COVID-19: Expert Review of Relevant and Emerging Literature

COVID-19: Expert Reviews of Relevant and Emerging Literature2020-08-07T11:15:25-04:00

This cross-sectional study examines associations between county prevalence data and characteristics of 3,357 skilled nursing facilities (SNFs) in 25 states (341 Genesis facilities and 3,016 non-Genesis), including 64 Genesis SNFs which underwent universal testing.

  • 118 (35%) Genesis and 640 (21.2%) non-Genesis SNFs had outbreaks (one or more residents testing positive for SARS-CoV-2)
  • SNFs with outbreaks were larger, had higher Star-ratings for both overall staffing and RN staffing, and had higher proportions of Black residents; however, in multivariate analyses that included geographic location only facility size remained significant.
    • These facilities were most frequently located in counties with higher SARS-CoV-2 prevalence, higher population densities, and larger Black populations.
  • A 10-bed increase in facility size was associated with a 0.9% (95% CI: 0.6, 1.2; P<.001) increase in probability of SNF outbreak.
  • An increase of 1,000 per 100,000 cases in county SARS-CoV-2 prevalence was associated with a 33.6% (95% CI: 9.6, 57.7; P<.001) increase in probability of SNF outbreak and a difference of 12.5 SNF cases.

The authors conclude that size was the only facility characteristic associated with case count, and this depended significantly on overall county prevalence. There were no consistent relationships between facility quality and outbreak severity. The authors suggest geographic location is a necessary factor when considering the allocation of limited resources and the ability of state health departments to aid in staffing shortages.

White EM, Kosar CM, Feifer RA, et al. Variation in SARS-CoV-2 Prevalence in US Skilled Nursing Facilities. Journal of the American Geriatrics Society. n/a(n/a). doi:10.1111/jgs.16752

This review was posted on behalf of Lauren Albert, IU School of Medicine student, and reviewed by Dr. Kathleen Unroe, IU School of Medicine Associate Professor, geriatrician, and IU Center for Aging Research Scientist.

This article was published on June 1st, 2020 in the Journal of the American Medical Directors Association (JAMDA). A group of medical directors from several New York skilled nursing facilities (SNF) give detailed consensus policy recommendations on COVID-19 management. Key recommendations include:

Measures Regarding Staff and Residents

  • Employees should be screened for COVID-19 symptoms at beginning of shift. Screen all residents for symptoms of COVID-19 twice daily. Facemasks should be provided to both staff and residents.
  • N-95 masks and eye-shields should be given to staff when in direct patient care/contact.
  • COVID-19 testing should be done only if: testing is performed on staff/residents without a history of COVID-19, testing occurs with at least 3 rounds of testing 1 week apart, up to date technology to ensure quicker results, and a plan for if staff/resident test is positive.

Management of COVID-19 Positive/Presumed Positive Cases

  • If a resident tests positive, a designated unit should be created to cohort positive patients, with specific staff assigned to unit.
  • Management of positive patients:
  • Provide antipyretic therapy with acetaminophen as needed.
  • Provide supplemental O2 if pulse oximetry is <90%. Advance to venti-mask if hypoxia not improved.
  • Consider prophylactic anticoagulation therapy as COVID-19 is found to be procoagulant. Consider Antibiotics if a concern arises for bacterial pneumonia.
  • Consider h2 blocker as a treatment for reflux disease.
  • Transmission based precautions can be discontinued if:
  • At least 3 days have passed without a fever (without use of antipyretics), improvement in respiratory symptoms, and at least 14 days have passed since COVID-19 symptoms started.

OR

  • Lack of fever (without use of antipyretics), improvement in respiratory symptoms, and negative results on at least 2 consecutive COVID-19 tests at least 24 hours apart.

Admissions

  • Hospitalized patients who are COVID-19 positive should be admitted to positive unit in the SNF. Hospitalized patients who are COVID-19 negative can be admitted to transition unit for 14 days while symptoms are monitored.

