Crisis Standard of Care Spreads Fast, Worries Officials

Rationing of patient care: everything is different, but nothing has changed.

EDITOR’S NOTE: Crisis Standard of Care, first reported here on RACmonitor, occurred in the state of Idaho but now other states are expected to initiate the same emergency policy this week

Towards the end of 2020, an article was written and published in RACmonitor on the impending rationing of patient care in this pandemic. The number of cases and hospitalizations were increasing to a level that was overwhelming our healthcare system, hindering its ability to adequately handle treatment.

This led to about almost a year ago making considerations and decisions that could be considered radical and far-reaching from what was common practice: rationing care. The type of rationing that was suggested was unprecedented for healthcare, but is not uncommon in military, combat, and disaster scenarios. Those situations are still to this day referred to as mass casualty incidents (often shortened to MCIs, and sometimes called multiple-casualty incidents or multiple-casualty situations). This describes an incident within the United States in which emergency medical resources, such as personnel and equipment, are overwhelmed by the number and severity of casualties.

We typically associate this response with natural disasters, such as earthquakes or large events such as massive explosions, fires, etc. – but not what we saw with the pandemic. As we all know, we navigated through those troubled times over the next couple of months, and as a vaccine became available, we watched the situation improve, with a lessening of cases, hospitalizations, and deaths.

With MCIs, the goals are not dissimilar to what is being attempted today with the pandemic. The principles or goals for rationing care in the military/combat world can be summarized here as follows:

    1. Accomplish the greatest good for the greatest number of casualties;
    2. Employ the most efficient use of available resources; and
    3. Return personnel to duty as soon as possible.

Briefly, triage will classify the injured into four categories, denoted by colors:

Green – These are simply the “walking wounded,” and require very minimal care.

Yellow – These patients are more seriously injured and may eventually need intervention, but it can be delayed without danger to life or limb, and will suffice with medical treatment for the time being, as they are hemodynamically stable.

Red – These patients require immediate lifesaving intervention. They need to be recognized as such quickly, as if there is a delay, they may die.

Black – These patients would be highly unlikely to survive, and comfort measures, including pain medication, are typically the extent of their treatment.

Well, here we are again! In essence, everything is different now, but nothing has changed, only the name and type of the virus. Upon the arrival of variants, specifically the “Delta” variant, everything is going in a worse direction. This is what we saw months ago and now seem to be experiencing again, but very possibly in worse iterations. Even though new daily COVID-19 hospitalization rates in the U.S. have decreased by 5 percent over the last two weeks, as of Sept. 17, according to the U.S. Department of Health and Human Services (HHS), 30 states are still seeing hospitalization rates trend upward, according to data tracked by the New York Times.

What we are seeing today seems to be driven by the fact that there are many Americans who remain unvaccinated. The numbers of unvaccinated vary from state to state, but the most urgent situations are in those states with low rates. For example, the vast majority of people in Pennsylvania who have contracted the coronavirus were not vaccinated, according to state officials. Through early September, there have been nearly 640,000 positive cases across the state, of which 94 percent were unvaccinated. Close to 35,000 hospitalizations occurred in these positive cases, of which 95 percent were unvaccinated. In addition, there were almost 6,500 deaths, and 97 percent of these deaths were in the unvaccinated or partially vaccinated – and included more younger people than the original wave of the virus did.

This is not unique to Pennsylvania. Many hospitals are instituting something now called crisis standards of care. It is a variation of the MCI protocol.

Crisis standards of care give legal and ethical guidelines to healthcare providers when they have too many patients and not enough resources to care for them all. Essentially, they spell out exactly how healthcare should be rationed in order to save the most lives possible during a disaster. 

Under crisis standards of care, providers may have to triage patients by survival chances; medication may be rationed, and patients who would normally be kept for observation may be sent home for recovery.  

“We are giving our staff permission to not do it all,” said Shelly Harkins, MD, a hospital’s chief medical officer. “The hardest thing they will do in their careers is not giving the care they are used to giving, but they simply can’t.”

