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At the Top of the Covid-19 Curve, How Do Hospitals Decide Who Gets Treatment? At the Top of the Covid-19 Curve, How Do Hospitals Decide Who Gets Treatment?
(about 3 hours later)
A hospital in Washington State projects that it may not have enough ventilators in two weeks. New York State could be thousands of ventilators short of what it needs. In Michigan, a hospital system has prepared warnings for patients about what will happen if it gets more patients than it can handle.A hospital in Washington State projects that it may not have enough ventilators in two weeks. New York State could be thousands of ventilators short of what it needs. In Michigan, a hospital system has prepared warnings for patients about what will happen if it gets more patients than it can handle.
The answers are stark: some patients would get full intensive care treatment, some would not. But which ones?The answers are stark: some patients would get full intensive care treatment, some would not. But which ones?
Across the country, hospitals and public health officials are working on plans for what happens if the number of coronavirus patients exceeds the available space in intensive care units.Across the country, hospitals and public health officials are working on plans for what happens if the number of coronavirus patients exceeds the available space in intensive care units.
Many states have developed triage plans for what happens in a natural disaster or a severe pandemic, if hospitals are overwhelmed. As the coronavirus pandemic expands, they have been re-examining those plans, hoping they will be useful if hospitals have more critically ill patients than ventilators.Many states have developed triage plans for what happens in a natural disaster or a severe pandemic, if hospitals are overwhelmed. As the coronavirus pandemic expands, they have been re-examining those plans, hoping they will be useful if hospitals have more critically ill patients than ventilators.
The New York Times reviewed triage strategy documents from Alabama, Arizona, Kansas, Louisiana, Maryland, Michigan, New York, Pennsylvania, Tennessee, Utah and Washington State to see what factors they propose to use to decide which patients get potentially life-saving treatments.The New York Times reviewed triage strategy documents from Alabama, Arizona, Kansas, Louisiana, Maryland, Michigan, New York, Pennsylvania, Tennessee, Utah and Washington State to see what factors they propose to use to decide which patients get potentially life-saving treatments.
Some of the plans may be revised as more information on Covid-19 becomes available; these are the versions that have been made publicly available.Some of the plans may be revised as more information on Covid-19 becomes available; these are the versions that have been made publicly available.
Almost all of the plans give priority to otherwise healthy people who are most likely to fully recover. But it is not that simple.Almost all of the plans give priority to otherwise healthy people who are most likely to fully recover. But it is not that simple.
The plans struggle to address a range of ethical issues, and also matters of social equality. People with underlying medical problems may get ranked lower, yet low-income people and people of color often have more health problems because they cannot afford top-notch care.The plans struggle to address a range of ethical issues, and also matters of social equality. People with underlying medical problems may get ranked lower, yet low-income people and people of color often have more health problems because they cannot afford top-notch care.
Do they go to the back of the line? People with disabilities also have concerns.Do they go to the back of the line? People with disabilities also have concerns.
How much legal force these plans carry varies from state to state. Some states have laws that may protect providers from at least some types of liability for following the guidelines in an official emergency; in most states, including New York, the legal protections they offer are less clear.How much legal force these plans carry varies from state to state. Some states have laws that may protect providers from at least some types of liability for following the guidelines in an official emergency; in most states, including New York, the legal protections they offer are less clear.
One underlying assumption: They should only be implemented if other measures fail. “When the system is at risk of becoming overwhelmed, the goal then becomes to conserve, substitute, adapt and reuse,” said a report released Sunday by the National Academies of Sciences, Engineering and Medicine.One underlying assumption: They should only be implemented if other measures fail. “When the system is at risk of becoming overwhelmed, the goal then becomes to conserve, substitute, adapt and reuse,” said a report released Sunday by the National Academies of Sciences, Engineering and Medicine.
Making these life and death choices, it said, should be done “only in the most extreme of circumstances.”Making these life and death choices, it said, should be done “only in the most extreme of circumstances.”
If a hospital has a shortage of resources, the first thing it may consider is whether to decline admission to an intensive care unit to people who have conditions that will likely result in near-immediate death even if they get that treatment.If a hospital has a shortage of resources, the first thing it may consider is whether to decline admission to an intensive care unit to people who have conditions that will likely result in near-immediate death even if they get that treatment.
