Think Out Loud

Oregon develops new ‘crisis standards of care’

By Sage Van Wing (OPB)
Jan. 10, 2022 4:28 p.m.

Broadcast: Monday, Jan. 10

The Oregon Health Authority has published new directions for hospitals in the event they need to triage patients and decide who gets urgent, life-saving care in a crisis — and who may not — when there aren’t enough critical resources, such as intensive care beds, available. Dana Hargunani, Chief Medical Officer at Oregon Health Authority, explains.

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The following transcript was created by a computer and edited by a volunteer.

Dave Miller: This is Think Out Loud on OPB, I’m Dave Miller. Omicron case counts in Oregon are surging, they are way above the Delta peak. So far, hospitalizations have not followed suit. But hospital administrators are preparing for the worst. And now, they have updated guidance from the state about what to do if that happens. Last week, the Oregon Health Authority published new interim crisis care guidelines. It’s a triaging tool for how to proceed if there are not enough healthcare resources to go around.

Dana Hargunani is OHA’s Chief Medical Officer. She joins me now with more. It’s good to have you back on Think Out Loud.

Dana Hargunani: Thanks Dave, glad to be here.

Miller: So what exactly, from the state’s perspective, are “crisis standards of care?”

Hargunani: Thanks for that question. I’d just like to start with the fact that every healthcare provider wants to do everything they can to take care of patients in the best possible way. And certainly throughout the last two years of this pandemic, our doctors, nurses and other front line healthcare workers have been working incredibly hard, and are exhausted.

So with the rise of Omicron cases in front of us, as you’ve mentioned, we’re recognizing there may be a future point that the resources necessary to provide the best care that patients need are not available, or are limited. So this tool that we developed and presented last week really is a tool that can assist hospitals and health care providers at this difficult time, and in the event of this scarce critical care resource situation.

Miller: What would trigger a hospital to go into a crisis and employ these standards?

Hargunani: I’d start by saying when there are adequate resources to meet patients’ needs in Oregon, they will continue to receive the best possible care. However, Oregon hospitals may have to activate these types of standards if their critical care resources are severely limited. The number of patients presenting for critical care exceeds their capacity, and there’s no other option to transfer patients to another facility.

Miller: In the worst case scenarios, and I know you’ve had two caveats so far at the beginning of each of your answers, so clearly nobody wants this to happen, but in the worst case scenarios, what are we talking about?

Hargunani: I can walk through how this tool works, and absolutely, no one wants to have to go to this position, and we’re doing everything we can to mitigate the possibility.

The first step in this situation would be to determine if a patient needs critical care resources. And if so, then we would determine whether an admission to the intensive care unit for example, or use of those types of resources are in alignment with the patient’s care preferences. So for example, it’s important to take care to understand whether or not patients want life sustaining treatments, such as being intubated and mechanically ventilated. In that situation, if the answer is yes to both of those questions, then hospitals would determine whether there are adequate resources to meet all patients’ critical care needs. And if the answer’s no, that’s when this triage protocol would be activated.

Miller: I looked throughout the 15 page guidelines that you recently published, and I didn’t see the word rationing there. It’s a scary word. But is that, in a sense, what we’re talking about? To use your example, there are two patients who need a ventilator, and there’s one ventilator. Aren’t we talking about rationing?

Hargunani: Dave, I think that’s right. In the way that we outline it in this document, we talk about who would be prioritized for a scarce resource over someone else. In this example that we’ve outlined, the treating provider for that patient would present clinical information about the patient to a separate triage team. Then, that triage team would make a decision about the likelihood of that patient surviving the hospital stay using objective medical information. Those that are most likely to survive, and make it to hospital discharge based on this medical objective criteria would be prioritized for these critical care resources above those that are less likely to survive the immediate clinical event. And it would be the role of this triage team that’s faced with such an extremely difficult task to determine who would get a life sustaining treatment based on that prioritization.

Miller: Is the assumption that people would want to be put on a ventilator unless they had specifically communicated that they had not? This is an issue that we talked about a lot well before the pandemic, but not one that we’ve talked about too much during the pandemic.

Hargunani: Yeah, there’s lots of information we’ve outlined in this document, the importance of making sure we understand a patient’s care preference. It’s always a good time for people to be thinking about what their preferences would be in this type of critical situation. And as we’ve really focused on this tool that we presented, it’s important to make sure that at the time these decisions are made, we have all the information and understanding of patients’ preferences, to move forward in the appropriate way in these decisions.

Miller: The example that you gave of being intubated or needing a ventilator, that is medical equipment, where it’s relatively easy to say we have X number of these machines, and we have X number of patients. But is it fair to say that right now, and potentially going forward, the biggest issue facing hospitals isn’t equipment or beds, but staffing?

