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‘Chilling’ Plans: Who Gets Care as Washington State Hospitals Fill Up? ‘Chilling’ Plans: Who Gets Care as Washington State Hospitals Fill Up?
(3 days later)
SEATTLE — Medical leaders in Washington State, which has the highest number of coronavirus deaths in the country, have quietly begun preparing a bleak triage strategy to determine which patients may have to be denied complete medical care in the event that the health system becomes overwhelmed by the coronavirus in the coming weeks.SEATTLE — Medical leaders in Washington State, which has the highest number of coronavirus deaths in the country, have quietly begun preparing a bleak triage strategy to determine which patients may have to be denied complete medical care in the event that the health system becomes overwhelmed by the coronavirus in the coming weeks.
Fearing a critical shortage of supplies, including the ventilators needed to help the most seriously ill patients breathe, state officials and hospital leaders held a conference call on Wednesday night to discuss the plans, according to several people involved in the talks. The triage document, still under consideration, will assess factors such as age, health and likelihood of survival in determining who will get access to full care and who will merely be provided comfort care, with the expectation that they will die.Fearing a critical shortage of supplies, including the ventilators needed to help the most seriously ill patients breathe, state officials and hospital leaders held a conference call on Wednesday night to discuss the plans, according to several people involved in the talks. The triage document, still under consideration, will assess factors such as age, health and likelihood of survival in determining who will get access to full care and who will merely be provided comfort care, with the expectation that they will die.
The effort is statewide so individual doctors and hospitals will not be left to make such decisions, said Cassie Sauer, chief executive of the Washington State Hospital Association, one of the groups convening the call.The effort is statewide so individual doctors and hospitals will not be left to make such decisions, said Cassie Sauer, chief executive of the Washington State Hospital Association, one of the groups convening the call.
“It’s protecting the clinicians so you don’t have one person who’s kind of playing God,” she said, adding, “It is chilling, and it should not happen in America.”“It’s protecting the clinicians so you don’t have one person who’s kind of playing God,” she said, adding, “It is chilling, and it should not happen in America.”
Ms. Sauer stressed that several things, including more hospital beds and equipment, could reduce the need to make such decisions. “This country has resources,” she said.Ms. Sauer stressed that several things, including more hospital beds and equipment, could reduce the need to make such decisions. “This country has resources,” she said.
The state has been urgently seeking ventilators for patients and protective masks for health care workers, including from the Strategic National Stockpile, a repository of critical medical supplies for public health emergencies. Officials have also been looking to have the U.S. Navy hospital ship Mercy, which has 80 intensive care beds, dock near Seattle to handle seriously ill patients other than those who have contracted Covid-19, the disease caused by the virus.The state has been urgently seeking ventilators for patients and protective masks for health care workers, including from the Strategic National Stockpile, a repository of critical medical supplies for public health emergencies. Officials have also been looking to have the U.S. Navy hospital ship Mercy, which has 80 intensive care beds, dock near Seattle to handle seriously ill patients other than those who have contracted Covid-19, the disease caused by the virus.
In the meantime, officials in King County have begun building a field hospital on a soccer field north of Seattle. One large hospital system based in the area has started making masks and face shields by hand. Hospitals have already postponed elective surgeries to preserve resources.In the meantime, officials in King County have begun building a field hospital on a soccer field north of Seattle. One large hospital system based in the area has started making masks and face shields by hand. Hospitals have already postponed elective surgeries to preserve resources.
Dr. Chris Spitters, the interim health officer for the Snohomish Health District, where the nation’s first coronavirus case was diagnosed, was part of the group that discussed the rationing proposals this week. He said that while the crisis strategies were not something anyone wants to anticipate, it would be worse not to be ready in the event they were needed.Dr. Chris Spitters, the interim health officer for the Snohomish Health District, where the nation’s first coronavirus case was diagnosed, was part of the group that discussed the rationing proposals this week. He said that while the crisis strategies were not something anyone wants to anticipate, it would be worse not to be ready in the event they were needed.
