COVID in NYC: What New York Did, and Should Have Done

Koch, Valerie Gutmann; Han, Susie A.

doi:10.1080/15265161.2020.1777350

Cited by 7 publications

(5 citation statements)

References 5 publications

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“…To date, only the American Hospital Association tracks IMCU bed capacity in the United States (51). d) Crisis level surge triage: Under extraordinary circumstances, when all the resources have been maximally used and optimized, difficult resource allocation decisions may be necessary even including ICU ventilator triage (31,(52)(53)(54). These decisions are very complex and require broad society support, and even then, may never be implemented as in the case of the ventilator allocation guidelines crafted by the New York State Task Force on Life and the Law (53,54).…”

Section: Table 3 (Continued)mentioning

confidence: 99%

Flow-Sizing Critical Care Resources*

Nates

Oropello

Badjatia

et al. 2023

Critical Care Medicine

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OBJECTIVES: To describe the factors affecting critical care capacity and how critical care organizations (CCOs) within academic centers in the U.S. flow-size critical care resources under normal operations, strain, and surge conditions. DATA SOURCES: PubMed, federal agency and American Hospital Association reports, and previous CCO survey results were reviewed. STUDY SELECTION: Studies and reports of critical care bed capacity and utilization within CCOs and in the United States were selected. DATA EXTRACTION: The Academic Leaders in the Critical Care Medicine Task Force established regular conference calls to reach a consensus on the approach of CCOs to “flow-sizing” critical care services. DATA SYNTHESIS: The approach of CCOs to “flow-sizing” critical care is outlined. The vertical (relation to institutional resources, e.g., space allocation, equipment, personnel redistribution) and horizontal (interdepartmental, e.g., emergency department, operating room, inpatient floors) integration of critical care delivery (ICUs, rapid response) for healthcare organizations and the methods by which CCOs flow-size critical care during normal operations, strain, and surge conditions are described. The advantages, barriers, and recommendations for the rapid and efficient scaling of critical care operations via a CCO structure are explained. Comprehensive guidance and resources for the development of “flow-sizing” capability by a CCO within a healthcare organization are provided. CONCLUSIONS: We identified and summarized the fundamental principles affecting critical care capacity. The taskforce highlighted the advantages of the CCO governance model to achieve rapid and cost-effective “flow-sizing” of critical care services and provide recommendations and resources to facilitate this capability. The relevance of a comprehensive approach to “flow-sizing” has become particularly relevant in the wake of the latest COVID-19 pandemic. In light of the growing risks of another extreme epidemic, planning for adequate capacity to confront the next critical care crisis is urgent.

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Section: Table 3 (Continued)mentioning

confidence: 99%

Flow-Sizing Critical Care Resources*

Nates

Oropello

Badjatia

et al. 2023

Critical Care Medicine

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“…As hospitals and physicians became increasingly overwhelmed, Arizona and New Mexico officially activated crisis standards of care (CSC)plans, or triage plans for scarce medical resources 1 . Facing similar circumstances, other states refused to endorse draft CSC plans to guide clinical decisions during the pandemic, depriving hospitals and physicians of consistent and transparent guidelines for making almost‐impossible allocation decisions 2 . This failure left institutions to develop and implement their own rationing plans.…”

Section: At Lawmentioning

confidence: 99%

“…1 Facing similar circumstances, other states refused to endorse draft CSC plans to guide clinical decisions during the pandemic, depriving hospitals and physicians of consistent and transparent guidelines for making almost-impossible allocation decisions. 2 This failure left institutions to develop and implement their own rationing plans.…”

mentioning

confidence: 99%

Reciprocity and Liability Protections during the Covid‐19 Pandemic

Koch¹,

Hoffmann²

2021

Hastings Center Report

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During the Covid‐19 pandemic, as resources dwindled, clinicians, health care institutions, and policymakers have expressed concern about potential legal liability for following crisis standards of care (CSC) plans. Although there is no robust empirical research to demonstrate that liability protections actually influence physician behavior, we argue that limited liability protections for health care professionals who follow established CSC plans may instead be justified by reliance on the principle of reciprocity. Expecting physicians to do something they know will harm their patients causes moral distress and suffering that may leave lasting scars. Limited liability shields are both appropriate and proportionate to the risk physicians are being asked to take in such circumstances. Under certain narrow circumstances, it remains unclear that the standard of care is sufficiently flexible to protect physicians from liability. Given this uncertainty, the likelihood that physicians would be sued for such an act, and their desire for such immunity, this limited protection is morally legitimate.