Lester PE, Holahan T, Siskind D, Healy E. Policy Recommendations Regarding Skilled Nursing Facility Management of Coronavirus 19 (COVID-19): Lessons from New York State. J Am Med Dir Assoc. 2020;21(7):888-892. doi:10.1016/j.jamda.2020.05.058

This review was posted on behalf of Spencer Hofschulte-Beck, medical student at Marian University, and approved by Dr. Kathleen Unroe, IU School of Medicine Associate Professor, geriatrician, and IU Center for Aging Research Scientist

This European article focuses on emergency medicine palliative care guidelines for assessment and treatment of COVID-19 patients who are stable, unstable or near the end of life.

3 categories of palliative care patients were created by initial assessment (WHO early warning parameters, saturation levels, respiratory rate, and a local COVID-19 specific assessment tool):

  • Stable- Patients may still recover but have a high symptom burden. Morphine and Lorazepam were often utilized to manage symptoms. Virtual family visits were possible, but in-person visits were time-consuming for staff and risked contamination.
  • Unstable-Patients are not going to recover. They experience rapid deterioration and O2 saturation < 88% irrespective of oxygen supplementation. Treatment focuses on symptom management, hydration, and comfort care. Family visits may be possible but brief.
  • End of Life– Patients have low saturation levels and are dying. Inability to communicate necessitates more frequent symptom assessment, and combinations of benzodiazepines and anti-psychotics were used for sedation. Oxygen supplementation was not helpful, opioids for comfort were preferred. In person visits were preferred as virtual visits were found to be highly distressing to the patient’s family.

For patients whom mechanical ventilation is an unsuitable treatment, palliative care management is needed. The authors have generated clear care guidelines, including specific assessment tools and medication dosing, to aid in palliative treatment by non-specialist medical professionals who may not be as familiar with end-of-life and comfort care.

Fusi-Schmidhauser T, Preston NJ, Keller N, Gamondi C. Conservative Management of COVID-19 Patients—Emergency Palliative Care in Action. J Pain Symptom Manage. 2020;60(1):e27-e30. doi:10.1016/j.jpainsymman.2020.03.030

This review was posted on behalf of Lauren Albert, IU School of Medicine student, and reviewed by Dr. Kathleen Unroe, IU School of Medicine Associate Professor, geriatrician, and IU Center for Aging Research Scientist

]This case report details the association between hip and lower limb fractures in three elderly patients and COVID-19. It was published on 4/7/2020 out of Isfehan University of Medical Science in Iran by the Archives of Bone and Joint Surgery.

Introduction

Badrood General hospital in Iran was a hospital especially hit hard by the COVID-19 outbreak. In March of 2020, they noticed both an increase in positive COVID-19 cases and hip fractures.

Case Presentation

Patient 1 – A 73 year old male admitted with an intertrochanteric femoral fracture.  Preoperatively he complained of generalized weakness. Surgery proceeded without complications. Discharged 2 days post-op. 3 days after surgery he returns with new onset of fever, weakness, dyspnea and anorexia. Labs showed positive C-reactive protein(CRP), elevated liver tests, lymphocytopenia, and chest CT scan was diagnostic for COVID-19.

Patient 2 – A 69 year old male admitted with an intertrochanteric femoral fracture who also complained of weakness, but denied a cough or fever. A chest CT was ordered and was positive, considered as diagnostic for COVID-19. Labs showed elevations in CRP and showed lymphocytopenia.

Patient 3 – A 93 year old female admitted with a femoral neck fracture. On admission, patient showed low grade fever, cough, and fatigue. Labs showed leukocytosis, lymphopenia, and an elevated CRP. A chest CT scan was diagnostic for COVID-19.

Discussion

Weakness and fatigue were the most common complaints of the three patients. Patients with fragility lower extremity fractures are often older adults with multiple underlying conditions, their hospital stays are often lengthy, increasing their chances of obtaining and transmitting the infection. Stress associated with fracture/surgery can trigger a series of oxidative stress responses and inflammation making these patients more vulnerable to COVID-19. Authors conclude there is a possible relationship between COVID-19 infection and fragility fractures.