“I would love to learn a month from now that the social distancing measures we adopted did indeed curb the outbreak enough to avoid going into that crisis zone of activity,” Dr. Spitters said. “But that would be poor planning — to simply hope.”“I would love to learn a month from now that the social distancing measures we adopted did indeed curb the outbreak enough to avoid going into that crisis zone of activity,” Dr. Spitters said. “But that would be poor planning — to simply hope.”
Dr. Spitters said hospitals are also strategizing how to repurpose space, staff members and resources to help deal with an expected surge in patients.Dr. Spitters said hospitals are also strategizing how to repurpose space, staff members and resources to help deal with an expected surge in patients.
Those involved in the discussions said the goal for developing criteria for prioritizing care is to provide fair and evenly applied practices across the region and eliminate the possibility that the care a patient receives might depend on which hospital he or she goes to. They said they also hope to avoid placing the responsibility and anguish of denying lifesaving aid on any individual doctor or nurse.Those involved in the discussions said the goal for developing criteria for prioritizing care is to provide fair and evenly applied practices across the region and eliminate the possibility that the care a patient receives might depend on which hospital he or she goes to. They said they also hope to avoid placing the responsibility and anguish of denying lifesaving aid on any individual doctor or nurse.
“They look at the criteria — in this case it would likely be age and underlying disease conditions — and then determine that this person, though this person has a chance of survival with a ventilator, does not get one,” Ms. Sauer said.“They look at the criteria — in this case it would likely be age and underlying disease conditions — and then determine that this person, though this person has a chance of survival with a ventilator, does not get one,” Ms. Sauer said.
“This is a shift to caring for the population, where you look at the whole population of people who need care and make a determination about who is most likely to survive, and you provide care to them,” she said. “Those that have a less good chance of survival — but still have a chance — you do not provide care to them, which guarantees their death.”“This is a shift to caring for the population, where you look at the whole population of people who need care and make a determination about who is most likely to survive, and you provide care to them,” she said. “Those that have a less good chance of survival — but still have a chance — you do not provide care to them, which guarantees their death.”
In Washington State, the crisis care planning is being led by the Northwest Healthcare Response Network, a coalition of hospitals assembled to handle disaster response, in conjunction with the Washington State Department of Health.In Washington State, the crisis care planning is being led by the Northwest Healthcare Response Network, a coalition of hospitals assembled to handle disaster response, in conjunction with the Washington State Department of Health.
The group pulls on expertise in many disciplines, including specialists in pulmonary care, emergency medicine, infectious diseases, pediatrics and medical ethics.The group pulls on expertise in many disciplines, including specialists in pulmonary care, emergency medicine, infectious diseases, pediatrics and medical ethics.
“Now we are getting down to the point of how you would deploy it, when would you deploy it, who needs to know about it,” said Dr. Cameron Buck, president of the Washington chapter of the American College of Emergency Physicians.“Now we are getting down to the point of how you would deploy it, when would you deploy it, who needs to know about it,” said Dr. Cameron Buck, president of the Washington chapter of the American College of Emergency Physicians.
“In my career, I can’t think of any other example where we have come this far, and had to make these preparations and develop these frameworks in real time with a moderate probability of having to use this work,” Dr. Buck said.“In my career, I can’t think of any other example where we have come this far, and had to make these preparations and develop these frameworks in real time with a moderate probability of having to use this work,” Dr. Buck said.
Dr. Kathy Lofy, the state health officer, said the guidelines under discussion have come from a group of clinical experts who have in recent years worked on the issue of providing health care in challenging circumstances. “We are doing everything possible to slow the spread of the virus and increase resources within the health care system so that resources will be available for everyone who needs them,” Dr. Lofy said in a statement.Dr. Kathy Lofy, the state health officer, said the guidelines under discussion have come from a group of clinical experts who have in recent years worked on the issue of providing health care in challenging circumstances. “We are doing everything possible to slow the spread of the virus and increase resources within the health care system so that resources will be available for everyone who needs them,” Dr. Lofy said in a statement.
