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During surges in COVID-19 infections, the lack of regional, statewide, and national data has made it difficult to locate available resources when extra equipment, staff, and space are needed.
This kind of crisis requires a model that runs counter to the typical way competing health systems operate, said Laura Evans, MD, medical director of critical care at the University of Washington Medical Center in Seattle.
When regional disaster responses work well, no hospital is in a substantially different stage of crisis management than its neighboring hospitals, Evans explained during her presentation at the virtual COVID-19: What's Next conference, organized by the Society of Critical Care Medicine.
But to share resources, walls between competing healthcare entities must be broken down and new models of allocation must be implemented.
Oregon is an admirable example of this kind of coordination, Evans told Medscape Medical News. When the virus hit the West Coast, Oregon Health & Science University took the lead and developed a tracking system to facilitate the sharing of resources.
The dashboard uses information in electronic health records and updates — every 5 minutes — the number and types of beds and ventilators available at every hospital in the state.
Now is the time, before a potential second wave of COVID-19, for hospital administrators to develop relationships across health systems and formulate strategies to track inventories and share resources, Evans said.
Although the allocation of scarce resources has focused on beds and ventilators, decisions also need to be made about who gets access to other resources that are in short supply, such as dialyzers and drugs like remdesivir, said Ryan Maves, MD, a critical care specialist at the Naval Medical Center in San Diego.
Effective Triage Plans
Triage policies should ideally be made by independent and objective critical care clinicians who can develop strategies before another surge, Maves said during his presentation.
"The absence of a triage system, consistently applied within and between hospitals, may lead to unnecessary deaths, increased moral distress for frontline physicians, and a lack of public confidence in the fairness of scarce resource allocation," he and his colleagues say in their implementation guide recently published in Chest.
In San Diego, Maves explained, leaders in academic, private, and federal health systems had regular discussions about topics such as how to distribute remdesivir when it arrived from the Federal Emergency Management Agency, how to distribute sedative drugs, such as neuromuscular blockade agents, and how to move patients from hard-hit to less-hard-hit hospitals.
Plans should also clearly establish whether children will be regarded separately or in combination with adults, and whether pediatric hospitals will be preserved as distinct entities. Such decisions are complicated, Maves said, because COVID-19 is much more prevalent in adults than in children.
Recent triage algorithms tend to shy away from exclusion criteria — age, for instance — but have taken specific groups into consideration, such as pregnant women, healthcare workers, and first responders.
And potential biases against particular populations should also be taken into account.
For example, Black and Latinx populations have a higher burden of pre-existing conditions that could unfairly affect their care, so factoring Charlson Comorbidity Index scores into triage decisions could put such patients at a disadvantage.
"They potentially may suffer even more from a lack of resource allocation, especially when you look at how these communities have been hit so much harder with COVID," Maves said.
At this point, triage criteria are too local to call for nationwide or international triage policies. In general, however, triage should be for patients who are neither too sick nor too well to need intensive-care resources.
"The goal of triage can be summed up in one of two philosophies," Maves said: "To save the most lives or to save the most life years."
Patients and their families should also have a voice in their care, said Shahla Siddiqui, MBBS, an anesthesiologist at Beth Israel Deaconess Medical Center in Boston.
"It becomes important to give them some aspect of control in deciding how far they want to go based on their disease severity and the knowledge we have at the time," she explained during her presentation.
But the toll taken on providers who must decide how to share resources should not be underestimated, Evans noted.
"These are decisions that nobody wants to have to make," she said. "Organizational support is essential [and gives] people safe spaces to share those experiences and debrief."
Current models that assess emotional responses of providers who face disasters look at discrete events, such as hurricanes or earthquakes, not long-term events, such as this pandemic.
"A lot of us in the field are worried about the lasting impacts on the healthcare workforce," she added.
Evans, Maves, and Siddiqui have disclosed no relevant financial relationships.
COVID-19: What's Next. Presented September 11 and 12, 2020.
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Cite this: Scarce COVID-19 Resources Demand That Competitors Share - Medscape - Sep 18, 2020.