Shariyate MJ, Kachooei AR. Association of New Coronavirus Disease with Fragility Hip and Lower Limb Fractures in Elderly Patients. Arch Bone Jt Surg. 2020;8(suppl1):297-301. doi:10.22038/abjs.2020.47626.2333

This review was posted on behalf of Spencer Hofschulte-Beck, medical student at Marian University, and approved by Dr. Kathleen Unroe, IU School of Medicine Associate Professor, geriatrician, and IU Center for Aging Research Scientist.

In this opinion paper, authors focus on the role of malnutrition in the elderly and its associations with immune health and suggest treating malnutrition could aid in decreasing the effects of COVID-19.

  • Advanced age and comorbidities are associated with impaired nutritional status, a multifactorial etiology with associations including impaired cell-mediated immunity, decreased cytokine production, decreased phagocytic ability, and difficulties with antibody production.
  • Nutrients including vitamins (A, B group, C, D, E) and minerals such as zinc, selenium, iron, copper, and magnesium have been shown to support both innate and adaptive immunity.
  • Treatment of malnutrition has demonstrated improvement in immune responses within the aging population.

Therefore, the authors suggest that malnutrition could contribute to increased susceptibility and worse outcomes in aging patients with SARS-CoV-2, and further research is needed on the role of nutritional support and its ability to both identify high risk patients and to reduce mortality rates.

This review was posted on behalf of Lauren Albert, IU School of Medicine student, and reviewed by Dr. Kathleen Unroe, IU School of Medicine Associate Professor, geriatrician, and IU Center for Aging Research Scientist.

Bencivenga L, Rengo G, Varricchi G. Elderly at time of COronaVIrus disease 2019 (COVID-19): possible role of immunosenescence and malnutrition. GeroScience. Published online June 23, 2020:1-4. doi:10.1007/s11357-020-00218-9

Published on :  | By Ross Silverman

Covid-19 Law & Ethics Round Up for August 4, 2020

Reopening Primary Schools During the Pandemic

An important perspective published in the New England Journal of Medicine. Indiana is one of the earliest states to start the new school year. However, school districts around the country are struggling with the task of protecting students, faculty, and staff (and their communities) while safely reopening. What follows below are recommendations for how to view and provide support for primary schools that can apply to all school districts. According to the authors:

[W]e would argue that primary schools are essential — more like grocery stores, doctors’ offices, and food manufacturers than like retail establishments, movie theaters, and bars. Like all essential workers, teachers and other school personnel deserve substantial protections, as well as hazard pay. Remote working accommodations should be made if possible for staff members who are over 60 or have underlying health conditions. Adults who work in school buildings (or drive school buses) should be provided with PPE, and both students and staff should participate in routine pooled testing.” (citations omitted)

Conclusion:

Whether (and how) to reopen primary schools is not just a scientific and technocratic question. It is also an emotional and moral one. Our sense of responsibility toward children — at the very least, to protect them from the vicissitudes of life, including the poor decision making of adults who allow deadly infections to spiral out of control — is core to our humanity. Our expectations of school personnel are equally emotionally and morally fraught. It is not incidental that the majority of primary school teachers are undercompensated women who are expected to sacrifice themselves “for the sake of the children.” School closures have also brought social, economic, and racial injustice into sharp relief, with historically marginalized children and families — and the educators who serve them — suffering the most and being offered the least. For all these reasons, decisions about school reopenings will remain complex and contested.

But the fundamental argument that children, families, educators, and society deserve to have safe and reliable primary schools should not be controversial. If we all agree on that principle, then it is inexcusable to open nonessential services for adults this summer if it forces students to remain at home even part-time this fall.

Is Telehealth Here to Stay?

The New York Times asks whether this intervention that has rapidly expanded in use during the epidemic will stick around once the emergency passes. Telehealth has been a significant benefit for those seeking treatment for substance use disorder and mental health services during the Covid-19 epidemic. And this week, the Center for Medicare and Medicaid Services proposed rules that would expand Medicare reimbursement beyond the public health emergency.

