DENVER — Colorado health officials hosted a meeting on Thursday to discuss next steps if COVID-19 case counts and hospitalizations keep worsening.
During a lunch Zoom meeting, state health experts discussed the Colorado Crisis Standards of Care of hospital-based decision making. These are guidelines the state can implement to give health care facilities more flexibility in how they operate.
“It allows hospitals and other kinds of health care institutions to gracefully degrade their levels of service,” said Glen Mays, a professor of health policy at the Colorado School of Public Health.
Throughout the course of the pandemic, the state has implemented crisis standards of care in different areas depending on the influx of patients and constraints on hospitals.
Last year, one of these standards was implemented for emergency medical services to allow dispatch centers to only send essential resources out, ask patients to meet the EMS service outside of their home, change who is transported in an ambulance, etc. That emergency standard was deactivated in February.
During the nationwide shortage of personal protective equipment, another crisis standards of care was implemented for PPE use. It allowed PPE to be reused in some instances or used for longer than normal standards would permit, among other things.
Most recently, the state has reactivated its crisis standards of care plan for health care staffing. This allows facilities to move around staff and allow some doctors to have purview over more patients with the help of nurses and other physicians not necessarily in the field or to delegate some of a patient’s care like feeding and washing to a family member, among other things.
Although it has been discussed, never in the course of the pandemic has the crisis standards of care been implemented for hospital-based decision making.
However, with intensive care units nearing their capacity, the team of health care experts is, once again, revisiting those standards and what it would recommend to hospitals if things continue to worsen.
“It means, clearly, we have institutions bumping up against their capacity limits and they’re under stress,” Mays said.
During the emergency committee meeting Thursday, experts said these standards would not mandate anything since facilities in different parts of the state are dealing with different capacity and staffing constraints.
However, for triage of patients, the standards of care would center around three questions.
First, if a patient is not admitted, how likely are they to survive and not need to return to the hospital for the same issue?
“We’re not trying to predict mortality. We’re trying to predict will you be OK if you don’t get the service?” said Matthew Wynia, the Director of the University of Colorado's Center for Bioethics and Humanities
Others wanted more language clarification around how likely the patient is not only to survive but for their condition to improve without intervention.
They pointed out that some accidents or conditions are not necessarily life-threatening but can be incredibly painful and would need treatment.
“If were discharging people are sending them out from the [emergency department] to only present tomorrow with the same complaint, they should, based on this principle, be admitted,” said Dr. Anuj Mehta, a pulmonary critical care physician at Denver Health.
The second triage question the standards of care could have hospitals consider is if a patient is admitted to the hospital, how likely are they to not survive?
“If the patient is not going to survive even with the intervention, then that’s a potential time we should be thinking about alternate pathways,” Mehta said.
The third question hospitals reaching capacity might need to consider with these standards is would the patient have access to alternative levels of care without being admitted to the hospital? This could mean not admitting patients who might be able to get help from an urgent care, pharmacy or other service provider.
Socioeconomic status would also be considered, so people who are experiencing homelessness or who don’t have someone at home who can help care for them would be more likely to be admitted under these standards.
There was also discussion about applying these standards equitably.
For non-COVID-19 emergencies, the updated standards of care could also make room for hospitals to increase its risk level in the patients they discharge. Currently, many hospitals will admit a patient with less than a 1% mortality rate. These emergency standards could bump up that risk tolerance to 5% in some scenarios.
“Eventually, it may have to be how likely are you to survive? In a real dire strait, that may be how we limit it. But I think we’re not there yet,” Mehta said.
During the discussion, experts said vaccination status should not be considered in the standards.
After Thursday’s discussion, the team is now reviewing the proposed guidelines and will made their own recommendations on how to revise the standards.
Mehta believes this framework could be transformative in areas beyond COVID-19.
The framework we’re developing here, the general framework, I think has a lot of applicability for a lot of things, including mass casualty incidents that could happen at any point,” he said.
The committee is hoping to have a final standards plan by next week. It will not be implemented, however, unless the situation worsens.