Updated June 5, 2020 Updated June 12, 2020
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.
Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.Exercise researchers and physicians have some blunt advice for those of us aiming to return to regular exercise now: Start slowly and then rev up your workouts, also slowly. American adults tended to be about 12 percent less active after the stay-at-home mandates began in March than they were in January. But there are steps you can take to ease your way back into regular exercise safely. First, “start at no more than 50 percent of the exercise you were doing before Covid,” says Dr. Monica Rho, the chief of musculoskeletal medicine at the Shirley Ryan AbilityLab in Chicago. Thread in some preparatory squats, too, she advises. “When you haven’t been exercising, you lose muscle mass.” Expect some muscle twinges after these preliminary, post-lockdown sessions, especially a day or two later. But sudden or increasing pain during exercise is a clarion call to stop and return home.
States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications.Taking one’s temperature to look for signs of fever is not as easy as it sounds, as “normal” temperature numbers can vary, but generally, keep an eye out for a temperature of 100.5 degrees Fahrenheit or higher. If you don’t have a thermometer (they can be pricey these days), there are other ways to figure out if you have a fever, or are at risk of Covid-19 complications.
The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.If you’re sick and you think you’ve been exposed to the new coronavirus, the C.D.C. recommends that you call your healthcare provider and explain your symptoms and fears. They will decide if you need to be tested. Keep in mind that there’s a chance — because of a lack of testing kits or because you’re asymptomatic, for instance — you won’t be able to get tested.
Roughly 280 people were on Wednesday’s three-hour conference call, including the chief medical officials and nursing representatives for most of the state’s hospitals and hospital systems, Ms. Sauer said. There was an overwhelming sense of shock, she said, as clinicians realized that the time to begin discussing such dire plans had arrived.Roughly 280 people were on Wednesday’s three-hour conference call, including the chief medical officials and nursing representatives for most of the state’s hospitals and hospital systems, Ms. Sauer said. There was an overwhelming sense of shock, she said, as clinicians realized that the time to begin discussing such dire plans had arrived.
“It just takes a lot of time for people whose lives are about saving lives to process that they may have to make these decisions,” she said.“It just takes a lot of time for people whose lives are about saving lives to process that they may have to make these decisions,” she said.
Hospitals in the greater Seattle region already have been working to distribute patients evenly so no single hospital truly reaches its capacity. Seattle Children’s Hospital has taken pediatric patients from other facilities and begun admitting people up to 21 years old to free up more beds in adult hospitals.Hospitals in the greater Seattle region already have been working to distribute patients evenly so no single hospital truly reaches its capacity. Seattle Children’s Hospital has taken pediatric patients from other facilities and begun admitting people up to 21 years old to free up more beds in adult hospitals.
Teams from regional health departments and hospitals would be responsible for triaging patients and potentially making these decisions, and the crisis-based decision-making criteria could be turned off and on as the situation evolved, Dr. Buck said.Teams from regional health departments and hospitals would be responsible for triaging patients and potentially making these decisions, and the crisis-based decision-making criteria could be turned off and on as the situation evolved, Dr. Buck said.
The group plans additional calls twice a week, to get updates on the capacity challenges and to share proposed changes to the criteria that are still under consideration.The group plans additional calls twice a week, to get updates on the capacity challenges and to share proposed changes to the criteria that are still under consideration.
Dr. Buck said the health care rationing that occurred recently in Italy in response to the coronavirus outbreak weighed heavily on doctors as they discussed how their own work might have to proceed. “This is something that is obviously very serious and that we take very seriously.”Dr. Buck said the health care rationing that occurred recently in Italy in response to the coronavirus outbreak weighed heavily on doctors as they discussed how their own work might have to proceed. “This is something that is obviously very serious and that we take very seriously.”