Covid-19 Vaccine Policy 

The news that one vaccine in development has moved into Phase 3 testing has increased the public discussion about:

(a) ensuring the vaccine’s safety and efficacy; (b) ensuring adequate engagement and health communication to maintain public trust in the vaccine’s safety and efficacy (see this piece and the associated summary from the Johns Hopkins Center for Health Security); (c) the distribution of the vaccine, including how to prioritize what populations receive the vaccine when supply may be scarce; as well as (d) whether or not states should require that certain populations receive the vaccine.

For a discussion of many of these issues, see Ensuring Uptake of Vaccines against SARS-CoV-2, a piece I coauthored in the New England Journal of Medicine.

Eviction

The expiration of federal protections against eviction (as well as expiring protections against foreclosures and utility shutoffs) raises significant concerns about the near-term and long-term health-harming disruption to the lives of hundreds of thousands in the midst of the ongoing public health crisis. Governing magazine has a piece discussing recent policy steps states have taken to protect renters

Contact Tracing

Contact tracing efforts have been failing in many states, here’s why

Law & Ethics During the Covid-19 Epidemic: Webinar Series

This summer, the American Society for Bioethics + Humanities has held a webinar series with leaders in the fields of public health law and bioethics on issues arising in the Covid-19 Epidemic. Full videos of these talks are linked below:

  1. Nursing and the Law with Prof. Emily Largent of the University of Pennsylvania
  2. Public Health Law (Part 1 & Part 2) with Prof. Lindsay Wiley of American University
  3. The Changing Terrain of Healthcare on the Front Lines with Dr. Michael Stephen of Jefferson Hospital in Philadelphia
  4. Crisis Standards of Care and Liability Shields with Prof. Valerie Gutmann Koch of the University of Houston
  5. The Ethics of Immunity Based Licenses (“Immunity Passports”) with Prof. Govind Persad of the Sturm College of Law
  6. Covid-19 Research Law & Ethics with Prof. Kayte Spector-Bagdady of the University of Michigan School of Medicine
  7. Health Equity & Justice in the Covid-19 Pandemic (Part 1, Part 2, Part 3) with Prof. Ruqaiijah Yearby of St. Louis U. School of Law, our own Prof. Seema Mohapatra from IU McKinney School of Law, and yours truly.

The authors of this article respond to the American Geriatric Society’s (AGS) position paper on the importance of not using age as exclusion factor when considering allocation of scarce resources during the COVID-19 pandemic in the emergency department (ED). They also provide recommendation to provide high quality care to older adults in the ED during the pandemic.

When a COVID-19 patient that is an older adult presents to the ED they are often in respiratory distress or their illness severity is high. This leads to quick decision making. An informed clinical decision needs to considered with knowledge of the patient, their history, their prognosis, and their values which may be difficult to obtain in an urgent situation.

One of the first pieces of information given when a patient presents to the ED is their chronological age. Without further information on a patients history, a team may use the chronological age of a patient (consciously or subconsciously) to guide them in their clinical decision making.

Many ED’s have decision rationing frameworks that to attempt to avoid age as the primary criteria. Triage frameworks to assess likelihood of survival some may include:

  • Sequential Organ Failure Assessment (SOFA), which relies on laboratory values
  • Clinical Frailty Scale (CFS), can be used before laboratory values are returned in cases of urgent decision making

In addition to age, another piece of information typically know on arrival is that the patient was from transferred from a “facility,” which is often misinterpreted. Although skilled nursing facilities (SNF) often house the frail, chronically ill, and long term residents, there are many facilities that house otherwise healthy older adults that are receiving short term care.

COVID-19 may cause delirium in older adults and impair their decisional capacity. Older adults can also have visual and hearing impairment, impairing their capacity to express their wishes. With the COVID-19 pandemic, many hospitals and ED’s have limited the amount of visitors, which takes away advocates for cognitively impaired individuals. These advocates, with the proper PPE, should be allowed to accompany the patient. To gain more information about the family, the care team should make an effort to talk to the family, make telephone calls to health care proxy/surrogate decision makers, outpatient providers, skilled nursing facility providers, and extensively review outpatient and hospital visit history.

