TRIAGE AND RESOURCE ALLOCATION

This webinar on Thursday at 3pm EST from the Network for Public Health Law includes expert speakers on critical ethical issues related to COVID-19, including ventilator allocation, triage priority, and the consideration of age, disabilities, and long-term survival.

This article by Piscitello et al. systematically reviews state ventilator allocation guidelines, finding that only about half of US states have publicly available guidelines and that significant variation in states’ approaches could cause inequities in allocation during a widespread public health emergency in which resources are insufficient to meet medical demand. The study’s results are consistent with those from another recent review by Romney et al. of state crisis standards of care documents. Both found widespread use of scoring tools (particularly SOFA score) but substantial variation in prioritization of specific groups (e.g., children, health care workers, pregnant patients), use of age as a tiebreaker, and application of exclusionary criteria (which some states have removed from their plans in response to criticism and legal challenges).

This Wall Street Journal article draws attention to potential failures to provide appropriate treatment to elderly COVID-19 patients in Sweden. Reports indicate instances of elderly patients being provided only palliative care when treatment for the disease would be appropriate and non-futile. Sweden has notably declined to institute mandatory public lockdown measures in favor of relying on building population herd immunity, but the country now has among the highest number of deaths as a proportion of population. Swedish medical authorities issued voluntary guidelines for prioritizing treatment early in the pandemic that allowed for consideration of age as part of overall health and prospects for recovery.

 Health Care Workforce

This NEJM perspective by Fraher et al. calls for active changes to expand health care workforce capacity to respond to expected increases in critically ill patients during the continuing pandemic. The authors cite both legal restrictions and internal organizational policies as restricting the ability to shift tasks and responsibilities among personnel to create additional surge capacity. The authors note several connected solutions to expand and maintain workforce capacity, including public and private payer policy changes (e.g., coverage of telehealth services), availability of third- and fourth-year medical students if provided appropriate training in immediately needed skills, utilization of retired volunteer health care professionals through license reinstatement, and deployment of other health care professionals (e.g., dentists, optometrists) whose practices are closed due to the pandemic but could be trained to provide various services such as screenings and data collection. They also call for examination of restrictions on scope of practice, cross-state licensure, and other legal and regulatory provisions that may unnecessarily hamper effective response. Notably, many states’ laws allow for temporary waiver of such restrictions during a state of declared emergency, typically by authority of the governor.

Supplies

This article by Tabah et al. reports the results of a survey of over 2700 health care workers regarding availability and use of PPE in caring for COVID-19 patients in the ICU during April 2020. A majority of respondents were physicians (67%; 27% nurses; 6% allied HCW), and most respondents were based in Europe (61%; 16% Asia; 8% North America; 8% Oceania; 3% South America) but in total represented 90 different countries. Over half of respondents reported at least one type of PPE was not available, and many (30%) reported reuse or washing of PPE due to shortage. Most (83%) reported a lack of formal training in PPE use in institutional training or pandemic-related training. As the authors note, the results are consistent with numerous accounts of supply chain problems and shortages, with significant implications for equity, justice, and health care worker safety.

This Washington Post story details several changes in management of the Strategic National Stockpile, a national network of supply caches held to respond to disasters and emergencies. Supplies of PPE, ventilators, and other equipment in the stockpile were a source of significant tension during initial response to the pandemic, with criticism of both insufficient replenishment of the stockpile over the past decade (following substantial utilization in response to H1N1 in 2009) and questionable strategies for allocating supplies to different locations. New funding for the stockpile was included in the Cares Act, and control has shifted back from FEMA to HHS, which has indicated forthcoming changes to allocation formulas and supply tracking.