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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
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2

Reflections, Inflections, and the Future

The world has experienced numerous public health emergencies since 2012, when the first crisis standards of care (CSC) frameworks and concepts were released (IOM, 2012; Wilder-Smith and Osman, 2020). Reviewing the initial work and reports to gauge their merit and to determine where updates might be helpful is an important step forward when assessing this large body of work. This chapter reviews the framework and initial concepts developed around CSC, presents various scenarios where they might be used, and includes a description of the discussion that followed this workshop’s presentation. These discussions highlight lessons learned from those working in the field over the last decade, in terms of what went well during implementation, as well as what is still needed to make future plans more resilient and to better support health care systems, clinicians, and other stakeholders during the next catastrophic emergency.

THE FIRST 10 YEARS OF CRISIS STANDARDS OF CARE

When the Forum on Medical and Public Health Preparedness for Disasters and Emergencies convened the workshop Crisis Standards of Care: Ten Years of Successes and Challenges in November 2019,1 the first cases of COVID-19 were already appearing in Wuhan, China. Dan Hanfling, vice president of Technical Staff at In-Q-Tel, noted that this unfortunate pandemic experience has provided an opportunity to reexamine the CSC

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1https://www.nap.edu/catalog/25767/crisis-standards-of-care-ten-years-of-successes-and-challenges (accessed January 5, 2022).

Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×

framework and its implementation as well as the successes and failures of current CSC approaches. Sharing a quote from a 2017 World Bank report, he said:

Multiple pandemics, numerous outbreaks, thousands of lives lost and billions of dollars of national income wiped out—all since the turn of this century, in barely 17 years—and yet the world’s investments in pandemic preparedness and response remain woefully inadequate. (World Bank Group, 2017)

To be clear, he added, “This finding was before COVID-19 arose.”

Reviewing the last 10 years of work by the National Academies, Hanfling shared the original definition of CSC from the initial 2009 report: “A substantial change in usual health care operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g., pandemic influenza) or catastrophic (e.g., earthquake, hurricane) disaster” (IOM, 2009). With the release of the 2012 and 2013 IOM reports came more focus on a systems framework and the identification of indicators and triggers. Hanfling commented on the mindset that CSC was more of a continuum, requiring movement from conventional care, to contingency surge, to crisis surge—not a switch to toggle on and off. He illustrated this through a graph representing a supply-and-demand curve for health care services (see Figure 2-1). By having enhanced preparedness and availability of resources, he said, the time available before entering the area under that

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FIGURE 2-1 Demand for health care services and supply of resources as a function of time after disaster onset, taking into account care capacity as a function of time.
SOURCE: Dan Hanfling presentation, September 27, 2021. (Original source: IOM, 2012.)
Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
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curve is increased, and the area below the curve can be entered at a later point, allowing more time to operate under normal standards of care as the event progresses.

Taking the graphical representation a step further, Hanfling also shared a structural image resembling the Lincoln Memorial as a metaphor for the CSC framework (see Figure 2-2). He explained that the success of planning is built on engagement, education, ethical considerations, legal authorities, and information sharing, with all working together to improve performance. And while each of the pillars of hospital care, public health, emergency management, emergency medical services (EMS), and others are often operating within their own siloes, they all must coordinate to shift to standards of care that are still ethical and equitable across a city or region. He commented on the importance of being open to learning what works and making midcourse corrections when things are not working. For example, in the spring of 2020 in New York City, providers overrun by COVID-19 patients began to realize that early aggressive airway management and intubation was not as successful as initially thought. They instead shifted to other means of managing patients such as placing them prone to provide more oxygen.

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FIGURE 2-2 Structural metaphor resembling the Lincoln Memorial for CSC planning.
NOTE: EMS = emergency medical services.
SOURCE: Dan Hanfling presentation, September 27, 2021. (Original source: IOM, 2012.)
Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×

Hanfling reviewed where CSC stood in 2021, in terms of what worked for planning and what did not. He said the requirement for this type of catastrophic emergency planning has not been completely invalidated, the systems framework as designed is still relevant and can provide a solid foundation, and the nomenclature for terms and recommendations from the first 2009 report are still valid and necessary (IOM, 2009). He said this was important because more and more health care workers rightfully believe this will not be the last pandemic they will be a part of in their careers. However, he also had several examples of what did not work through this experience.