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“…The COVID-19 pandemic triggered unprecedented strain on the health care system. During the spring 2020 surge in New York City (NYC) there was a palpable concern that ventilators might need to be rationed by implementing crisis standards of care (CSC) . Many CSC provide a protocol for triage whereby patients are ordered to potentially receive a scarce resource.…”

Section: Introductionmentioning

confidence: 99%

“…During the spring 2020 surge in New York City (NYC) there was a palpable concern that ventilators might need to be rationed by implementing crisis standards of care (CSC). 1 , 2 , 3 , 4 Many CSC provide a protocol for triage whereby patients are ordered to potentially receive a scarce resource. Such a triage process, with the magnitude of supply limitation, determines which patients receive that resource.…”

Section: Introductionmentioning

confidence: 99%

Simulation of New York City’s Ventilator Allocation Guideline During the Spring 2020 COVID-19 Surge

Walsh,

Zhu,

Feng

et al. 2023

JAMA Netw Open

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ImportanceThe spring 2020 surge of COVID-19 unprecedentedly strained ventilator supply in New York City, with many hospitals nearly exhausting available ventilators and subsequently seriously considering enacting crisis standards of care and implementing New York State Ventilator Allocation Guidelines (NYVAG). However, there is little evidence as to how NYVAG would perform if implemented.ObjectivesTo evaluate the performance and potential improvement of NYVAG during a surge of patients with respect to the length of rationing, overall mortality, and worsening health disparities.Design, Setting, and ParticipantsThis cohort study included intubated patients in a single health system in New York City from March through July 2020. A total of 20 000 simulations were conducted of ventilator triage (10 000 following NYVAG and 10 000 following a proposed improved NYVAG) during a crisis period, defined as the point at which the prepandemic ventilator supply was 95% utilized.ExposuresThe NYVAG protocol for triage ventilators.Main Outcomes and MeasuresComparison of observed survival rates with simulations of scenarios requiring NYVAG ventilator rationing.ResultsThe total cohort included 1671 patients; of these, 674 intubated patients (mean [SD] age, 63.7 [13.8] years; 465 male [69.9%]) were included in the crisis period, with 571 (84.7%) testing positive for COVID-19. Simulated ventilator rationing occurred for 163.9 patients over 15.0 days, 44.4% (95% CI, 38.3%-50.0%) of whom would have survived if provided a ventilator while only 34.8% (95% CI, 28.5%-40.0%) of those newly intubated patients receiving a reallocated ventilator survived. While triage categorization at the time of intubation exhibited partial prognostic differentiation, 94.8% of all ventilator rationing occurred after a time trial. Within this subset, 43.1% were intubated for 7 or more days with a favorable SOFA score that had not improved. An estimated 60.6% of these patients would have survived if sustained on a ventilator. Revising triage subcategorization, proposed improved NYVAG, would have improved this alarming ventilator allocation inefficiency (25.3% [95% CI, 22.1%-28.4%] of those selected for ventilator rationing would have survived if provided a ventilator). NYVAG ventilator rationing did not exacerbate existing health disparities.Conclusions and RelevanceIn this cohort study of intubated patients experiencing simulated ventilator rationing during the apex of the New York City COVID-19 2020 surge, NYVAG diverted ventilators from patients with a higher chance of survival to those with a lower chance of survival. Future efforts should be focused on triage subcategorization, which improved this triage inefficiency, and ventilator rationing after a time trial, when most ventilator rationing occurred.

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COVID in NYC: What New York Did, and Should Have Done

Cited by 7 publications

References 5 publications

Flow-Sizing Critical Care Resources*

Flow-Sizing Critical Care Resources*

Reciprocity and Liability Protections during the Covid‐19 Pandemic

Simulation of New York City’s Ventilator Allocation Guideline During the Spring 2020 COVID-19 Surge

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