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.