Hanfling said the multiple levels of dysfunctional government action that were seen across the country between February 2020 and September 2021 made it even more difficult for health care workers and planners to adequately respond. The clear inequities in disease burden and the effects of systemic racism also demonstrated a critical need to examine how the system can be changed to improve outcomes and equity. Finally, the lack of decision-support tools to assist in bedside clinical decision making was noticeable, especially in an ever-changing world of emerging data and new protocols for care.

Hanfling concluded that CSC planning is at an inflection point, and that the ethical framework, in the midst of a national crisis, demands some reconsideration in terms of accountability and reciprocity. Hanfling noted that while it is not clear if some of the available tools should actually be used at the point of care when resources are in high demand, what is clear is that the inherent inequities that have been illuminated throughout this crisis need to be given more attention and addressed at a systems level. This includes investment in capabilities, platforms, data analytics, and community engagement to provide as much situational awareness as possible so hospital systems and frontline care providers can make well-informed decisions about when the allocation of care delivery needs to be modified.

THREE SCENARIOS OF CRISIS STANDARDS OF CARE

Craig Vanderwagen, the first assistant secretary for preparedness and response (ASPR) within the U.S. Department of Health and Human Services (HHS), and founder and general manager of East West Protection, LLC, provided three different, successful scenarios to elucidate the range of situations that could call upon CSC planning.

Developing CSC Planning for Nationwide Hospitals

The first scenario refers to HCA Healthcare, a nationwide health system, and how it approached CSC in early March 2020 in response to

Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×

COVID-19. Vanderwagen reviewed HCA Heathcare’s characteristics, noting it includes 200 hospitals nationwide and has a sophisticated planning and operational capability for preparedness. The issue of CSC had been lurking in the background for HCA Healthcare, but by February 2020 the leadership realized CSC challenges needed to be addressed in a systematic way. In March 2020, ASPR began working with HCA Healthcare and its lawyers, clinical staff, and chief medical officers to develop an effective CSC program that prioritized resource sparing2 and contingency standards. He noted that the system preemptively developed a legal and ethical framework for crisis standards with transparency and accountability and operated in the context of legal stipulations.

Then, HCA Healthcare worked with medical staff to develop a triage system and set of processes. Systemwide, it was recognized that individual hospitals had their own governance committees and their own medical staff engaging with their communities and making decisions, so there was not an option for a one-size-fits-all approach, he explained. Instead, HCA Healthcare gave every hospital an operating set of guidelines that could be tailored to the reality of the communities and practices in which they operated. By the end of March 2020, every facility had embraced the notion of CSC, the governance boards approved it, and they all engaged with communities to discuss what it would mean for them. Medical and nursing staff had strong input into the processes that would be used, included triage and quality assurance.

Vanderwagen highlighted an interesting spinoff, as HCA Healthcare is supplied by an organization that supplies 1,600 hospitals nationwide. This organization also provides logistical support for the supply chains to most of those hospitals, Vanderwagen noted, so they also were involved in the CSC development process. That organization wanted to understand how it could support moving away from just-in-time supply chains and move toward a resource-sparing strategy. Over the last year and a half, he said, that organization has begun investing in manufacturing capacity for certain kinds of products that are known to be in short supply in this kind of event. Because of those investments, he said, this supply chain group can now be ahead of the preparedness curve and shorten the time spent under the curve, as previously portrayed in Figure 2-1. This is the kind of forward and innovative thinking that needs to be encouraged and incentivized within all hospital systems, he said. HCA Healthcare viewed CSC as critical to the community good. It was willing and able to invest in that process, but not every hospital system can do that. All systems should be incentivized

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2 The process of maximizing the utility of supplies and material through conservation, substitution, reuse, adaptation, and reallocation.

Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×

to ensure they can take those kinds of steps toward multidisciplinary CSC planning, he concluded.