Hargunani: Dave, I think that’s right. We are seeing staffing shortages across the entire health care system. We’ve been working very closely with our hospitals and other healthcare providers to mitigate the situation where there wouldn’t be enough resources, such as staffing. Some examples, you know, we’ve put in place contracts with hundreds of clinical staff and situating those staff in hospitals across the state, in long term care facilities and behavioral health centers. You heard last week that the Oregon National Guard is coming back to assist these healthcare settings once again, and we are so thankful for that.

So you’re right, at the time where many people are getting sick and where it’s been really hard to recruit new people into healthcare settings, staffing has definitely been one of the challenges.

Miller: So, to put a finer point on it, could staffing issues themselves lead a hospital to go into crisis mode?

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Hargunani: Staffing is one of the many things that could require a hospital to move into this place. You are correct. And like I said, we are working with hospitals to mitigate that chance. Also, I would say throughout this pandemic, there’s just been remarkable coordination across Oregon hospitals to manage available resources, and for example, to transfer patients when needed to the hospital that’s best situated to serve the patient’s needs. We know that that type of work together has happened, for example, when there were evacuations during the wildfires and ice storms. So hospitals are working really closely together to coordinate and get patients to a staffed bed, if you will, when needed. And we are working really hard to provide additional staffing to try to mitigate that situation. But you’re right, staffing is one of the critical things we’re facing in this state.

Miller: Have any hospitals officially hit this crisis point, so far, over the course of this pandemic, over almost two years?

Hargunani: No. We are hearing from hospitals that they’re not at this point. They’ve all had to think about this. They’ve been preparing for the potential of this. But as you stated earlier, our hospital occupied beds are not the place we’ve seen Omicron. But we are also monitoring the increasing rates of  Omicron that are astonishing. We need to be ready in the case that clinicians are placed in this really difficult situation.

Miller: I guess I’m reminded of something that our health care reporter Amelia Templeton told us over the summer during the Delta surge, after she spent a couple of days at the ICU at OHSU. She and some of the nurses she talked to noted that at that point, in some hospitals outside the Portland area, there weren’t enough staff to turn patients over, to prone them, to make it easier for them to breathe, something that relatively early on hospitals figured out was a low technology but really high impact way to improve patient outlooks, so it was easier for people to breathe. But it was actually a complicated physical process, you needed a number of people to do that safely, especially with patients who were hooked up to all kinds of lines. And what she told us was that, in some hospitals, there just weren’t enough people to do that. So if you were in a hospital, say, in Medford, it may have been that you couldn’t get the best possible care, literally because people weren’t there to turn you over enough.

I guess I’m wondering, in your mind, if that falls under this category? Or if that’s the kind of thing that’s not even taken into account before you get to what’s officially a crisis?

Hargunani: Thank you for sharing that example. Again, I will say these situations are incredibly complex. You’ve just outlined some of the complexities that you might not know not working at the front line. We have had across the state so much learning throughout this pandemic, and we continue to learn. That example is just one of those.

It is true that staffing needs are really in depth, not just the care providers at the bedside, but enough to turn beds over and to make sure people have food. Those are all things we’ve been focused on, and our hospitals have been focused on. I don’t anticipate that those are the types of things to put people in a crisis situation. But there are all things we’re staying critically focused on to try to mitigate any chances of a difficult situation ahead.

Miller: Is triaging like this, is hitting a crisis point always going to be specific to an individual hospital? Or could it be a regional or statewide declaration?

Hargunani: Our experience is that a hospital will need to be ready to enact such a crisis tool when the issue presents itself. They’ll need to be able to make that decision and confidently act on it when they face a situation where their immediate resource needs are overwhelmed. But as I said before, there’s a tremendous amount of coordination happening across Oregon hospitals, and we continue to support that. Where there’s an opportunity to move a patient to another bed, that will happen. I will not be surprised if these situations are faced that it’s going to have to be faced across the region. But again, we want hospitals to be ready to have to use the tools confidently in front of them, should that situation arise at their own hospital.

Miller: In the spring of 2020, Disability Rights Oregon filed a federal civil rights complaint alleging that the state’s older standards discriminated against older people, people with disabilities, people of color, and other groups. I’m curious how these new interim standards, this new triaging tool, is different from what was in place before?

