DENVER — A committee in Colorado has agreed to update the state’s emergency guidelines regarding what to do if the healthcare system becomes overwhelmed by a major public health event, like the novel coronavirus.
Crisis standards of care are the guidelines put in place when normal healthcare operations become impossible due to an event, like the novel coronavirus pandemic, or a natural disaster. These recommendations help professionals decide where to allocate scarce resources when patient needs exceed what is available.
Under a Public Health Emergency, the governor or a public health official may authorize crisis standards of care. As of Monday morning, this has not been activated.
Dr. Eric France, chief medical officer at the Colorado Department of Public Health and Environment, said the state has been working to avoid having to use the crisis standards of care.
“We’re working with the hospitals to increase the number of ICU beds and ventilators to try and meet the anticipated demand,” he said. “We need everyone’s help to slow the spread of the virus by following public health orders, to reduce the likelihood of putting these standards into practice.”
The state is continuing to try to obtain additional resources from the Strategic National Stockpile and private partners, but the public can help even more by obeying state and local public health orders, such as social distancing.
Colorado developed crisis standards of care recommendations in 2018, but they are broad and not exclusive to the precise challenges of COVID-19. A group of experts has been working to update the standards in case they need to be activated for the pandemic. The experts used community feedback when crafting the updates.
According to the Colorado Department of Public Health and Environment, the updated crisis standards of care say that:
- Each triage team should consist of an expert on ethics or palliative care, a physician familiar with critical care, a representative of the nursing staff and a representative of the hospital’s leadership
- A patient’s primary medical team shouldn’t be involved in the crisis triage decision-making for that individual. Crisis triage teams need to remain objective and removed from the patient.
- Triage teams shouldn’t make decisions based on information that is either clinically or ethically irrelevant to the triage process (ex. race, ethnicity, disability status, national origin, primary language, immigration status, sexual orientation, gender identity, religion, veteran status, criminal history, etc.)
- Healthcare providers can use some personal protective equipment (PPE) multiple times instead of once if it is scarce. They may also use alternate equipment to provide protection from disease spread.
- Each hospital should have a crisis triage team that could be activated in a crisis when the facility nears its minimal operating capacity for required resources, such as ventilators. This team should use a tiered approach when deciding how to allocate the resources on-hand. Should there be a tie, the team would move to the next tier of considerations: Tier 1 (scoring system based on severity of illness, morbidity, measure of chronic illness), Tier 2 (pediatric patients, healthcare workers, first responders), Tier 3 (pregnancies, sole caregivers and other special considerations), and Tier 4 (random allocation)
These updates align Colorado with the National Academies of Sciences, Engineering, and Medicine’s Rapid Expert Consultation on Crisis Standards of Care for the COVID-19 Pandemic, which was published in March 2020. You can read this document here.
Colorado doctors are preparing to make the difficult decisions of who gets treatment and who doesn’t, should the crisis standards of care be activated.
Dr. Matthew Wynia, the director of bioethics at the University of Colorado, is part of the GEEERC.
"These are decisions we hope to never have to make, but it would be irresponsible given what has happened in the rest of the world — including Seattle, in New York and New Orleans, and other places around the U.S. — to assume that we are never going to see that kind of a situation here,” he said.
He said no hospital in Colorado has reached capacity or run out of ventilators, but many of the facilities are seeing a surge in potential COVID-19 patients and those in need of critical care.
Dr. Stephen Cantrill, a Denver Health emergency physician who is also part of GEEERC, said they hope Colorado never becomes so stretched that it runs out of resources.
“We never want to have to resort to crisis standards of care,” he said. “But we’ve worked with experts and received community feedback to develop recommendations that we believe are equitable and ethical in case we do have to put them into effect.”
The CDPHE will make a recommendation to Gov. Jared Polis to active crisis standards of care should the healthcare system’s staff, resources and beds become overwhelmed.