Deploying an Alternate Care Site in a Major Metropolitan Area

The second scenario involved the deployment of an alternate care site in the Boston area involving 20–30 hospitals banding together to take action. Beginning in late March 2020, hospitals in that community began to realize they needed to develop a strong contingency plan that focused on resource sparing so they could continue to manage the patient flow confronting them. They decided to set up alternate care sites to decompress their hospitals and support intensive care capability, he explained, but they wanted to do it in a way that was ethical and accountable. Given the fact that COVID-19 was thus far significantly affecting neighborhoods of color and the large homeless population in Boston, there were questions about how to deliver appropriate supports for these types of populations.

Vanderwagen explained that the program of care in the alternate care facility was designed around rehabilitation, noting that when patients came out of the intensive care unit (ICU), the system needed to be prepared to provide the right rehabilitation services to get the patients back into their community with their care managed appropriately. With this in mind, the effort involved community health providers and local long-term care facilities, though many were shut down at the time or not in business owing to the restrictions and stay-at-home orders. The hospitals did have strong support from the mayor and governor in terms of ensuring the supply chain throughout the process, Vanderwagen noted, which was helpful in getting what they needed.

For 8 weeks from April to June 2020, the alternate care site was able to serve 800 patients, including 100 homeless people. The hospitals were able to effectively provide rehab services and link the patients back to their community once they were discharged from the alternate care site. The system used a community-wide approach, employed equity as a basic principle, and linked the design to what those patients needed when they recovered. The hospitals also coordinated and clarified discharge criteria, so there were clear standards for admission and discharge.

Community Efforts to Develop Alternate Care Sites

The third scenario involves the community’s effort in El Paso, Texas, that used its unity to meet the needs of the population, even without political support at the state level. The state did not have a CSC plan, Vanderwagen explained, but the significant surging of patients in El Paso during the first wave of the pandemic resulted in all hospitals being confronted

Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×

with the need to conduct very aggressive resource-sparing strategies. Among those strategies was the use of an alternate care site, but there were concerns about the need for a common message to patients and the community about what the facility would be. He explained that the state wanted to ensure the community understood the alternate care site was not to be a depository for COVID-19 patients, but that it would be built around principles of equity and rehabilitation services to get recovered patients back into their home environment in the best shape possible.

The community did have strong political leadership and support at the local level from the mayor and the county judge executive, who supported hospitals collectively taking advantage of alternate care sites with common messaging and discharge criteria. This made the facility into a critically important resource, he added. He concluded that the site became a very successful transitional service, where people understood they were being cared for and in the right shape when sent home.

These three scenarios demonstrate a few important lessons, Vanderwagen concluded. First, community-wide planning is critical. Additionally, clinical participation in determining the standards of care and how resource sparing will be employed, as well as education in how that can be used creatively, are critically important. Alternate care sites can be very effective in a resource-sparing strategy. He noted a failure in this process at the national level, though, saying that the Army Corps of Engineers went too far and built too many facilities during the pandemic, and many went unused. He explained that joint community planning that includes all stakeholders can lead to much more effective use of the facilities that are built. Finally, he suggested the Centers for Medicare and Medicaid Services (CMS) think about how to provide incentives through payment to support this kind of resource-sparing strategy for hospitals and health care organizations.

LOOKING BACK AT FIRSTHAND EXPERIENCES AND LESSONS LEARNED

To take a deeper look at what has been learned over the past 10 years, Eric Toner, senior scholar at the Center for Health Security, Johns Hopkins University, introduced a panel of experts with firsthand experience in CSC planning and implementation. They introduced topics that are also discussed in further depth throughout this workshop series, including ethics and equity, staffing considerations and clinical issues, and legal lessons and accountability.

Ethics and Equity

Monica Peek, professor of medicine at the University of Chicago, believes that CSC planning has reached a tipping point. Experts had worked

Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×

to gather information from the community about what was important, she said, but that information had not yet been translated to implementation when COVID-19 first emerged. She also pointed out that many thought leaders have emphasized the engagement of politicians and health care leaders to get the right buy-in and support, but she emphasized that there is a lot of work that can be done right now. She shared the quote “Every system is perfectly designed to get the results it gets,” hinting that the inequities that have emerged throughout the pandemic are not singular, isolated mistakes or gaps, but instead demonstrate a more pervasive issue within the system.

