Arizona Department of Health Services activates plan to ration
healthcare for COVID-19 patients
2 July 2020
The state of Arizona, and the American Southwest more generally,
have become a new epicenter of the coronavirus pandemic. This region was among
the first where state governments ended lockdowns and other restrictions, and
record infections and rising deaths are the consequence.
On Wednesday, Arizona, with over 84,000 cases (24,118 cases in
one week), surpassed its previous one-day high set on Tuesday with 4,877 new
cases and 88 fatalities. The death toll for Arizona stands at 1,720 (257 deaths
since last week). With a per capita infection rate of 43 new daily cases per
100,000 residents on a seven-day rolling average, Arizona leads nationally,
with Florida second with 34 new cases per 100,000 residents.
By way of comparison, New York state with 2,009 total cases per
100,000 residents experienced a one percent rise since June 24. Arizona, with
1,290 total cases per 100,000, experienced a 40 percent increase. With testing
capacity strained, 28 percent of diagnostic tests are returning positive, which
indicates both dwindling resources as well as a significantly entrenched
community transmission.
Last Friday, Arizona hospitals asked their state’s health
department to formally activate the “Crisis Standards of Care” guidelines that
would provide hospitals the legal right to determine who and how patients
should be treated for the coronavirus. This essentially means hospitals will
have to decide who receives life-saving measures and who will not.
Throughout June, the local media, via updates from the health
department, had been highlighting Arizona hospitals’ dwindling ICU capacity.
The plan ushered in with the words “a compassionate and ethically-based
healthcare response for catastrophic disasters within the State of Arizona”
went into effect Monday afternoon.
The Arizona Department of Health promulgated a COVID-19 addendum
for the allocation of scarce resources in acute care facilities back in April
during the initial surge of the pandemic in the United States. Health systems
throughout the country were facing severe shortages of PPEs and testing
capacity. Based on estimates provided by various health officials, concerns
were raised that there would be insufficient capacity to ventilate patients.
Equally distressing was the shortage of critical care capacity at health
systems overwhelmed by COVID-19 cases. Experiences in Italy had raised the
issue of how to allocate limited resources to patients in critical condition infected
with COVID-19.
The proposal,
written in careful medical-legal jargon, was drafted by the chief medical
officers of the University of Arizona College of Medicine, Abrazo Healthcare,
Carondelet Healthcare, Common Spirit Arizona Division Dignity Health, Banner
Health, and Phoenix Children’s Hospital. They wrote that “it is the intention of Arizona
health systems to collaborate such that no system reaches a contingency or
crisis level unless all do … if time does not permit and/or other facilities
are short on critical resources (hospital beds, ICU beds, ventilators, dialysis
machines, etc.), triage protocols as outlined here will go into effect.”
When a “Crisis Standards of Care” is implemented, a facility
system Incident Commander will coordinate priorities within the Emergency
Operations Center. At the same time, the triage officers review cases according
to protocols and guidelines approved by the Department of Health. Infected
patients who have arrived for life-saving treatments and critical care at the
hospital will have to first undergo an assessment on “the best available
relevant and objective medical evidence.”
Patients are given a scorecard that assigns them a “triage
priority score” based initially on their Sequential Organ Failure Assessment
(SOFA) Score [from 1 to 4], a mortality prediction score that is based on the
degree of dysfunction of six organ systems—respiratory, cardiovascular, liver,
coagulation, kidney and neurological systems. The higher the score, the higher
the predicted mortality rate.
Though the guidance states that age will not be a factor in
triaging, the second step involves determining the individual’s 1-year or
5-year mortality. The SOFA score is added to the mortality score—ranging from 1
to 8—after which a triage color grouping is assigned—Red for those expected to
survive, while Yellow then Blue are afforded the lowest priority for critical
care resources. Treating physicians are recused from decisions regarding the
allocation of “scarce resources.”
However, if resources remain exceptionally dire—two patients
needing one resource—additional factors may need to be addressed in a manner
that seems like a coin toss but includes such considerations as whether those
being treated are pediatric patients, frontline workers, single caretakers of
minors, pregnant patients, and those deserving the opportunity to experience
life stages, which brings age back into the equation.
As the final throwing up of the hands, to quote, “if patients
requiring the same scarce resource cannot be effectively prioritized with any
of the above, the allocation should proceed randomly.” Though the process
allows for appeals, triaging of patients is continuously assessed throughout
the admission. Motions could be denied in matters that are time-critical and
insufficient to conduct the appeal.
Will Humble, former director of the Arizona Department of Health
Services, speaking on MSNBC’s “Rachel Maddow Show” on June 27, said, “Standard
of care changes when you get into surge status … when they [governors and
elected officials] start talking about hospital capacity as a control measure,
as an endpoint for how they are going to manage this epidemic, start worrying.
What you really should be doing is putting together policies in place to change
people’s behavior, to slow the spread of the virus, so you don’t end up like us
in crisis standards of care.”
However, Governor Doug Ducey's response to this catastrophe has
been insensitive and irresponsible, even while knowing that the peak in the
surge is yet to arrive. Insultingly, he has announced band-aid measures with
the closure of bars, nightclubs, and outdoor waterparks for 30 days while
pushing back school openings two weeks to August 17. He continues to refuse to
mandate face masks in public. During his press brief on Monday, he said, “This
is not another executive order to enforce, and it’s not about closing
businesses. This is about public education and personal responsibility … do it
for your family, for your friends, for your neighbors, for our frontline
healthcare workers. You can help reduce the risk for the most vulnerable in our
society.”
As part of a damage control effort, Vice President Pence and the
Coronavirus Task Force flew in to meet with Ducey on Wednesday to attempt to
shore up confidence in the governor’s failed leadership and ensure Arizona
holds a steady course as a retreat would reflect poorly on the Trump campaign’s
efforts.
After congratulating Ducey for his handling of the pandemic,
Pence admitted that the governor had requested 500 medical personnel to assist
with the devolving health disaster. He also acknowledged that “something
changed in the middle of May” that led to the rapid surge of COVID-19 cases. He
added that the United States had to “keep our economy moving forward and get
our kids back to school.”
All the warnings by hospitals, health officials, and epidemiologists
appear to have had little influence or weight on Ducey and other state and
local officials, who were only more than eager to throw the doors wide open in
early May for business, commerce, social events, and political rallies all the
while remaining utterly indifferent to the developing calamity which amounts to
criminal negligence.
There are currently 2,793 patients hospitalized with 683 in the
ICUs (89 percent full) and 465 on mechanical ventilators. Some Arizona nurses
have commented on social media that high flow oxygen was exceedingly difficult
to find for two local hospitals in Maricopa County. They also listed a shortage
of Propofol and Precedex, two essential medications for sedating patients
before intubating them. Many nurses and physicians have sounded the alarm that
Arizona needs to lock down. A petition drafted on June 28 with over 1,000
signatures is being sent to the Governor.
No comments:
Post a Comment