Hargunani: Yeah, there are some significant differences from the tool that had been developed pre-pandemic, and that’s really true for so many states across the country. People have been learning and realizing how we need to focus these tools differently, with a focus on fairness and equity and non-discrimination. Some examples of tools, both in Oregon prior to this pandemic and across the country, had included things such as making judgments about the quality of life, particularly for people with disabilities. Or they had considered longer term outcomes, like looking ahead and making estimations about five or ten year survival. Or perhaps even focusing on healthcare underlying health care conditions, which don’t specifically indicate anything about surviving the immediate hospital stay. So really, the tool that we’ve presented, and many states have made these updates, is a tool that’s based and fairness and equity, and really responsive to the concerns we’ve been hearing, such as those you outlined.

Miller: Still though, my understanding is that other states have adopted certain standards that still do include different versions of prioritizing different groups for lifesaving care. Some states award more points for pregnant people or to kids or to healthcare workers or to single parents. This is obviously morally complex, but that comes with the territory, that comes with this scarcity. Why didn’t Oregon make any of those difficult decisions?

Hargunani: Again, I have to say that the tool that we have adopted is really focused in fairness, equity, and non-discrimination. There is not a single approach for how clinicians are making these decisions across the country, are preparing to make these decisions. Every state, as you’ve outlined, is dealing with these difficult decisions in different ways. We are focused on survivability through the hospital stay for anyone who’s needing these resources. And in our opinion, this is the most objective and fair way to make those determinations.

We know that they’re still gonna need work to monitor and learn and adjust, but we really think this is the tool that’s necessary at this time.

Miller: So just so I understand this, if there are two people, one pregnant, one not, the state of Oregon wouldn’t consider the survivability of two potential human lives as being worth more than one, if only one person can be intubated?

Hargunani: Again, we are really focused on survivability in our tool and the decisions we’re knowing that clinicians may need to face. As a doctor and a mom, I know that hospital staff are struggling to do everything they can to save every life they can. Fortunately, for example, you mentioned children, they do really well often, and bounce back from illness and usually have a high likelihood to survive. But we also know there’s rare heartbreaking deaths out there, and we need to feel like we can focus on the most objective data to look at who is going to survive the hospital stay. So that’s what we’ve put in this tool as the focus of these determinations.

Miller: We reached out to Disability Rights Oregon to get their take on the new interim standards. We got this statement from Emily Cooper, the legal director at DRO:

“Where you live in Oregon, or having a disability, should never dictate whether you get treated fairly or turned away from medical care during a crisis. During the pandemic, we know some hospitals developed their own problematic, homegrown crisis standards to pick who gets care and who doesn’t. Often, these made existing healthcare disparities worse for people with disabilities, older adults, and BIPOC communities. Now that the Organ Health Authority has issued crisis standards that actively worked to prevent bias and discrimination, it’s time for all hospitals to publicly adopt them, and for the Health Authority to be prepared to enforce them.”

First of all, my understanding is that hospitals don’t have to use these particular standards. They can adopt their own. Am I right about that?

Hargunani: That’s right. We’ve presented a set of principles over a year ago, and outlined those same principles in this specific tool that we’ve shared last week. So if a hospital has a tool that they’ve been preparing for, and it’s in alignment with our principles and with the tool that we just published, they can go ahead and continue to use it.

Miller: So let’s turn to enforcement, which is what Disability Rights Oregon is turning their attention to now. They say they want to make sure that you are prepared to enforce these principles. Almost by definition, if we get to the point where one or more hospitals in Oregon is using these standards of care, we’re literally going to be in a crisis, and we can imagine it would be a kind of all hands on deck unfolding emergency in various parts of the state. In that scenario, it’s hard to imagine the Oregon Health Authority proactively enforcing these guidelines. So how is enforcement going to work in the most crucial times?

Hargunani: Yeah, you’re right, these are gonna be very crucial times and difficult times. So what we’re asking and what we’re focusing on, is really focused on communication and transparency. So if hospitals need to activate a tool like we’ve been talking about, they need to tell us that, and they need to share that information with the public to keep everybody up to date. And certainly, if there’s an individual patient who has been affected or whose care may be affected by these types of situations, that communication needs to occur. Again, everybody is in agreement that this communication and transparency are going to be the most important during such a difficult and intense time if it were to occur.

Miller: But do I understand correctly that, in the end, it’s going to be up to individual patients or their family members to bring complaints to OHA, and that’s how enforcement is going to work? It’s going to be complaint based?

Hargunani: Well, that is always the case. Patients and families can speak with advocates or the right individuals at hospitals if they have concerns about their care. And as you already mentioned, we have organizations like Disability Rights who will be looking at these situations and responding to those types of concerns, as is the Health authority. But right now, our focus is on asking hospitals to align their tools or use the tool we’ve shared, alongside those principles we articulated. We’re focused on the fact that this tool is really one that is based in equity and fairness and non-discrimination.

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