On April 16, the Illinois Department of Public Health notified the State Emergency Operations Center that hospitals may need to institute crisis standards of care pursuant to their disaster response plans. The day prior, the IDPH issued “Guidelines on Emergency Preparedness for Hospitals During COVID-19.”
The IDPH Guidelines include the graphic below, which illustrates the continuum of changes in health care delivery. The Guidelines state that crisis care standards should be triggered based on the “exhaustion of specific operational resources that require a community, rather than an individual, view be taken in regard to resource allocation strategies.” These Guidelines address the uncomfortable issue of rationing healthcare resources. The Guidelines specifically note that the Governor earlier issued an executive order limiting hospital civil liability during this emergency.
The IDPH Guidelines recognize that crisis standards of care involve a number of ethical considerations, including:
- Non-Discrimination in the Delivery of Health Care. This ethical frameworks does not permit prioritizing resources based upon judgements about an individual having greater “social value” in comparison to others.
- Ethical Conservation of Scarce Resources. The Guidelines encourage hospitals to “implement strategies now to conserve resources while they are available to prepare for rationing when they are not.” This includes the possibility of reusing items normally considered single uses, substituting drugs or devices, lowering dosages and “restricting use of resources to those patients with the greatest need.”
- Distribution of Scarce Resources. The Guidelines recognize that “hospitals will face decisions regarding how to ration resources,” and sets out factors such as the following:
- Team decisions. Hospitals must implement triage teams, rather than allowing individual providers to make allocation decisions.
- Factors for de-prioritization. The system of rationing resources should allow for de-prioritization of patients who are unlikely to benefit from the scarce resource or treatment based on factors such as (1) risk of mortality or morbidity for a particular patient; (2) likelihood of good or acceptable response to a treatment or resource for a particular patient; and (3) community risk of transmitting infection and ability to reduce that risk by using a particular resource.
- Essential workers. Hospitals should prioritize essential or key workers within the health care system in order to maintain acceptable staffing levels. This includes prioritizing available personal protective equipment to health care workers so they can continue to provide essential care.
- Randomized selection. After application of the above criteria, randomized selection processes may still be necessary if two patients are equally likely to benefit from a resource.
The Guidelines specifically provide that ventilator policies should not be based upon “first come, first served” policy.
- Composition and Function of Triage Teams. Another part of the guidance states that “One of the key elements of crisis standards of care is having an established triage plan that removes decision-making from one individual. . . . . The triage team is responsible for making scarce resource allocation decisions based on the hospital’s ethical framework”. For this reason the guidelines state that the bedside care team caring for a particular patient should not be part of the triage in order to have consistency and to maintain objectivity.