In this case, she continued, the systems are designed for inequity. Peek called for designing systems using an ethical framework so people who have historically had less can have more, so outcomes are equitable, not equal. She added that people take for granted that everyone has equal access to goods, resources, and opportunities in their everyday lives, but there has been enough evidence to show that this is not the case. Peek emphasized that unless equity was specifically and purposely designed in, instead of just trying to reduce health disparities retroactively, the outcome would always be inequity. She pointed to several missed opportunities in this aspect throughout the pandemic, including issues such as scarce resource allocation (e.g., vaccines) (Parker et al., 2021) and hospital transfer issues within a region (Schorsch, 2020) while trying to maintain equitable care.

Staffing Considerations and Clinical Issues

Highlighting the multidisciplinary nature of hospital staffing, Anuj Mehta, assistant professor at the University of Colorado, emphasized the importance of the team-based mentality, saying it is at the core of their work in the hospital (see Figure 2-3). He elaborated on lessons learned regarding staffing and how it is interrelated with CSC planning and needs. While the focus in the media is often on the “stuff” that is in shortage, such as how to decide who gets limited ventilators, who gets beds, or who gets the limited oxygen supply, Mehta explained that what is actually occurring is that systems may have all of those resources but not have enough clinicians to deliver that care. He also reminded the audience that this issue of a health care workforce shortage was not new, but COVID-19 has brought a spotlight to it, reinforcing that staff are a finite resource and not infinitely flexible. Mehta noted that politicians talk about how staff can be stretched thinner, but eventually it does affect patient safety and morale in the field, with recent reports of 30 percent of health care workers considering leaving the field (Wan, 2021). This is truly an imminent crisis, he added.

Mehta also discussed various methods to augment the staffing crisis, but because trained workers are truly a finite resource, there is always a conse-

Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×
Image
FIGURE 2-3 Core principles of multidisciplinary staffing in a hospital system.
NOTE: LTC/SNF = long-term care or skilled nursing facility.
SOURCE: Anuj Mehta presentation, September 27, 2021.

quence to most of the changes. For example, nurses and ancillary staff have moved from nursing homes and long-term care centers to acute hospitals and health care facilities to help with the increased surge of patients during the pandemic, creating a workforce shortage in nursing homes. This then makes it difficult for hospitals to offload patients who are ready to recover, so bed availability is still a challenge. But there are tweaks and process changes that can be employed to use technology and augment staffing, he noted. For example, in his ICU in Denver, they moved the patient’s medication pump outside the room, so the respiratory therapist or nurses do not need to suit up in personal protective equipment every time they need to modify levels. This makes it easier for providers to care for multiple patients. But once the pandemic has truly ended or become much less of a threat, he concluded, hospitals and hospital systems need to think about how to augment staff, whether through new staffing models or other changes, so that the health care system can be more prepared for the next pandemic.

Mehta also provided an overview on the planning, implementation, and monitoring of CSC, highlighting several of the lessons that he has learned throughout the process. One of the key lessons he noted through the precrisis planning process in Colorado was the idea of community engagement. Often this is done as an afterthought, or just using feedback from doctors and lawyers involved in the absence of community, he said. But while rewriting the Colorado CSC plan, they met with people in an ongoing manner over several weeks, which contributed a large amount of helpful information regarding age-based and disability-based discrimination.

Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×

Another important lesson to consider during preplanning is the inclusion of equity in load-balancing3 considerations across hospitals to ensure that people get the same care regardless of which hospital they are taken to. Crisis activation has been extremely variable throughout the pandemic, Mehta said, and what is on paper may be different than what is happening in real life. He advocated for more attention on defining certain triggers when either “staff or stuff” is in shortage. He highlighted the importance of determining how the process of triage is implemented ahead of time—all the way from activation, who constitutes the triage teams, how to calculate triage scores, how to reassess these scores, and how to triage transfer patients.

