If Colorado’s COVID-19 situation continues to worsen and the state moves to ration care, who gets all possible treatment would depend on a formula calculating the odds of surviving.
On Thursday, Gov. Jared Polis said if the COVID-19 situation doesn’t improve in the next few days, the state will have to take action to preserve hospital capacity.
The state is offering monoclonal antibodies — a treatment option that can reduce the odds of hospitalization from COVID-19 — to more people, but state officials acknowledged that may not be enough. If cases and hospitalizations don’t start falling soon, the state could call in health care teams from the Federal Emergency Management Agency; issue an order to remove barriers for moving patients between hospitals; halt non-emergency surgeries; or activate “crisis standards of care.”
Polis said the state could use “two or three” of those options, but didn’t specify how they would choose tactics. Health officials have said they won’t reinstate a statewide mask mandate or capacity restrictions.
Crisis standards give hospitals and other providers a framework for stretching limited resources, and legal cover if the care they can provide under the standards isn’t what usually would be acceptable.
Dr. Eric France, chief medical officer for the Colorado Department of Public Health and Environment, said it’s “likely” the state will activate crisis standards of care for health care staffing. Possible changes under those standards include:
- Redirecting health care workers to help out in strained units, with an experienced worker overseeing them;
- Considering having nurses work longer, ideally less-frequent, shifts;
- If possible, having family members or volunteers help patients with hygiene to free up medical staff;
- Activating the Colorado National Guard for nonclinical jobs, like COVID-19 testing or delivering supplies.
To some degree, those standards are already here. Some hospitals have been moving new graduates or staff who’ve had limited intensive-care training to help out in ICUs, under an experienced nurse, for weeks.
The state also could implement crisis standards for rationing care, France said. Broadly speaking, those standards prioritize patients expected to live at least one year, regardless of whether they have COVID-19 or another condition. Under those standards:
- A triage team not involved in caring for patients makes decisions.
- Patients are given scores based on measures of how well their lungs, hearts, kidneys and other organs are working; this attempts to predict how likely they are to survive one month, and a lower score is better.
- Points are added to the score based on patients’ ages and whether they have conditions that make it less likely they’ll live one year, like a cancer that has metastasized or severe liver disease.
- If patients are tied after considering their odds of survival, children, health care workers and first responders get priority.
- If there’s still a tie, the team could consider other factors, such as if one patient is an essential worker, is pregnant, or is the sole caregiver for a child or vulnerable adult. They could also give priority to younger patients, to try to save more years of potential life.
- If all other attempts to break a tie fail, the state recommends choosing at random which patient gets the resources.
- Not all decisions are between two patients; a hospital may decide not to put a very sick patient on a ventilator, for example, if they expect patients with a better chance of survival will need it later that day. It could also direct resources to another patient if one continues to get worse and isn’t likely to survive.
Early in the pandemic, the focus was on deciding who would get a ventilator. Now, the more urgent concern is allocating beds in intensive-care units, because low staffing has limited how many patients each ICU can take. Patients who weren’t assigned an ICU bed would still get a bed on a regular floor and whatever care could be offered there.
Colorado has used crisis standards of care twice, but never the standards related to rationing treatment. Initially, hospitals were allowed to reuse personal protective equipment that was designed to be used only once, like N95 masks, but the state deactivated that standard in June 2021 because of improved supply.
From April 2020 to February 2021, standards for first responders allowed them to not take lower-risk patients to a hospital and to direct them to other resources, especially if their main problem appeared to be mild or moderate COVID-19 — though if a patient directly asked to go a hospital, the response team still had to take them. The restrictions also allowed first responders to pronounce a patient dead if their heart had stopped, the odds of resuscitation weren’t good and trying to revive the patient could put the responder at risk of infection. The crisis standards for staffing were also in place during that period.
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