Crisis Standards of Care

This report from the Johns Hopkins Center for Health Security analyses the experience of hospitals across New York City during the surge of COVID-19 patients in the city from April to June 2020 with a focus on experiences with implementation of crisis standards of care (CSC). Using a virtual working group that included 15 NYC intensive care unit directors, the report presents findings around the following major themes:

• CSC planning prior to the pandemic did not always align with realities and clinical needs during the pandemic.
• COVID-19 surge response was effective but often chaotic.
• Interhospital collaboration was an effective adaptive response.
• Situational awareness was challenging for many clinicians, particularly related to information on patient load and resource availability.
• Several CSC challenges had to be overcome, especially around triage and allocation of life-sustaining care.
• Healthcare workers experienced profound psychological effects from dealing with CSC during the surge.

The report includes themes and suggestions for future CSC planning efforts that include more operational focus and more clinician involvement, as well as additional research that includes discussion between clinicians and legal advisors. Additionally, the working group indicated that clinicians need additional CSC that includes a broader understanding that “CSC fundamentally involves making the best decision one can when in an unfamiliar situation that involves risk to the patient or provider” and is “not limited simply to ventilator triage or other formal triage processes.” The group also emphasized a need for clarity in formal CSC declarations, education on the spectrum of crisis care from conventional to contingency to crisis, a focus on staffing challenges, greater family engagement regarding end-of-life discussions, and improved efficiency and rapid decision-making.

Emergency Medical Services

This study by Cash et al. assesses training and awareness regarding PPE among emergency medical services (EMS) personnel. The study used a survey of nationally certified EMS personnel in non-military positions and assessed awareness and fit testing of N95 respirators in the prior 12 months along with other related PPE awareness and training issues. Even before the emergence of the COVID-19 pandemic, nearly all personnel reported awareness of N95 respirators. Study data indicated an increase in N95 fit testing and other PPE training following issuance of CDC guidance for EMS in February 2020; however, personnel had lower odds of awareness and training if they were employed part-time, provided 911 response service, worked at a non-fire-based EMS agency, or worked in a rural setting. The authors conclude that these training gaps indicate the importance of continued efforts to support and adequately prepare EMS staff over the course of the pandemic and beyond.

Assisted Living Facilities

This CDC MMWR continues the documentation of the impact of COVID-19 in long-term care facilities, adding data specifically regarding residents and staff members in assisted living facilities (ALFs). As of October 15, 22% of ALFs (in 39 states with available data) reported one or more cases among residents and staff members, and 21% of resident cases were fatal (several times the rate of ~2.5% among the general population in the same states).