Other suggestions to assist in optimal decision making for older adults include:

  • Involving triage teams, other disciplines/providers, and administrative leadership in decision making Providers should be made aware of advanced directives and have goals of care conversations
  • Providers may consider delaying intubation when possible to allow for more time to make informed decisions, as many patients can be maintain on external oxygen for a period of time

This call to action was written by an international consortium of long term care researchers.  They draw a direct line from the societal under-responses, globally, for the support and safety of workers in nursing homes to the devaluation of these workers and nursing home residents.

The authors provide some short term considerations for nursing home leaders and policy makers to support the well-being of their residents and staff:

  • Clear direction and guidance in keeping staff informed through daily huddles and messaging platforms to enhance communication
  • Keep staff healthy and focus on stress management as well as meeting their basic needs including providing daily meals and promoting physical activities
  • Implementing new clinical changes including offering hazard and sick pay, proper PPE training for staff, and policies to expand the work force
  • Supporting end-of-life care through implementing education/training opportunities to insure staff have the proper knowledge and skills

Longer-term solutions in nursing homes are also needed to combat the poor public image, address a broken funding system, improve working conditions for staff, and address the lack of meaningful data to monitor and develop practice. The authors recommend:

  • A focus on leadership training for nurses in nursing homes
  • Appropriately staffing facilities, and equipping staff with appropriate tools and training, to address both the social and medical needs of residents
  • Use of interprofessional teams and changing the culture to support person-centered working environments

This research letter discusses a study that employed universal COVID testing of previously untested nursing home residents across 11 Maryland long-term care facilities.

  • Untested residents were asymptomatic.
  • This study identified an additional 354 cases of positive SARS-CoV-2 infection(39.6% of residents tested) . This is compared to the original 153 cases identified via targeted symptom-based testing.
  • Solely utilizing symptom-based testing may miss a substantial number of asymptomatic residents who can perpetuate transmission in long-term care facilities.
  • COVID outbreaks and mortality in long term care facilities may be lowered by increased testing and case detection.

Bigelow BF, Tang O, Barshick B. Outcomes of Universal COVID-19 Testing Following Detection of Incident Cases in 11 Long-term Care Facilities.  JAMA Intern Med. Published online July 14, 2020. doi: 10.1001/jamainternmed.2020.3738

Summary authored by Daniel Chimitt with edits by Jennifer Carnahan, MD, MPH, MA

This article examines the COVID-19 preparedness of fifty-six nursing homes across the United States.

  • 56 of 942 nursing homes surveyed responded to this survey
  • The greatest preparedness concerns of the 56 nursing homes in this study were: lack of supplies (43%), staff shortages (34%), and resident health and safety (14%).
  • The financial burden of the pandemic on nursing homes is immense. Increased cost of supplies has led to inadequate supply of PPE and staff shortages have resulted in increased overtime.

Quigley DD, Dick A, Agarwal M, et al. COVID ‐19 Preparedness in Nursing Homes in the Midst of the Pandemic. Journal of the American Geriatrics Society. Published online April 28, 2020. doi: 10.1111/jgs.16520

Summary authored by Daniel Chimitt with edits by Jennifer Carnahan, MD, MPH, MA

Published on :  | By Megan McHenry

Weekly Review: Clinical testing and treatment

Clinical Testing and Evaluations

In a cohort of 145 patients with mild to moderate COVID-19 illness, replication of SARS-CoV-2 in older children led to similar levels of viral RNA as adults, but significantly greater amounts are detected in children younger than 5 years. While the study only looked at nucleic acid levels rather than infectious virus, it draws concerns that young children could potentially be important drivers of SARS-CoV-2 spread in the population.
In a study of 85 COVID+ patients, SARS-CoV-2 RNA in serum (which generally has lower levels that the corresponding viral loads of throat swabs) was detected at highest levels between 11-15 days after symptom onset. The extent of lab derangement was higher and end organ damage was more common in those with higher SAR-CoV-2 RNA serum levels compared to those with lower levels. Mortality rates were also higher among patients with RNAemia.

