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A Guide To Hospital Standards of Care And What To Expect Now

What Crisis Standards of Care Are and How They Are Changing

A photo frames a hospital hallway, as a health care worker in their gown looks down with their back facing the camera. This image accompanies the Flatland guide on what to know about the evolving standards of care in hospital systems and health care clinics.
The care hospitals were able to offer communities changed during COVID-19. Why? (Splash)
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When Cynthia Olavarria Kaufman rushed to the emergency room in December 2021, she could hardly stand up straight. The omicron wave had just hit and she tried hunkering down at home to get well.

But Olavarria Kaufman had been expelling all liquids, unable to keep anything down. She became weak. 

So, her 22-year-old son urged her to go to the ER for help. After nearly five hours of waiting, she was taken to a makeshift room. In the hallway. 

“I’m sitting there in a lot of pain, my son is there. I asked, ‘Are they eventually gonna take me in?’ And (the nurse) she’s like, ‘We don’t have any beds for you,’” Kaufman recalled. “I was in the hallway the whole time.”

She saw several elderly patients laid on beds in the same hallway she was in, and nurse aides struggling to keep up with the amount of patients. What struck Olavarria Kaufman most was how impersonal and exposed it felt to be treated for an illness in a crowded hospital hallway, inches away from someone needing more critical care. 

In a previous Flatland report, burnout and moral distress was cited as a major reason why folks are leaving the health care profession. But what is less known are the measures – known as crisis standards of care – put together by bioethical institutions and health care coalitions to help guide systems in disaster situations. 

Dr. Michael Moncure was part of the regional coalition who contributed to pandemic preparedness and crisis conversations.
Dr. Michael Moncure was part of the regional coalition who contributed to pandemic preparedness and crisis conversations. (Contributed)

What Olavarria Kaufman witnessed was illustrative of these times and symptomatic of an overburdened health care system. Hospitals in the Kansas City area were on the brink of crisis status multiple times during the COVID-19 pandemic. 

So says Dr. Michael Moncure, who is the Regional Health Care Coalition Clinical Adviser housed at the Mid-America Regional Council and a physician at University Health.

This raised several questions: What measures are in place to protect health care workers in addition to their patients? What can medical systems do better in light of what the pandemic has revealed? What support do these systems need to support their staff? 

These considerations also put into perspective the role of governmental entities in public health. 

What follows is a guide prompted by public health professionals and other health experts. Scroll through to hear what experts in bioethics, medicine and those still on the frontlines have to say. 

“We’ve come really, really, really close to getting to crisis standards.”

Dr. Michael moncure, physician at university health and clinical adviser for the regional Health Care Coalition

What are crisis standards of care and how did they crop up in 2020?

John Carney, CEO of the Center for Practical Bioethics, put it like this: “Crisis standards of care are basically a quasi-governmental response document that speaks to how we will prioritize certain people and afford us to be able to provide services.

“What we do is we move from the individual to the greater good. We go from the patient in front of me, to the patients who need scarce resources.” 

John Carney, CEO of the Center for Practical Bioethics. (Contributed)
John Carney, CEO of the Center for Practical Bioethics. (Contributed)

The process is complicated but the idea is to standardize procedures at hospitals and health care facilities.

He broke it down: “What you would do is in the crisis standards, you would mobilize the emergency (response systems) within the country. And they would put all the resources together about moving certain kinds of things like Tamaflu or ventilators. 

“They’d put them on trucks and they would be ready to go from one part of the country to the other. All aspects of the medical response were dependent upon transportation, dependent upon governmental entities working together.”

This would apply to everything from vaccinations to distribution of therapies across states. 

There are four distinct levels to help inform what status leaders select. The idea is when crises worsen, leaders mobilize the next level to inform public health, hospital clinics and health systems’ strategies. 

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The Ladder of Care (download the graphic below):

  • Conventional Care: Systems are fully staffed and have all resources they need. Everybody’s taken into account, no change in prioritization; hospital and health care systems operate as normal and all patients are treated equitably. 
  • Surge Care: Systems may be under some stress and adjust rules around elective surgeries and other similar procedures. There is no change to patient outcomes.  
  • Contingency Care: Systems are under higher stress and less able to operate normally and, as done under surge care, the number of elective procedures are reduced. In addition, they may begin to conserve supplies for patients who can live or recover without them. Changes in care do not have an impact on patient outcomes.  
  • Crisis Care: Systems are under dire stress. Resources may be reused and recycled, using facilities or rooms for different kinds of care, and health care staff may be asked to practice “outside the scope of expertise,” according to an Institute of Medicine Forum on Medical and Public Health Preparedness for Catastrophic Events report from 2010.

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Crisis Care is the red zone.

A toolkit by the U.S. Department of Health & Human Services, said crisis standards should be a “last resort” if all other options have been exhausted and no regional resources are available. 

Moncure, who is a physician on the frontlines and helped the Kansas City region coordinate pandemic response, agreed. He said the hope is that hospitals never reach that point. 

“We’ve come really, really, really close to getting to crisis standards,” he added. 

In monthly, sometimes late-night, calls with regional health care leaders, he recounted, they’d often raise whether to sound the alarm. 

Ideally, he says, collaboration among regional health care systems and networks should be so strong that folks who may not be able to receive care in one hospital can be flown to another, for instance. The same goes for supplies. 

He pointed to an example. At one point during the second COVID-19 wave, Kansas City regional hospitals were able to provide ventilators, Protective Personal Equipment (PPE) and even personnel to areas in need. 

“We avoided a lot of things just by working together,” Moncure said. 

