Who will get ventilators and ICU beds? Ohio hospitals urged to plan

If Ohio’s hospitals become overrun with critically ill patients with COVID-19, the Ohio Hospital Association recommends that allocation of scarce resources, such as ventilators or intensive care beds, be made based on the likelihood of survival for each patient.

The plan, sent to hospitals this week, says it is intended to create an ethical and objective system that prevents bedside doctors and nurses from making gut-wrenching and often traumatic decisions about who gets what level of care.

The OHA produced a 54-page document to guide hospitals on managing the life and death decisions that they might be forced to make. Dayton area hospitals are still reviewing the proposal.

Ohio Gov. Mike DeWine said he doesn’t know if the state has the legal authority to order publicly and privately held hospitals to follow one set of protocols during an emergency.

“My understanding was the goal was to have the hospitals all agree to that (OHA plan,)” DeWine said on Tuesday. “I think we will let this play out. We will see where we are. These rules are not something that should be written by politicians. These should be open to the public to comment on but these are things that should be developed by people who look at the ethics, people who understand medicine. That’s really how it should be developed, in my opinion.”

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A crisis triage protocol as set out in the OHA plan would identify critically-ill patients who are most likely to survive with intensive-care interventions.

“An objective tool removes the bedside provider from having to make the agonizing decision of which critically-ill patients will receive scare life-saving resources. The process provides a fair and consistent method for allocating scarce critical care resources,” the OHA document says.

Patients would be scored on criteria such as whether they would likely survive with intensive care, any underlying illnesses with poor prognoses and if they require resources that cannot be provided.

The allocation of scarce resources should adhere to ethical considerations, such as fairness, stewardship of resources, consistency, accountability and transparency, the document says.

Access to life-saving interventions may not be available to all patients who need it, the document says. “These allocation decisions are extremely challenging, and require careful consideration, strong ethical foundations and thoughtful transition to palliative care,” it says

The OHA cautioned that its document isn’t a statewide plan and noted that hospitals and hospital systems have their own plans and approaches. It recommends that each hospital is encouraged to collaborate regionally and consider allocating resources within each region.

OHA spokesman John Palmer said the association isn’t aware of any authority vested in state law that would allow the governor or Ohio Department of Health to direct hospitals to follow a single plan.

Sarah Hackenbracht, president and CEO of the Greater Dayton Area Hospital Association, said they appreciate the work done by Ohio Hospital Association.

“GDAHA member hospitals are reviewing the OHA guidelines while taking into consideration recommendations from our regional hospitals and health-care community. GDAHA is convening ethics leaders and clinical staff from our regional hospitals to review and evaluate the proposed options,” Hackenbracht said.

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Representatives of Premier Health, Kettering Health Network and Mercy referred questions to GDAHA.

The document recommends organizations name management teams of experts to focus on ethics, outcomes and triage. The plans should be backed by top hospital leaders.

The triage team would collect scoring data and identify patients who do or don’t qualify for scarce lifesaving resources. The triage team’s primary goal is to provide the best outcomes for the largest number of patients.

The ethics team would be charged with promoting the rights of patients and shared decision-making between patients, their surrogates and their doctors. The ethics team would also be responsible for promoting fair policies.

The outcomes team would scrutinize patient outcomes to make sure triage protocols are in fact saving more lives.

Care decisions should be made based on the best available objective medical evidence — not stereotypes or personal judgments about someone’s personal worth, the document says.

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Space, staffing and supplies all depend on the volume of cases. As caseloads increase, facilities are compromised and trained staff are scarce, care decisions change. For example, resources might be re-used and allocated to those who have the highest change of survival.

The document also recommends that hospitals establish “triggers” — points when normal staff, space and equipment isn’t available. For example, when normal staffing can’t be maintained, hospitals would provide child care, housing and other staff support or limit elective or highly intensive treatments. Facilities should use conservation, adaptation, substitution and reuse of resources during surge events.

The DeWine administration has said the state must double its hospital capacity due to an oncoming surge of cases of COVID-19, the disease caused by the new coronavirus.

How big the surge will be remains to be seen, as the situation evolves every day, so it is not clear whether local hospitals will encounter the shortages the guidelines are preparing for.

Ohio State researchers have projected that efforts so far at social distancing have made a big difference in lowering the peak number of cases. Outbreak models themselves also can affect the surge when their predictions prompt officials to take big action to change the future.

Hospitals and public health officials are also making sweeping efforts to not just flatten the curve but raise the capacity bar by adding more beds and seeking out more supplies.

U.S. hospitals are already having to make tough decisions as they struggle to care for patients, acquire tests and keep staff safe, according to a newly released national survey by a federal watchdog agency.

Adding to the challenge is that hospitals are burning through their cash reserves as they suspend elective surgeries to conserve their supplies for the surge.

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The U.S. Health and Human Services took the pulse of 323 hospitals across the U.S. in a survey March 23 to 27, including a dozen Ohio hospitals.

Anticipated shortages of ventilators were identified as a big challenge for hospitals. Hospitals reported an uncertain supply of standard, full-feature ventilators and in some cases used alternatives to support patients, including adapting anesthesia machines and using single-use emergency transport ventilators. Hospitals anticipated that ventilator shortages would pose difficult decisions about ethical allocation and liability, although at the time of the survey no hospital reported limiting ventilator use.

Hospitals reported that they were not always able to have enough staff, having a shortage of specialized providers to meet the anticipated patient surge and fears that the virus infecting staff could further reduce who is able to care for patients. Hospital administrators also expressed concern that fear and uncertainty were taking an emotional toll on staff.

Administrators told the federal watchdog agency that they are running out of protective equipment like masks and gowns, needed to keep workers safe. But, without a unified purchasing strategy, and with everyone needing more supplies than usual, prices for the limited supply have been soaring. As one administrator said, everyone is “trying to pull (PPE) from the same small bucket.”

And supplies some hospitals have received were problematic, according to the federal report. Some masks had bands that were dry rotted. Another hospital’s shipment was child sized. Another shipment expired in 2010.