Crisis Standards of Care

This new report from the Center for Health Security at Johns Hopkins Bloomberg School of Public Health reports findings from a series of forums in which clinicians from hospitals across New York City discussed their experiences with implementation of crisis standards of care (CSC) during the city’s surge of COVID-19 cases between April and June 2020. An earlier set of interim recommendations was released in November 2020 based on a meeting of ICU directors, and this new report reflects findings from an additional meeting with emergency physicians in January 2021.

Several themes were consistent between the ICU directors and the emergency physicians meetings, including:

• Lack of patient load-balancing between hospital systems or to hospitals outside of New York City
• Absence of formal CSC declaration by the state, city, or any hospital
• Views of legal counsel as a barrier to CSC plans
• Limited timely information exchange within hospitals
• Insufficient training or experience among medical and nursing staff redeployed to help with COVID-19 patients
• Value of palliative care services in helping families of dying patients.

Additional themes discussed in the January meeting with emergency physicians included:

• Lack of awareness among staff with CSC concepts and lack of preparation by hospitals, administrators, and healthcare systems
• Lack of ready-to-implement CSC plans
• A “culture of secrecy” that prevented sharing of CSC-related documents with frontline clinicians
• Widespread shortages of critical equipment and supplies, including ventilators, respiratory supplies, oxygen cylinders, IV pumps, PPE, wall oxygen, and oxygen cylinders
• Mismatches between staff deployment and patient volume, including redeployment of ED staff due to lower total patient volume despite the influx of COVID-19 patients, healthcare worker furloughs and layoffs, and limited helpfulness of reinforcement clinicians deployed for surge capacity
• A “profound and ensuring” impact of the first surge on staff wellbeing and deep emotional ill effects.

The report lays out a number of stark examples of the challenges faced by frontline emergency clinicians during the first surge. Despite decades of discussion surrounding emergency preparedness and CSC planning, the report’s findings indicate several ways these efforts failed to meet the moment during the COVID-19 pandemic.

Health Care Workers

This article by Moore et al. reports a survey of nurses and nurse practitioners regarding their increased stress during the pandemic. The study found that anxiety related symptoms and perceived helplessness were correlated with how well respondents believed their employers managed PPE resources and that problematic stress was associated with a willingness to leave their current employer or the nursing profession within two years. The study used a 40-question survey administered between May and September 2020 with a convenience sample of over 400 nurses and NPs in Missouri and Georgia. While the findings provide only a snapshot of views within a geographically limited convenience sample of nurses at one point in time, the potential impact of any largescale attrition on patient care generally and on preparedness for the next pandemic would be immense. Institutional management, supply chain management, and health care workforce stress are areas that require substantial attention and improvement efforts to support staff and a functional health care system in the face of current and future challenges.