One of the challenges specifically with triage, he noted, is that there are different types to account for, not just multiple people waiting for one resource. For example, emergent triage relates to an unknown person coming into the hospital at any point, and it would be impossible to assess their needs ahead of time. But there is also prospective triage, where you are assessing survivability, but this also has nuances. Mehta shared that it can be quite difficult to weigh the needs of a person who shows up first versus the potential person who may come in later. It is also necessary to consider potential transfer patients.

Mehta said that as of September 2021, his ICU is not at a crisis activation level, but it does have patients from seven surrounding states and constantly receives calls from physicians in other states looking for beds. He noted there was also a need for monitoring and evaluation, but these are difficult to operationalize in a crisis. Other needs include monitoring before activation, and considering equity and fairness in the process, as well as reassessment. Reinforcing points made by Peek, he highlighted the need for having equity at the forefront of how planners are thinking about this process. As a final point, Mehta emphasized the importance of precrisis planning and exercising. He noted that while most CSC plans likely have triage teams enshrined in their process, it is necessary to have them practice and get a sense for the large moral burden they will endure by making some of these life-or-death decisions for people. He found this was an issue even just in a simulated exercise and recommended being aware of the mental health consequences and having the right resources available for staff.

Legal Lessons and Accountability

Jennifer Piatt, deputy director for the Network for Public Health Law–Western Region Office, offered lessons related to legal issues throughout the

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3 Load-balancing activities may include prehospital distribution of patients in other healthcare facilities in the area, patients transfers between facilities, or sharing resources between different facilities.

Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×

past decade of work. One of the first legal lessons highlighted in the 2019 workshop Crisis Standards of Care: Ten Years of Successes and Challenges,4 she said, is that while the initial conception of triggers included express or formal state-based invocation of CSC plans, planners and hospital systems should be conceiving of CSC triggers much more broadly. This could be informed by federal guidance, existing CSC plans, or regional agreements. Emergency declarations can also help facilitate CSC implementation. This is important, she continued, because full or express political support for CSC at the state level may be lacking, leaving decisions to individual localities or health systems. Shortages can also occur in the absence, delay, or rescission of formal declarations, so systems should understand how to proceed without that type of support and establish consistency across jurisdictions.

A second lesson that was brought forward in the 2019 workshop and further highlighted during the COVID-19 experience is that of accountability and the existing patchwork of liability protections. Litigation has already begun to emerge in nursing facilities alleging negligence in some cases during the COVID-19 pandemic. Piatt added that it will be important to guarantee that adequate liability protections are in place to ensure that health care workers remain willing and able to provide services in crisis scenarios, but that it is also important not to go too far in that direction, and maintain levels of accountability by not protecting actions that are willful.

Piatt concluded that one of the most important issues that emerged in this process of operationalization was equity. HHS and other health authorities uncovered that many plans had built in age or disability discriminations in terms of how they were allocating resources. Over the course of the pandemic, the Office of Civil Rights (OCR) within HHS laid out guidance with green, yellow, and red light distinctions for how plans should be put together to avoid explicit discrimination (HHS, 2021). For example, sequential organ failure assessment (SOFA) scores have been found to adversely affect black patients, so discontinuing use of those as a scoring mechanism is an important lesson.

Discussion

Hanfling highlighted some of the points throughout the panel’s presentations, noting that it is clear equity needs to be at the center of discussions, and providers need to remember to put the patient first in decisions. He reiterated Mehta’s points on staffing, adding that the next iteration of CSC planning will need that level of detail and should focus on separating what

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4https://www.nap.edu/catalog/25767/crisis-standards-of-care-ten-years-of-successes-and-challenges.

Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×

works from what does not, collecting the best practices that can be more widely applied.

Toner asked what could be done to improve situational awareness of the triggers, pointing out that many providers in the summer of 2021 knew that the Delta variant was outcompeting the Alpha variant in most regions, but all of their data and protocols were based on the Alpha variant. Hanfling replied saying there is a need to better hone data acquisition and increase the ability to examine data in real-time. He added that just 1 year ago, HHS did not have visibility on bed availability for tracking COVID-19 patients. In the midst of the emergency, it had to find a private company to help. This is an example of where more coordination at the federal level can help to provide interoperable systems.

