Here’s a hypothetical scenario that, very soon, may not be hypothetical at all in Colorado: Two patients arrive at a hospital emergency room, both gravely sick from the new coronavirus, both needing a critical-care bed.
But, in the crush of patients, there’s only one bed available. So, who gets it?
On Sunday, a special committee of Colorado doctors and public health experts unveiled their plan for how hospitals will make that decision as they fill up with patients suffering from COVID-19, the disease caused by the coronavirus.
The plan spells out exactly how doctors and hospitals should implement crisis standards of care — the triage protocols that effectively prioritize treatment for some above others during times when the hospitals can’t save everybody. It takes into account how sick people are when they arrive, what underlying medical conditions they have and how many years of life they may have left.
Except for special provisions for health care workers and first responders, there is no consideration of a patient’s social standing. A person’s race, religion, sexual orientation, gender identity, income level, disability or immigration status are not considered. There are no special exemptions for VIPs. Under the plan, the governor would be treated the same as everybody else.
“This is going to be a very somber discussion,” Jill Hunsaker Ryan, the executive director of the Colorado Department of Public Health and Environment, said at the start of the meeting. (Ryan has been in isolation after her husband tested positive for COVID-19. Ryan tested negative, though she had symptoms of the disease.)
On Sunday, the number of coronavirus-linked deaths in Colorado hit 140. The number of confirmed cases passed 5,000. Health officials have warned there may be 10 times that number infected, but because of a dearth of testing they haven’t been identified.
To ensure social distancing, committee members called in remotely through the video-conferencing program Zoom. One participant, a doctor, joined the videoconference from the hospital intensive-care unit where he was working. He wore a surgical mask throughout.
The crisis plans won unanimous support Sunday from the committee, which is known as the Governor’s Expert Emergency Epidemic Response Committee or GEEERC. But they will be implemented with the step-by-step caution of a nuclear missile launch.
Next, it is up to Gov. Jared Polis to issue an executive order authorizing potential use of the crisis standards. After that, it will fall to CDPHE Chief Medical Officer Dr. Eric France to decide when the health system has become so strained that the standards officially become necessary. And, then, each hospital or hospital system will have a triage team that implements them.
What would happen after that is something hospitals in Colorado have never done before: choose on a large scale who will likely live and die.
“This is completely uncharted territory,” said Dr. Stephen Cantrill, an emergency medicine specialist at Denver Health who helped write the plans.
Details on the standards
The GEEERC approved crisis standards for three areas Sunday, but the biggest — by far — was the plan for the hospital system. There is a four-step process for hospitals to evaluate patients, Cantrill explained to the committee.
Step one is assessing the patient’s health upon arrival and assigning a score that combines two different measurements. The first measurement is the Sequential Organ Failure Assessment, or SOFA, score. It looks at a patient’s oxygen levels and other medical data.
The second measurement is a modified version of the Charlson Comorbidity Index, which considers a patient’s age and whether the patient has any underlying medical conditions like cancer or cardiovascular disease.
Those two measurements combine into a score between 1 and 8, with 1 being better and 8 being worse. A patient who scores lower will have preference in receiving needed medical resources over a patient who scores higher.
But, if there’s a tie, Cantrill said the plan moves to step two — which will give preference to children, health care workers and first responders. If the tie still isn’t broken, it moves to step three, where pregnancy, years of life that could be preserved and whether a person is a caregiver for someone else are all considered.
And, if the tie still isn’t broken, it moves to step four — a random lottery. The exact method of the lottery would be decided by each triage team.
MORE: Read more about Colorado’s newly released crisis standards of care, including a short explanation and the detailed standards for hospitals, which includes a more thorough explanation of the scoring system.
During the GEEERC meeting, state Attorney General Phil Weiser asked how many patients are expected to get to that step.
“I wish we had a better handle on the numbers, but we don’t,” Cantrill said. “We hope they’re small.”
Cantrill said the plans will be implemented at each hospital or hospital system by triage teams that are separate from the doctors and nurses who are treating the patients, to keep the teams neutral. Triage teams must be available 24 hours a day, and they must be located in Colorado.
The plan also doesn’t just apply to incoming patients. People who have previously been admitted to the hospital but whose conditions are worsening could, for instance, be removed from a ventilator to give a new patient a chance, based on the scoring system.
But, Cantrill said it’s important to know that whatever resources a patient is assigned, doctors and nurses will do the best they can to treat that patient with the resources allotted.
“These patients will still be receiving the best care we can offer,” he said.
New protections for PPE use
The GEEERC also approved crisis plans for emergency medical services and another for the use of medical personal-protection equipment or PPE.
France said the PPE standards will likely be implemented soon, based on what hospitals across the state are reporting. Scott Bookman, CDPHE’s incident commander for COVID-19, said during the meeting that Colorado has now received everything it expects it will get from the Strategic National Stockpile.
But supplies are still running short. During the meeting, Dr. Anuj Mehta, the doctor who joined the GEEERC meeting from a hospital intensive-care unit, held up a single N95 mask for others to see. It was the only N95 mask he had been assigned for the day, he said. He was storing it in a pink pitcher for safekeeping when it wasn’t in use.
The PPE crisis standards legally authorize medical workers to use supplies in what would normally be substandard ways, such as reusing masks that are typically intended for one-time use. The federal government has already provided guidance for medical workers to do this, but the new crisis standards offer greater legal protection.
“This is to leave no room for debate,” Weiser said.
The standards also make clear that medical workers should not perform CPR on a patient with COVID-19 if adequate protective equipment is not available. Doing so would greatly expose the worker to infection, which could lead to fewer doctors and nurses available on the front lines to treat patients.
“Our first aim is to avoid this”
By the end of the meeting, the mood on the videoconference was glum. Ryan thanked GEEERC members for their work. She said there would be more crisis standards for palliative care and other areas to be debated at another meeting.
“We certainly hope that we don’t have to use these crisis standards of care,” she said earlier in the meeting.
But there is a looming sense that they may be unavoidable. National models suggest Colorado could run out of critical-care beds within days, if the numbers continue rising as they have been.
On Saturday, Dr. Deborah Birx, the coordinator of the White House coronavirus task force, specifically mentioned Colorado as a place that could soon become a hotpot.
Polis has said he won’t hesitate to authorize crisis standards of care. And hospitals are looking at ways to stretch their ventilators by treating two patients with a single machine.
But Cantrill said it’s important, if things do worsen, for the public to understand what will happen.
“Our first aim is to avoid this,” he said. “And, if we can’t, we want it done in a manner where we can still maintain social cohesion, trust in the health care system and the opportunity that we can come together and heal when this is over.”