One common strategy, including for New York and Maryland, is to exclude patients who may have a cardiac arrest that is unresponsive to standard interventions such as defibrillation. Plans can also exclude those who may have had a major brain injury or severe burns where the likelihood of survival is low.One common strategy, including for New York and Maryland, is to exclude patients who may have a cardiac arrest that is unresponsive to standard interventions such as defibrillation. Plans can also exclude those who may have had a major brain injury or severe burns where the likelihood of survival is low.
A triage plan on the Alabama health department’s website suggests that “persons with severe mental retardation” are among those who “may be poor candidates for ventilator support.” Washington State’s guidelines include the consideration of a “baseline functional status” for each patient, considering such factors as declines in energy level, physical ability and cognition.A triage plan on the Alabama health department’s website suggests that “persons with severe mental retardation” are among those who “may be poor candidates for ventilator support.” Washington State’s guidelines include the consideration of a “baseline functional status” for each patient, considering such factors as declines in energy level, physical ability and cognition.
Federal civil rights officials recently announced they will not allow hospitals to discriminate on the basis of disabilities, race, age or religion.Federal civil rights officials recently announced they will not allow hospitals to discriminate on the basis of disabilities, race, age or religion.
The plan on Alabama’s website would also use AIDS as a factor in deciding to exclude someone for ventilator support, but Alabama officials said they have replaced the plan with a different set of guidelines. The newer policies do not address questions about ventilator triage.The plan on Alabama’s website would also use AIDS as a factor in deciding to exclude someone for ventilator support, but Alabama officials said they have replaced the plan with a different set of guidelines. The newer policies do not address questions about ventilator triage.
In Washington State, doctors can also consider withholding advanced care for patients with “severe congestive heart failure,” “severe chronic lung disease” or “severe cirrhotic liver disease with multiorgan dysfunction,” as well as other major problems with a poor prognosis for recovery.In Washington State, doctors can also consider withholding advanced care for patients with “severe congestive heart failure,” “severe chronic lung disease” or “severe cirrhotic liver disease with multiorgan dysfunction,” as well as other major problems with a poor prognosis for recovery.
Louisiana may exclude patients with severe dementia.Louisiana may exclude patients with severe dementia.
For those who do qualify for I.C.U. care, hospitals would then look to further prioritize patients.For those who do qualify for I.C.U. care, hospitals would then look to further prioritize patients.
Maryland’s guidelines, for example, would score patients with a combination of factors that largely seek to assess both short-term and long-term survivability. In the event that two patients have the same estimated survivability, the scoring protocols give younger people better odds of getting treatment, with the “lowest priority” given to patients 85 and older.Maryland’s guidelines, for example, would score patients with a combination of factors that largely seek to assess both short-term and long-term survivability. In the event that two patients have the same estimated survivability, the scoring protocols give younger people better odds of getting treatment, with the “lowest priority” given to patients 85 and older.
Some of the states rely at least in part on a score known as the Sequential Organ Failure Assessment (SOFA), which measures the functioning of major body systems, including the heart, lungs, kidneys, liver, blood and neurological system. Patients with high SOFA scores would be less likely to qualify.Some of the states rely at least in part on a score known as the Sequential Organ Failure Assessment (SOFA), which measures the functioning of major body systems, including the heart, lungs, kidneys, liver, blood and neurological system. Patients with high SOFA scores would be less likely to qualify.
The scoring system was never meant for this use, and some experts question how accurate it will be in predicting survival. Some plans use different scoring systems or use a sliding scale so that someone whose score is slightly higher than an arbitrary cutoff does not get automatically excluded if it turns out there are enough ventilators.The scoring system was never meant for this use, and some experts question how accurate it will be in predicting survival. Some plans use different scoring systems or use a sliding scale so that someone whose score is slightly higher than an arbitrary cutoff does not get automatically excluded if it turns out there are enough ventilators.
The guidelines in Maryland also look at severe pre-existing health problems likely to result in death within a year. But they do not seek to project survivability beyond a year, in part to avoid disadvantaging the poor and people of color.The guidelines in Maryland also look at severe pre-existing health problems likely to result in death within a year. But they do not seek to project survivability beyond a year, in part to avoid disadvantaging the poor and people of color.
An interim guideline produced in Pennsylvania in March uses SOFA scoring but also takes into consideration the likelihood of long-term survival, such as for patients with Alzheimer’s disease or those with cancer who have less than 10 years of expected survival.An interim guideline produced in Pennsylvania in March uses SOFA scoring but also takes into consideration the likelihood of long-term survival, such as for patients with Alzheimer’s disease or those with cancer who have less than 10 years of expected survival.
