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State prepared with crisis plan for worst-case scenario in pandemic

The document created in November outlines how to ethically and fairly maximize resources when they're not enough
Posted at 6:25 PM, Dec 11, 2020
and last updated 2020-12-11 19:25:01-05

OMAHA, Neb. (KMTV) — It seems unlikely that hospitals will become overwhelmed by this coronavirus pandemic to the point where they have to triage patients, some health care officials say.

But they say that should it happen, Nebraska’s ethical framework and crisis management plan is now ready.

“I would say it’s unlikely that we will reach a point where we would have to implement crisis standards of care,” Dr. Cliff Roberston, CHI’s CEO, said on Nov. 24. “It is a possibility.”

Since then, Nebraska’s COVID-19 hospitalization numbers have improved.

Major healthcare players in the state have endorsed a Crisis Standards of Care plan created and reviewed by a large team of specialists in November. In the spring, metro-area hospitals approved a plan that was less broad and detailed.

“Numbers were getting to a point that we were concerned (in early November), said Rachel Lookadoo, who helped develop the plan and is the director of legal and public health preparedness at the University of Nebraska Medical Center’s Center for Preparedness Education. "It's a good idea to have that plan in place, regardless."

Nebraska Medicine, CHI, and Methodist announced their support in a joint statement, and it was endorsed by the Nebraska Hospital Association and Nebraska Medical Association.

The statement says the plan is “a proactive and much needed step for not only the health care providers in our state, but more importantly the citizens of Nebraska.”

“Patients seeking care across the state will be assured equitable and consistent treatment, regardless of where they live or where they seek care. If and when we reach a point in our battle with COVID-19 – we are NOT there yet – enacting the crisis standards of care does signal that we are facing a point of scarce resource allocation. By having a crisis standards of care plan that is based in sound ethical principles, triage teams will use the plan as a guide for such allocation, removing those tough decisions from the bedside care team.”

The overall goal is to ensure the “most good is done for the greatest number of patients,” Lookadoo said.

That means prioritizing people who are more likely to survive. For example, among people who need a ventilator, the first people to lose it would be those who are least likely to survive. It’s not an arbitrary decision: there would be a tiered point system that uses a modified version of a score known as the Sequential Organ Failure Assessment.

Triage teams would be responsible for making the tough decisions and implementing the system. This is done to “minimize moral distress” to those providing the care. It would allow them to focus on the care itself.

The plan calls for transparency with the public when the crisis standards are activated.

It also is clear on characteristics that don’t matter in rationing care including race, disability, gender identity, sexual orientation and perceived quality of life. The plan aims to ensure everyone has an equal shot at treatment and that care isn't offered on a first-come-first-serve basis.

Much of the planning is about avoiding needing crisis standards of care in the first place. Nebraska has six healthcare coalitions that connect area facilities, Lookadoo said.

The team that developed the Crisis Standards of Care plan also created the Nebraska Medical Emergency Operations Center.

“It breeds more collaboration...making sure we’re connecting dots and doing what we need to do to step into gaps when we have then,” said Abigail Lowe, who also helped develop the plan and is a UNMC ethics and preparedness specialist.

Nebraska’s plan lacks backing from the state government. Gov. Pete Ricketts says he does not have the authority to approve the plan. State Sen. Sara Howard of Omaha suggested a special legislative session to give the governor that authority. According to the Nebraska Hospital Association, Nebraska is one of 13 states that does not have a state-backed crisis standards of care plan.

A state-backed plan would give an “added level” of confidence in the statewide cohesiveness of a plan, said Stephen Doran, the bioethicist for the Archdiocese of Omaha. He said confidence in the plan’s cohesiveness is already high.

The plan outlines three levels of care: conventional, contingency, and crisis. While Nebraska hospitals haven’t reached the crisis level, they have been at contingency levels. For instance, some hospitals have had to set up ICUs in locations not typically used for intensive care, Doran said.

If care that would typically be received is denied, the family or emergency contact would receive an explanation, the document says.

The full Crisis Standards of Care plan is here.

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