Validation of a Crisis Standards of Care Model for Prioritization of Limited Resources During the Coronavirus Disease 2019 Crisis in an Urban, Safety-Net, Academic Medical Center

Albert Nadjarian, MD, MPH; Jessica LeClair, BS; Taylor F. Mahoney, MA; Eric H. Awtry, MD, FACC; Jasvinder S. Bhatia, MD; Lisa B. Caruso, MD, MPH; Alexis Clay, MD; David Greer, MD, MA; Karan S. Hingorani, MD, PhD; L. F. B. Horta, MD; Michel Ibrahim, MD; Michael H. Ieong, MD; Thea James, MD; Matthew H. Kulke, MD; Remington Lim, BA; Robert C. Lowe, MD; James M. Moses, MD; Jaime Murphy, MD; Ala Nozari, MD; Anuj D. Patel, MD; Brent Silver, MD; Arthur C. Theodore, MD; Ryan Shufei Wang, MD; Ellen Weinstein, JD; Stephen A. Wilson, MD, MPH, FAAFP; Anna M. Cervantes-Arslanian, MD

Disclosures

Crit Care Med. 2021;49(10):1739-1748. 

In This Article

Background

The coronavirus disease 2019 (COVID-19) pandemic has disproportionately impacted the United States, which represents 4.28% of the world's population, yet 23.93% of the total COVID-19 cases with over 500,000 fatalities as of March 26, 2021.[1] Despite being a high-income economy, the United States has faced a crisis with widespread reports of insufficient personal protective equipment for front-line medical workers and shortages of ICU beds. The early months of the pandemic found many countries struggling to deliver care when faced with the stark reality of insufficient beds, staff, ventilators, and supplies. With shortages in mind, many states needed to develop triage algorithms quickly in order to determine priority scoring should a healthcare system be forced to enter into crisis standards of care (CSC). CSC refers to a state when healthcare systems are so overwhelmed by a catastrophic public health event that it is impossible to provide the standard level of care to all patients.[2] At that juncture, prioritization would be made for patients who are most likely to survive the acute event, with some CSC frameworks also taking longer term survival into consideration. It is worth noting that as of May 2020 during the height of the first wave, only 29 of 50 states had any version of CSC guidelines.[3]

On April 7, 2020, the Commonwealth of Massachusetts released their initial CSC guidelines, which incorporated key components of the University of Pittsburgh model policy (Pitt Model).[4] The Pitt Model prioritizes patients using acute illness severity with the Sequential Organ Failure Assessment (SOFA) score,[5] as well as conditions prognosticating near-term survival. "Major" conditions (defined as > 50% chance of 5 yr mortality) were scored 2 points, and "severe" conditions (defined as > 50% chance of 1 yr mortality) were scored 4 points. The higher a patient's score, the lower their priority for receiving a scarce resource. However, the criteria for what classifies as poor prognostic factors for these conditions are not explicitly outlined in the Pitt model or the Massachusetts guidelines (Table 1). Hospitals were found in a unique situation of needing to clarify these conditions in order to determine resource prioritization. This issue extended to other states such as New Jersey and Pennsylvania, both which adopted similar CSC guidelines without specific scoring criteria for chronic conditions.

In April 2020, Boston Medical Center (BMC), a safety-net hospital caring for a primarily underserved and racial minority population, had the second highest total number of hospitalized patients in Massachusetts, and the highest percentage of COVID-19 patients per beds, peaking at greater than 70% of overall hospital capacity. At the peak of the initial COVID-19 surge between March 1 and May 18, 2020, 78.3% of the 1,186 patients hospitalized with COVID-19 at BMC were Black or Hispanic, 22.2% were homeless, and 24.1% were classified as critically ill.[6] A committee of BMC physicians representing several specialties met to operationalize the state's guidance on resource allocation and to define major and severe comorbidities. The representatives reviewed available prognostication models for chronic illnesses and in several cases sought alignment with other regional hospitals regarding the scoring system. When considering the task of needing to save the most lives and life-years, the committee followed the established model of developing a point system based on major and severe underlying conditions and outlined criteria to fulfill those conditions (Supplemental Table 1, http://links.lww.com/CCM/G513). The criteria were determined by extrapolation from prognostic models for chronic disease outside of the critical illness setting as well as expert consensus. In this study, we assessed mortality of patients at 1 and 5 years in a sample of hospitalized critically ill patients under nonpandemic conditions. Specifically, we hypothesized that our sample of patients who scored for major and severe conditions (using our hospital-adopted criteria) would have greater than 50% mortality at 1 and 5 years, respectively.

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