It groups people into different color codes: red, orange or yellow, with red being first in line for the most aggressive treatment. New York also uses color coding: blue for people who don’t qualify for such care, red for those who are the highest priority, yellow for those who should get ventilators if they are available and green for those who do not need lifesaving resources.It groups people into different color codes: red, orange or yellow, with red being first in line for the most aggressive treatment. New York also uses color coding: blue for people who don’t qualify for such care, red for those who are the highest priority, yellow for those who should get ventilators if they are available and green for those who do not need lifesaving resources.
Here’s an example of how the guidelines could compare patients needing a ventilator in Maryland:Here’s an example of how the guidelines could compare patients needing a ventilator in Maryland:
Patient A: 24 years old, with a SOFA score of 13 (indicating signs of failure across multiple organ systems) but no pre-existing conditions that would limit life expectancy to less than a year. The person’s high SOFA score would give them three overall points.Patient A: 24 years old, with a SOFA score of 13 (indicating signs of failure across multiple organ systems) but no pre-existing conditions that would limit life expectancy to less than a year. The person’s high SOFA score would give them three overall points.
Patient B: 72 years old, with a SOFA score of 10 (indicating significant but less-severe signs of organs failing), and moderate Alzheimer’s disease but no pre-existing conditions that would limit life expectancy to less than a year. This patient would end up with an overall score of two because the SOFA score is lower.Patient B: 72 years old, with a SOFA score of 10 (indicating significant but less-severe signs of organs failing), and moderate Alzheimer’s disease but no pre-existing conditions that would limit life expectancy to less than a year. This patient would end up with an overall score of two because the SOFA score is lower.
The older person would qualify for care first.The older person would qualify for care first.
But in Pennsylvania, the person with moderate Alzheimer’s would score additional points, under the guidelines, leading the younger person to qualify for care first.But in Pennsylvania, the person with moderate Alzheimer’s would score additional points, under the guidelines, leading the younger person to qualify for care first.
There are other factors that might get considered along the way.There are other factors that might get considered along the way.
For a pregnant woman with a healthy fetus, the Maryland guidelines give a one-point credit, while Pennsylvania offers a two-point benefit. Utah guidelines provide one or two points depending on how far into the pregnancy the mother is.For a pregnant woman with a healthy fetus, the Maryland guidelines give a one-point credit, while Pennsylvania offers a two-point benefit. Utah guidelines provide one or two points depending on how far into the pregnancy the mother is.
Updated May 28, 2020 Updated June 1, 2020
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.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.)
More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said.More than 40 million people — the equivalent of 1 in 4 U.S. workers — have filed for unemployment benefits since the pandemic took hold. One in five who were working in February reported losing a job or being furloughed in March or the beginning of April, data from a Federal Reserve survey released on May 14 showed, and that pain was highly concentrated among low earners. Fully 39 percent of former workers living in a household earning $40,000 or less lost work, compared with 13 percent in those making more than $100,000, a Fed official said.
There is an uptick in people reporting symptoms of chilblains, which are painful red or purple lesions that typically appear in the winter on fingers or toes. The lesions are emerging as yet another symptom of infection with the new coronavirus. Chilblains are caused by inflammation in small blood vessels in reaction to cold or damp conditions, but they are usually common in the coldest winter months. Federal health officials do not include toe lesions in the list of coronavirus symptoms, but some dermatologists are pushing for a change, saying so-called Covid toe should be sufficient grounds for testing.
Yes, but make sure you keep six feet of distance between you and people who don’t live in your home. Even if you just hang out in a park, rather than go for a jog or a walk, getting some fresh air, and hopefully sunshine, is a good idea.Yes, but make sure you keep six feet of distance between you and people who don’t live in your home. Even if you just hang out in a park, rather than go for a jog or a walk, getting some fresh air, and hopefully sunshine, is a good idea.
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.
Charity Navigator, which evaluates charities using a numbers-based system, has a running list of nonprofits working in communities affected by the outbreak. You can give blood through the American Red Cross, and World Central Kitchen has stepped in to distribute meals in major cities.Charity Navigator, which evaluates charities using a numbers-based system, has a running list of nonprofits working in communities affected by the outbreak. You can give blood through the American Red Cross, and World Central Kitchen has stepped in to distribute meals in major cities.
