Facilities & Providers

In response to case surge in Arizona, hospitals in the state requested waiver of several legal requirements that generally protect patients against abuse, neglect, and discrimination, as detailed in this Arizona Republic article. The state health department responded by waiving 16 of the 35 provisions highlighted by the hospital association. Among the requirements waived were mandates that hospitals post patient rights language in all facilities, provide written patient rights statements upon admission, and provide privacy during communications with social services. Among the provisions the state declined to waive were those requiring hospitals to provide emergency services to all individuals who request them, to ensure that all medical and nursing personnel are CPR qualified within 30 days of start date, and rules governing patient transfers.

This Acta Biomedica article by Capolongo et al. proposes 10 strategies for new hospitals and refurbishment of existing hospitals to improve resilience and ability to adapt quickly to new challenges. The authors structure the strategies in two tiers: design and operations. Design strategies discussed are: Strategic Site Location; Typology Configuration; Flexibility; Functional program; and User-centeredness. Operations strategies discussed are: Healthcare network on the territory; Patient safety; HVAC and indoor air quality; Innovative finishing materials and furniture; and Healthcare digital innovation.

This commentary by Sharma et al. discusses particular challenges faced by health care providers in rural and underserved areas, including limited health care infrastructure, distance to advanced care, and population characteristics such as tobacco use, hypertension, obesity, and age. The authors offer guidance to address these issues using alternative ventilator strategies, novel PPE, and common therapeutic options. Alternative ventilator strategies include conversion of non-invasive ventilators and anesthesia machines. Novel PPE includes use of anesthesia masks with HEPA filters, sewing masks from sterile wrapping material from surgical instruments, and using 3-D printing to produce masks and face shields. Therapeutic options discussed include convalescent plasma and remdesivir, as well as potentially tocilizumab with appropriate IRB oversight if data supports this. The article also recommends use of clear drapes or intubation boxes for high-risk airway procedures to reduce HCW exposure, as well as expanded screening of HCWs and nursing home residents.

Supplies

This CNN article and this STAT article discuss challenges currently facing hospitals regarding distribution of remdesivir. According to hospitals, distribution to hotspot locations has not kept pace with the number of hospitalized patients, while other states and locations have more than they currently need. Phamaceutical manufacturer Gilead Sciences donated 940,000 vials to the U.S. government, and the administration has secured a further supply for 500,000 patients and is distributing according to states according to case data.

This AJPH article by Sinha, Burgeois & Sorger address community-level responses to shortages of PPE and other supplies to address supply chain fragility. The authors discuss local fabrication of a variety of items with emphasis on regulatory considerations, including: ventilators, vent splitters, N95 respirators, mask frames, surgical/cloth masks, nasopharyngeal swabs, PAPRs, face shields, PPE sanitizing techniques, surgical/procedure gowns, hand sanitizers, and scrubs.

Resource Allocation

This article by Han and Koch in Disaster Medicine and Public Health Preparedness, written by staff members of the New York State Task Force on Life and Law involved in the group’s Ventilator Allocation Guidelines Project, compares the 2007 and 2015 versions of the guidelines with emphasis on incorporation of advances in medicine and societal values.

Both versions rely on the same ethical principles (duty to care, duty to steward resources, duty to plan, distributive justice, and transparency) and apply clinical criteria to evaluate likelihood to survival in order to allocate ventilators during scarcity (applying first exclusionary criteria, then assessment using SOFA score, then periodic clinical assessments). Key changes from the 2007 to 2015 guidelines include limiting definition of survival to short-term survival (limiting impact of personal bias or quality of life assessments), restricting exclusionary criteria to those associated with immediate and near-immediate mortality that can be assessed with appropriate accuracy, and clarification on use of SOFA scores and periodic clinical assessments.

The authors also discuss recommendations released by other entities, including those specific to COVID-19, and how they compare to the New York guidelines, including rejection of exclusionary criteria.

This Pediatrics article by Antiel et al. (currently a peer reviewed pre-publication version) addresses whether pediatric patients should be prioritized for scarce life-saving treatments (specifically ECMO) during the COVID-19 pandemic. The article presents comments by a variety of experts in critical care, end of life care, bioethics, and health policy. Reflecting the diversity of opinion on this issue, the comments offer a variety of approaches:

• Antiel & Curlin: 3-part rationing approach using prognosis first, followed by age as a tie-breaker, then random lottery for roughly equivalent cases
• Persad & White: age-based prioritization for pediatric patients based on “fair innings” theories (young patients have had the least opportunity to live through all stages of life), but distinguished from general prioritization by life expectancy
• Zhang, Clickman & Emanuel: multi-principle framework (based on the principle that any individual allocation principle will be flawed and insufficient standing alone) that incorporates pediatric prioritization as one among several factors for allocation that also considers prognosis, saving the most lives, lottery, and prospective instrumental value during a crisis.
• Lantos: priority for pediatric patients as reflecting fairness from a life stage perspective and distinct from other prohibited discriminatory factors such as social worth, race, disability, gender, wealth, or fame.