Treatment

In a comparative analysis of phase 3 data from a remdesivir trial and a retrospective cohort of patients with severe COVID-19 found that remdesivir was associated with significantly greater clinical recovery by day 14 and 62% reduced odds of death versus standard-of-care treatment in patients with severe COVID-19

Observational study of 255 patients w/ COVID-19 found when IL-6 receptor inhibitors (tocilizumab or sarilumab) was administered prior to >45%FiO2 requirements, there was an associated with improved COVID-19 outcomes, such as decreased intubation and reduced mortality.

A retrospective study looking at hospitalized patients with COVID-19 who were admitted to the ICU compared to those not admitted to the ICU, and the clinical data regarding use of tocilizumab (an IL-6 inhibitor) was compared. The ICU group had higher rates of preexisting co-morbidities (hypertension, diabetes, coronary disease, etc) and higher IL‐6 than non- ICU group (all P<0.05). Age, peak IL‐6, and peak d‐dimer were significant predictors of in‐hospital mortality (1.05 [1.01‐1.09], P=0.012, 1.001 [1.000‐1.002], P=0.002, 1.10 [1.03‐1.18], P=0.008). Tocilizumab did not affect in‐hospital mortality after adjustment for confounders including IL‐6 (OR [95% CI]: 1.00 [0.27‐3.72, P=0.998]).

This article describes some of the issues that older adults may face during the transition from the emergency phase to “phase 2” of the COVID-19 pandemic. It is written with regards to older adults in general and then discusses the implications on patients with dementia.

  • Most countries are beginning to reopen or shift into “phase 2” of the pandemic. This creates new challenges that will disproportionately impact the older adult population.
  • Social distancing and self-isolation policies have negatively impacted the health of older adults. This has taken form through missing scheduled clinical visits, social isolation, and increased sedentary lifestyle.
  • People with dementia have been affected by social distancing and isolation which can lead to worse pre-existing neuropsychiatric symptoms such as agitation, depression, and feelings of loneliness or abandonment.
  • Loss of nonpharmacological therapy for patients with dementia due to the pandemic may result in new or increasing dosages of psychoactive drugs, thereby causing undesired side effects.
  • As “phase 2” rolls out, it will be necessary to prioritize resources for those who need them. Patients with dementia can be given a brief triage questionnaire focused on biopsychosocial status in order to determine those with the greatest need for immediate care.
  • Remote care delivery strategies are often advantageous for older adults and especially those with dementia. We should continue to develop these systems and ensure that vulnerable populations have proper access to them.

Canevelli M, Bruno G, Cesari M. Providing Simultaneous COVID-19–sensitive and Dementia-Sensitive Care as We Transition from Crisis Care to Ongoing Care. J Am Med Dir Assoc. Published online May 21, 2020. doi:10.1016/j.jamda.2020.05.025

Summary authored by Daniel Chimitt with edits by Jennifer Carnahan, MD, MPH, MA

This commentary outlines challenges assisted living communities face in light of COVID-19 and provides recommendations for adhering to federal guidelines in spite of these challenges.

Assisted living providers face numerous challenges concerning federal guidelines to prevent the spread of COVID-19. Among them include family visitation restrictions, transfer policies, use of third-party providers as essential workers, staffing guidelines, and rural hospitalizations. To address all of these challenges, the authors recommend effective communication practices by assisted living providers that incorporates digital technology. Different forms of online communication can be used with families, government agencies, and other providers. Because of the unique structure and needs of assisted living communities, assisted living providers need to work alongside state and federal agencies to care for and reduce the number of people with COVID-19.

Published on :  | By Daniel Orenstein

Ethics, Law & Policy Roundup: Staff, Stuff, Space & Systems

Facilities and Staff

This Viewpoint by Guddati argues that facility policies that fail to provide adequate PPE for health care professionals, including those that prohibit using scarce PPE (specifically masks) when seeing patients not confirmed to be positive for COVID-19, are improper medically, ethically, and legally. The author describes a scenario in which a physician is prohibited from wearing a mask while seeing patients in a COVID-19 rule-out floor. Medically, the author argues, this is inappropriate because the floor has higher probability of having infected patients, posing higher risk to health care professionals and their families and increasing personnel shortages. Ethically, a duty to treat (distinct and broader than legal duty) requires health care professionals to provide care even at increased personal risk, but also requires reciprocal actions from facilities to balance patient care and personnel safety. Legally, the author cites to employer duties under Occupational Safety and Health Administration (OSHA) guidelines to provide a safe work environment. OSHA has issued guidance for employers regarding COVID-19, including specifically for health care that allow for flexibility to account for PPE scarcity, including prioritizing PPE for higher-risk exposure situations. However, OSHA’s guidance does not eliminate an employer’s duty to provide a safe work environment, which is also frequently required under parallel state laws.

