ICU

Gazette file. A team of medical workers adjourns from a hallway meeting to discuss patient needs in the intensive-care unit at Penrose Hospital in Colorado Springs.

Four months ago, the omicron variant ripped through Colorado. As much as 10% of the state was sick at one time in early January, and hospital staff were not spared. Between infections in their own ranks and intense patient pressure upon emergency rooms, facilities found themselves at one of their most critical points of the pandemic.

As omicron picked up pace, providers began asking that state leaders activate the crisis standards of care for hospitals. The guidelines dictate to hospitals how, in emergency situations, they should allocate limited resources to a crush of patients. An organization representing emergency room physicians publicly called for an activation so they could refer qualifying patients to outpatient care, freeing up space in the ER.

But no activation came. Some hospitals and systems enacted their own version, but it formed a patchwork approach that didn't provide the uniformity — and tracking — that a statewide activation would have brought. There was no mechanism for a partial activation that would've given ER physicians flexibility while not causing the public to think ICU beds were being overwhelmed (they weren't). There was concern among state officials that activating all of the standards would trigger panic about triaging ventilators and hospital beds, panic that would also keep patients who did need medical care from seeking it.

On Thursday, as COVID-19 cases slowly begin to tick upward again, a group of Colorado physicians gathered to address the barrier they ran into four months ago. The group — officially known as the Governor's Expert Emergency Epidemic Response Committee — unanimously approved changes to the crisis standards that, among other things, allow the state to partially activate its hospital guidance.

By allowing the state's chief medical officer — Eric France — to activate only parts of the standards, the state could mitigate some of that panic, said Anuj Mehta, a physician and researcher who's taken a leading role in crafting the guidance over the past six months. It would also require effective messaging, but it would hopefully not give the public the automatic impression that ventilators are being overrun or ICU beds were overwhelmed.

Under the change, if another COVID-19 wave occurred tomorrow that surged infections like omicron did, then France could choose to activate only the hospital "decompression" parts of the standards, as Mehta called them. That would allow emergency departments to assess a patient and determine if she can safely be referred to outpatient treatment. If so, space and time is saved in an emergency room facing a crush of patients. If the determination is she can't, she would be treated there.

"I think that helps to avoid some of those political fears associated with the activation of the crisis standards," Mehta told the committee when it first drafted the changes on April 21.

The change gives facilities "maximum flexibility," said Steve Cantrill, an emergency room physician at Denver Health. 

France, who supported the change, said hospitals didn't want to discourage patients who legitimately needed emergency care from seeking it because crisis standards had been activated. Coloradans had already delayed care throughout the first several months of the pandemic, which has contributed to hospitals seeing a larger, sicker population of non-COVID patients than they did pre-pandemic.

Colorado never enacted the crisis standards of care for hospitals, despite moments of extreme stress in late 2020, late 2021 and early 2022. It did enact the crisis standards for staffing, which relaxed per patient ratios and ambulance services, which allowed crews and dispatchers to determine if a patient really needed transportation to a hospital.

While COVID-19 is relatively calm now, particularly in comparison to earlier surges, officials have continued to warn that the situation could change quickly, should a dangerous new variant emerge, and that another peak of some sort is likely near the end of the year. The standards were last updated in November, amid the delta wave and as calls for their activation grew louder.

Allowing for partial activation, while perhaps the most high profile, was not the only change to the standards adopted by the committee Thursday. It also tweaked a rubric hospitals would use to help judge which patient should get care over another, in the event of limited resources like a ventilator. 

Mehta said the score — known as SOFA, or the Sequential Organ Failure Assessment — has built-in racial biases. It's used to gauge how acutely ill a patient is, and "patients that belong to certain underrepresented minorities are more likely to be chronically ill, which leads to a higher chance of being more acutely ill," he said. 

The crisis standards can't solve "decades and centuries of inequities," Mehta said. But they could be tweaked to at least be cognizant of them.

Mehta said research indicated that Black patients have better outcomes than white patients who have the same SOFA score. To address it, he proposed — and the committee accepted — changing how physicians would judge a patient's kidney function: Mehta said Black patients often have a higher "normal range" of kidney function than people of other ethnicities. Under the original scoring system, that would hurt a Black patient's score because the upper end of their normal would still be clocked as abnormal. By adjusting the rubric, he said, the committee would address part of the score's biases.

The committee also made changes so that people with disabilities aren't punished for being nonverbal or having other preexisting medical issues. While age is still included as a factor for assessing patients ill with COVID-19 — because age is a significant risk factor for death — the standards now include a statement that biases — based on race, age or disability status — "must be avoided." 

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