Some healthcare rationing steps have become commonplace during the pandemic, with hospitals postponing elective surgeries and some physicians switching to online visits, rather than seeing patients in person. But more serious steps – such as deciding which patients must be treated in a normal hospital room or intensive care unit bed, and which patients can be cared for in a hospital lobby or classroom – have been rare. 

At the extreme end of the spectrum, crisis standards of care generally use scoring systems to determine which patients get ventilators or other lifesaving medical interventions, and which ones are treated with pain medicine and other palliative care until they recover or die.

A sad fact: the collateral of where we are is the effect this is having on other diagnoses and critically ill non-COVID patients. As the nation’s hospitals are filling emergency rooms and intensive care beds with the COVID patients, treatment for other emergency care is being crowded out. An anecdotal example is that of a 12-year-old boy with acute appendicitis who was held off so long that by the time he had surgery, his appendix had burst, and he had a widespread infection – adding significant morbidity to his post-op course.

Here are just a few examples of where crisis standards of care are being initiated:

Helena, Mont.-based St. Peter’s Health enacted crisis standards of care on Sept. 16, as their critical care units and morgue hit 100 percent capacity, according to KTVH-DT. They said their intensive care unit, advanced medical unit, and morgue were all full.   

“The Medical Center at Bowling Green is at capacity. Critical care units are full,” said Katrina Wood, RN, MSN, CNML, Med Center Health’s chief nursing officer recently. “We are unable to accept patients from outlying facilities who we normally take and who need our help. Our emergency departments have patients waiting for critical care almost every day. The way the community can help us take care of you is to get vaccinated.”

“The hospitals that we usually call when patients need that higher level of care are now calling us looking for available beds,” said Trish Smith, director of the Appalachian Regional Healthcare command center. “I hear the distress, the worry, and the concern in their voices that patients will die if they don’t find the right level of care soon enough. Around 97 percent of the COVID-19 patients in our hospitals are unvaccinated. I am deeply concerned that we will not have the capacity to care for the next trauma patient, the next family member that has a stroke, the next neighbor having a heart attack.”

Overwhelmed by a surge in COVID-19 patients, Alaska’s largest hospital on Sept. 14 implemented crisis standards of care, prioritizing resources and treatments to those patients who have the potential to benefit the most.

“While we are doing our utmost, we are no longer able to provide the standard of care to each and every patient who needs our help,” Dr. Kristen Solana Walkinshaw, chief of staff at Providence Alaska Medical Center, wrote in a letter addressed to Alaskans and distributed Tuesday.

“Unfortunately, if you are seriously injured, it is possible that there will not be a bed available at our trauma center to save your life,” Walkinshaw wrote.

Across St. Luke’s facilities in Idaho, 39 percent of patients have COVID-19. Of those, 92 percent are unvaccinated. Furthermore, 83 percent of patients in St. Luke’s intensive care unit beds are COVID patients. Of those, 98 percent are unvaccinated.

The Idaho Department of Health and Welfare (IDHW) has activated crisis standards of care across the entire state of Idaho due to the state’s massive influx of COVID-19 patients being hospitalized. The surge, IDHW says, has exhausted existing resources in all areas of Idaho.

Crisis Standards of care were also activated in northern Idaho back on Sept. 6. This activation now expands that declaration to the rest of the state.

Statewide data from IDHW (from Monday, Sept. 13) shows there were a record 678 patients in Idaho hospitals being treated for coronavirus. A record 173 people were in ICUs, leaving only 12 open ICU beds available across the state.

Overall, only 723,255 people, or 40.47 percent of Idaho’s population, have been fully vaccinated.

This article is not political; it constitutes the facts of where we are today. We have an ongoing healthcare crisis, and many more lives are at stake. Vaccinations should be a very serious consideration for every American, and they should seek the advice of their private physician to decide if that is the right direction for them.


John Zelem, MD, FACS

John Zelem, MD, is principal owner and chief executive officer of Streamline Solutions Consulting, Inc. providing technology-enabled, expert physician advisor services. A board-certified general surgeon with more than 26 years of clinical experience, Dr. Zelem managed quality assessment and improvement as a former executive medical director in the past. He developed expertise in compliance, contracts and regulations, utilization review, case management, client relations, physician advisor programs, and physician education. Dr. Zelem is a member of the RACmonitor editorial board.

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