This article by Giangola et al. describes the approach taken by a New York medical center to increase capacity and provide intensive care during a surge of COVID-19 cases in March-April 2020. Among the strategies discussed is adaptation of the tiered staffing strategy provided by the Society of Critical Care Medicine as a staffing model for ICUs. Teams consisting of ICU physicians, non-ICU physicians, residents, Pas, and nursing staff were deployed, leveraging the competence of physician extenders and allowing rapid expansion of physical capabilities. Scheduling was designed to maximize contiguous days in-house and days off to prevent burnout. These approaches allowed utilization of surgeons as medical intensivists and rapid training of noncritical care-certified surgeons to manage COVID-19 patients with supervision.

This Health Affairs blog by Madad et al. discusses challenges in procuring equipment and supplies, protecting health care workforce, and adapting to changing supply chains and complexities of operationalizing crisis capacity strategies in another large New York health system. System-wide guidance was provided on extending and reusing PPE, video and photo guides were developed to adapt to different ventilator models, protocols were created to decrease the amount of medications requiring IV infusion pumps, and a central network was utilized to coordinate and source equipment and PPE from non-traditional sources. Among other strategies, training videos, guidance documents, tip sheets, pictorial guides, and a hotline helped train and re-train health care workers on infection prevention and PPE donning and doffing as public health guidance evolved.

Resource Allocation

This article by Iyer et al. discusses resource allocation in the context of enrollment in COVID-19 treatment trials. Specifically, the article addresses how to determine who should be enrolled when there are more interested and eligible patients than trial slots and the importance of avoiding ad hoc and potentially biased decision-making, which in addition to ethically problems could also compromise the value of the trial. The article notes that trials more often face the challenge of sufficient recruitment, but allocation of limited trial slots has arisen in the context of experimental treatments for conditions with limited therapeutic alternatives, such as AZT trials during the early HIV epidemic. The article argues that at least four ethical principles are relevant: social value, fair participant selection, risk-benefit profile, and collaborative partnership. Based on these, the article recommends using a weighted lottery system to select participants. A random lottery enhances fairness of selection and stewardship of resources, but does not optimize risk-benefit profiles or social value, but appropriate weighting (e.g., algorithmically ensuring proportionate representation of persons with clinically relevant comorbidities) can expand the advantages of a lottery system to ethically allocate resources and enhance the social value of trials.

This article is the American Geriatrics Society (AGS) position statement, “Resource Allocation Strategies and Age-Related Considerations in the COVID-19 Era and Beyond”. It includes the official recommendations of AGS, designed to guide stakeholders in the allocation of resources during the COVID-19 pandemic.

  1. Age should not be a factor in resource allocation nor should it be used to exclude patients from standard of care interventions.
  2. Social determinants of health should be regarded during the assessment of comorbidities.
  3. When there is a need for allocation of limited supplies key factors to consider are in-hospital survival and comorbidities contributing to short-term mortality.
  4. Criteria including “life-years saved” and “long-term predicted life expectancy” create bias and should not be considered in regard to resource allocation.
  5. Individuals charged with triage should have knowledge of available resources and be available to clinicians during the decision-making process of resource allocation; however, they should not be involved in the care of patients needing the limited resources. If feasible triage committees should be multidisciplinary.
  6. Resource allocation plans should be transparent and administered consistently. These plans should be created with guidance from ethics, medicine, law, and nursing. Reassessment of plans should be at regular intervals to include current scientific developments and to evaluate impact and potential bias.
  7. Advance care planning discussions play a crucial role in delivery of ethical patient centered care. While these discussions would ideally occur in advance of a crisis, attempts to conduct advance care planning in all settings should be escalated.
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