis, not leave the call up to individual institutions.
Dr. Renee Edwards, chief medical officer for OHSU, agreed. She said the institution had already established its own standards of care and saw no conflict between the state tool and its own. But they do differ in some ways. In the event of a tie between two patients seeking the same treatment, OHSU’s standards go a step further than the state’s in that they also consider patients’ life expectancy six months out from discharge.
She said that would likely become part of the discussion over permanent standards, as well as whether hospitals should be prioritizing care for children or pregnant women. The state’s interim tool doesn’t address those situations.
Edwards said the crisis standards may or may not be needed during the current surge, but she highlighted the need for Oregonians to keep their guard up and keep exercising COVID-19 protocols. The crisis care standards don’t differentiate between a patient who shows up at the emergency room with a heart attack, a car accident or coronavirus, she said, but hospitals around the state are already effectively full.
Meanwhile, their ability to delay so called “elective surgeries” is declining for patients who have already seen those procedures delayed and their conditions become more acute.
As of Thursday, Oregon reported nearly 600 hospitalized patients statewide tested positive for the coronavirus, about half as many as the delta peak. Forecasts suggest the number could increase to about 1,650 by month’s end.
“We’re already full,” she said. “Even small number of patients that require ICU care can tip us over the top.”
To see more data and trends, visit https://projects.oregonlive.com/coronavirus/
— Ted Sickinger
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