The Pennsylvania guidelines also offer a one-point benefit to health workers playing a role in responding to a crisis.The Pennsylvania guidelines also offer a one-point benefit to health workers playing a role in responding to a crisis.
If two people have the same score under the Pennsylvania guidelines, the tiebreaker goes to the person in the youngest age group. Maryland also uses age as a tiebreaker, and says hospitals that need to make further evaluations should use a fair and transparent way of deciding: “This might mean first-come, first-served or some form of lottery.”If two people have the same score under the Pennsylvania guidelines, the tiebreaker goes to the person in the youngest age group. Maryland also uses age as a tiebreaker, and says hospitals that need to make further evaluations should use a fair and transparent way of deciding: “This might mean first-come, first-served or some form of lottery.”
There are fewer intensive care unit resources for children in the United States, compared to adults, and children often require different equipment than adults do. Relatively few children have become critically ill with Covid-19. Still, some of the plans offer specific guidelines for younger patients.There are fewer intensive care unit resources for children in the United States, compared to adults, and children often require different equipment than adults do. Relatively few children have become critically ill with Covid-19. Still, some of the plans offer specific guidelines for younger patients.
In New York, the guidelines rely heavily on the judgment of doctors to assess a young patient’s risk of death. The doctor is supposed to take into consideration a variety of health conditions, including morbid obesity, impaired growth and intractable seizures, all of which may weigh against the most advanced lifesaving care for coronavirus.In New York, the guidelines rely heavily on the judgment of doctors to assess a young patient’s risk of death. The doctor is supposed to take into consideration a variety of health conditions, including morbid obesity, impaired growth and intractable seizures, all of which may weigh against the most advanced lifesaving care for coronavirus.
Pennsylvania’s guidelines follow a similar scoring protocol as the one used for adults. They offer some specific guidance, such as for extreme preterm infants with low birth weights and a low chance of survival. If there is a scarcity of neonatal I.C.U. beds, those newborns would not be candidates for ventilator support.Pennsylvania’s guidelines follow a similar scoring protocol as the one used for adults. They offer some specific guidance, such as for extreme preterm infants with low birth weights and a low chance of survival. If there is a scarcity of neonatal I.C.U. beds, those newborns would not be candidates for ventilator support.
In Alabama, the guidelines on the state website say that “children with severe neurological problems” may be denied ventilator support.In Alabama, the guidelines on the state website say that “children with severe neurological problems” may be denied ventilator support.
Washington State’s strategy asks doctors to re-evaluate their patients on ventilators about once a day. If a patient’s condition has improved, they could be moved out of the I.C.U. to make room for new patients. If their condition is worsening, even with the ventilator, it suggests that doctors may want to shift them into end-of-life care to free up space for someone else.Washington State’s strategy asks doctors to re-evaluate their patients on ventilators about once a day. If a patient’s condition has improved, they could be moved out of the I.C.U. to make room for new patients. If their condition is worsening, even with the ventilator, it suggests that doctors may want to shift them into end-of-life care to free up space for someone else.
Doctors are particularly concerned about these measures, because the conditions of critically ill patients with Covid-19 often worsen before improving. Some people who survive require days to weeks on a ventilator. If patients are removed too quickly, they may lose their chance to recover.Doctors are particularly concerned about these measures, because the conditions of critically ill patients with Covid-19 often worsen before improving. Some people who survive require days to weeks on a ventilator. If patients are removed too quickly, they may lose their chance to recover.
New York’s guidelines say that if a patient continues to show improvement, he or she will continue on ventilator therapy. But if that person’s condition worsens, ventilator care may be discontinued.New York’s guidelines say that if a patient continues to show improvement, he or she will continue on ventilator therapy. But if that person’s condition worsens, ventilator care may be discontinued.
Those who prepared New York’s plan acknowledged that a decision to remove someone from a ventilator may be traumatic to patients, families and staff members.Those who prepared New York’s plan acknowledged that a decision to remove someone from a ventilator may be traumatic to patients, families and staff members.
“However, removing a ventilator from a patient who worsens or does not improve so that another patient with a strong likelihood of survival may have an opportunity for treatment helps support the goal of saving the greatest number of lives,” it says.“However, removing a ventilator from a patient who worsens or does not improve so that another patient with a strong likelihood of survival may have an opportunity for treatment helps support the goal of saving the greatest number of lives,” it says.
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