Colorado has yet to get to the point where hospitals will ration health care, but a panel of experts advising the governor is planning how best to do this if the state’s COVID-19 situation continues to deteriorate.
As of Thursday, 72 beds were available in Colorado intensive care units, 12% less than one day, and only 570 general beds were open statewide.
If the current acceleration of COVID-19 hospitalizations continues, the state could run out of hospital beds by the end of December, although Gov. Jared Polis has urged facilities to find space for another 300-500 patients. However, it is unclear how hospitals will find enough staff for these additional beds.
Government officials estimate that there are between 2,000 and 2,200 beds in Colorado that could potentially be used for COVID-19 patients, and 1,466 of them had been filled as of Thursday afternoon. If all those bunks were filled with people who had the virus, there would be very little room for anything else, from a bad flu season to road traffic injuries during a blizzard.
Dr. Eric France, the state’s chief physician, said at a meeting of the Governors’ Emergency Epidemic Response Expert Committee on Thursday that Colorado may need to activate its hospital crisis management standards that allow for rationing in the next few weeks.
The advisory group will need to meet again to approve any changes to the anti-crisis standards, and Polis will need to authorize their use. At this point, France will require them to be activated.
Crisis standards define what hospitals must do to make the most of their resources and provide legal protection if they cannot provide adequate levels of care. They were written when Colorado faced the first wave of COVID-19 in the spring of 2020, but will apply to all patients, not just those being treated for the virus.
At the moment, only anti-crisis standards regarding staffing are in effect. This means hospitals do not have the authority to standardize care, but patients can receive care from a nurse who has little experience with their type of care or who serves more patients than is ideal.
The state has already taken a number of actions to keep people out of the hospital or free up more resources to care for them, including expanding places where people can receive monoclonal antibody treatment to reduce the likelihood of being hospitalized with COVID. -19; temporary cessation of cosmetic surgeries; an appeal to the Federal Agency for Emergency Situations with a request to send medical workers to “hot spots”; requiring hospitals to accept any transferred patient they can care for; and allowing nearly all adults to receive booster shots.
If the situation deteriorates enough to require rationing, decisions will depend on the answers to three broad questions, said Anuj Mehta, a lung intensive care unit physician at Denver Health, who wrote the first draft of the updated current guidelines:
- Will the patient recover with a lower level of treatment?
- Is the patient likely to die anyway, even with the utmost care?
- And if patients are okay with outpatient care, will they be able to get it, or will factors such as lack of insurance get in the way?
The current standards for health care rationing are largely based on a formula to quantify a patient’s chances of survival in the next month and next year. Patients will receive a score based on how well their organs are currently functioning, with scores added if they are older or have a condition that increases their risk of dying in the next few months. The lower the score, the better.
If two patients have equal scores, the hospital triage team may consider other factors, such as whether the patient is a child, health care provider, first aid provider, or primary care worker; if one of them is pregnant; or if one of them is the only caregiver or vulnerable adult. If all else fails, the last step is a random draw.
Existing standards have been set to determine who is unlikely to be helped if they get the last fan, Mehta said. Currently, hospitals generally have enough ventilators, but they may not have enough staff to care for everyone who might benefit from an ICU bed or even a bed on a regular floor. There may also be a shortage of equipment, such as dialysis machines and high-flow oxygen units, he said.
For example, according to crisis standards, a hospital can send patients home when they are slightly worse than usual because it needs these beds for more seriously ill patients, Mehta said. Or he may decide that each patient with kidney failure will be given slightly less dialysis time than would ideally be so that no one is denied help, he said.
“I think the concept of ‘safe enough’ is critical,” he said. “This is not a no-worry sorting. “
“The scoring system does not allow the triage team to consider non-medical factors such as a person’s socioeconomic status, but these can play a role in deciding who can be safely sent home for outpatient referrals,” said Matthew Vinia, member of the advisory group. and director of the Center for Bioethics and Humanities at the University of Colorado Anschutz Medical Campus. Mehta said he will work to figure out when it is appropriate to account for patient funds.
“I wouldn’t want to… send someone homeless home,” Vinia said.
Advisory group members who spoke also stated that they would like vaccination status to be listed as a factor that cannot be used to exclude patients from receiving certain types of care, along with race, disability and other protected categories. According to the state, about 80% of people currently hospitalized in Colorado with COVID-19 are not vaccinated.
Mehta acknowledged that the issue is controversial but said he would support adding it.
“Our ethical principles are to save most lives,” not punish irresponsible behavior, ”he said.