Hanfling also saw an opportunity for health care coalitions to play a role in bringing information up from the local level. He noted that the goal of CSC planning is to have situational awareness driving decision making to avoid having to ration care. Mehta added that too often bed capacity is represented as physical beds, but “staffed beds” should be the critical measure, and that number is in flux every day. He also called for identifying an upper limit of what providers can handle and defining capacity during surges to ensure safety is prioritized.

Peek explained that in addition to aligning staffing with bed capacity and other resources, the quality of training that people get in tertiary care hospitals and community hospitals is variable. For example, a well-trained ICU physician can staff more beds than a different type of clinician. There needs to be a better understanding of what the true capacity is of available staff, she said, especially those serving communities who bear a larger burden of diseases and have higher proportions of COVID-19 patients. Finally, Vanderwagen added that the linkage between public health authorities and hospital facilities is very weak in most places, but there is a need to incentivize stronger dialogue between these sectors.

On triage and protocols, Mehta noted that SOFA is part of many triage protocols, but it was not designed for this level and scale of use. As of September 2021, there was still a poor understanding of who was likely to survive COVID-19, he said, as well as poor metrics. As another note on equity, Peek added that different social identities intersect in different ways and can affect equity. For example, thinking about race and age, she said, potential policies that have a strict age guideline must be considered within the context that not everyone might be able to get to that age. She explained that because of structural inequities, black people on average do not live as long compared to white populations. So, to make these concepts fairly accessible to everyone, protocols may need to be adjusted for these factors and must incorporate multiple types of vulnerability, she said.

Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×

Mehta added that triage for a ventilator, ICU bed, hospital bed, or dialysis all rest on different predictors. And there is no one singular algorithm that will satisfy the needs of saving the most lives while still being equitable. He said that core ethical principles by which health care professionals want to make those decisions must be defined, and real-time access to data is necessary to constantly be able to better inform the dynamic situation and needs. Hanfling added that federal government partners need to engage in this discussion to help advance to the next level of planning and capabilities. The best capabilities science can bring are needed to discover how to make smarter decisions, he said. For example, it is still unclear what the correlates of protection are for medical countermeasures, whether for COVID-19 or other risks.

In conclusion, Toner commented on how complex CSC truly is, and how many layers have emerged and continue to emerge from the COVID-19 pandemic, creating more need for learning. As of September 2021, this coronavirus, SARS-CoV-2, was only 5 percent as lethal as severe acute respiratory syndrome (SARS), which emerged in 2003, and 2.5 percent as lethal as Middle East respiratory syndrome (MERS), affecting multiple countries since 2015; the need for robust and engaged CSC planning is even more critical now than we thought it was in 2009, he stated.

Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×

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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×
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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×
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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×
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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×
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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×
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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×
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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×
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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×
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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×
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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
×
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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
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Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
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Page 17
Suggested Citation:"2 Reflections, Inflections, and the Future." National Academies of Sciences, Engineering, and Medicine. 2022. Evolving Crisis Standards of Care and Ongoing Lessons from COVID-19: Proceedings of a Workshop Series. Washington, DC: The National Academies Press. doi: 10.17226/26573.
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Page 18
Next: 3 Considerations for Staffing, Effects on the Workforce, and Future Trends »
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Crisis Standards of Care (CSC) inform decisions on medical care during a large-scale crisis such as a pandemic or natural disaster, eliminating the need to make these decisions at the bedside without protections or guidance. Numerous points throughout the COVID-19 pandemic have demonstrated the necessity of this type of crisis planning. The National Academies of Sciences, Engineering, and Medicine Forum on Medical and Public Health Preparedness for Disasters and Emergencies convened a series of public workshops to examine the experiences of healthcare providers during the COVID-19 pandemic and identify lessons that can inform current and future CSC planning and implementation. The workshops examined staffing and workforce needs, planning and implementation of CSC plans, and legal, ethical, and equity considerations of CSC planning. Topics of discussion included improving coordination between the bedside and boardroom, increasing buy-in from elected officials, expanding provider engagement, and addressing health equity issues. This publication summarizes the presentation and discussion of the workshops.

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