But he said this is not a guaranteed solution: “We’ve got to really be careful because now crisis standards could arise as a result of us just not having a lot of health care colleagues to work at the bedside.” 

Guides by national science leaders outline just that. 

The formula emerged when public health leaders were bracing for an influenza crisis in the mid-2000s. Armed with tactics and emergency stockpiles, health leaders felt ready. 

But when the flu outbreaks didn’t last as long as they originally thought they would, they never replenished the stockpiles and were never able to test their packets in the real world. 

“We find ourselves immediately in crisis, not only because it’s exploding everywhere, but we don’t have stockpiles that we can send to people. And so then we pushed it back onto the hospitals and said, ‘Well, you should be ready to triage your people’,” Carney explained.

“Emergencies are usually very short lived,” Carney said. “Then you would go to what was called a disaster, which was beyond emergency. So it wasn’t just local people that couldn’t do it. It was bigger than that.”

What crisis guidance existed before? 

Efforts to reduce the need to employ crisis standards of care, or what National Academy of Sciences (NAS) experts called “COVID surge demands in July 2020,” were two pronged: community-wide and health care specific. 

The community efforts outlined by NAS included:

  • Reduce the Burden of Disease
    • Messaging and education was key to ensuring communities were empowered to protect themselves, their families and the frontline workers: “Given the impact of certain interventions on reducing the spread of disease and decreasing the stress to the health care system, the public needs to understand its role in keeping health care workers safe and available to work to care for those who become ill.”
  • Transfer Patients to Diffuse Impact
    • When one hospital is overwhelmed, patients can be transferred to a nearby facility who has the capacity, resources and staffing to care for the patient. This would be organized by local health care coalitions: “The use of health care coalitions and Medical Operations Coordination Centers … as ‘level-loading’ mechanisms should be in place to ensure that all available inpatient capacity is leveraged.”
  • Curtail Elective Procedures and Appointments
    • To reduce staff overwhelm and viral spread, this effort would pause elective procedures to ensure available health care workers could be available when needed: “A ranking system for procedures may be helpful not only to determine prioritization (based on risk if the procedure is postponed) but also balanced against the need for the staff and the risk of transmission of COVID-19.”
  • Ensure Support for Existing Staff
    • Support looks like a number of things. Hiring more folks, for instance, would not only help support patients, but also hospitals that have shortages because of illness, health risks or other responsibilities such as childcare or caregiving. But another focus has been on personal incentives and psychological support: “Facilitating expanded availability of staff is not just a matter of identification and incentives. Current staff must also be supported psychologically, physically, and financially. … A major driver of burnout is dysfunctional systems of care.”

The health care-specific strategies included:

  • Obtain Additional Staffing
    • With the support of regional health care coalitions, staff moved across systems and regions should help alleviate overwhelming demands: “Existing staff-sharing agreements may be leveraged to move staff from one facility to another.”
  • Re-Deploy Staff and Adjust Job Responsibilities
    • Health care educators and folks who no longer work bedside returned to the floors to treat patients. This was common during the height of the pandemic, especially as new COVID waves swelled, overwhelming hospitals everywhere: “Education and administration personnel with clinical backgrounds (nurse managers, supervisors, clinical educators) should be returned to practice and relieved of their other duties unless those duties involve direct COVID-19 or other critical operational roles.”  
    • Example: Bioethicist Terry Rosell knows a hospital administrator who had to move from working in an office and back on the floor. “Just a few weeks ago (she) called and … it turned out that she had just done night duty on a holiday weekend, no less,” Rosell said. “Going back onto the unit.”
  • Change Staffing Model
    • Nurses are instructed to take on more patients than usual, increasing their nurse-to-patient ratio: “Most hospitals maintain a critical care staffing ratio of 1 nurse per 2 patients. This may vary depending on the case mix and responsibilities. Adjusting this ratio to 1:3 or even 1:4 may be possible with appropriate patient selection.”
  • Application of Telemedicine
    • Care that can be done online or virtually can help ensure patients get the attention and care they need, relieving strain and extra time staff may experience who need to work in the hospitals. “A number of large medical systems have been deploying tele-critical care services that could be expanded and assisted under circumstances where staffing shortages, especially physician shortages, might exist.”

Did KC-area hospitals enact Crisis Standards? Why or why not?

Since the Kansas City region straddles a state line, the response by hospital and political leaders influences what they did. Kansas leaders provided protections, while Missouri leaders did not. However, neither truly enacted crisis standards.

Only five states have implemented crisis standards of care so far: New Mexico, New Hampshire, Idaho, Arizona and Alaska. 

Carole Thomas, vice president of clinical operations at the Kansas City Care Clinic, said while governors never declared “Crisis Standards of Care” health care workers were very much in crisis mode.
Carole Thomas, vice president of clinical operations at the Kansas City Care Clinic, said while governors never declared “Crisis Standards of Care” health care workers were very much in crisis mode. (Catherine Hoffman | Flatland)

Carole Thomas, vice president of clinical operations at the Kansas City Care Clinic, said while a crisis was never formally declared, hospital systems and clinics felt the strain. 

“Even though maybe we didn’t say, ‘today, we implement crisis mode,’ we went into a crisis mode,” Thomas said. “I don’t think in general, we could say that we didn’t practice crisis mode care. We practiced it, we didn’t label it.”

She added: “We just said, ‘We are stepping up our game because our volume is high, critically and very acute patients, and we still have to continue to operate.’ I often wonder if sometimes if this moniker of critical care, did it really exist ahead of time.”

In her experience, medical staff and other health care workers operated without a “playbook.” 

Kansas Gov. Laura Kelly issued a Disaster Declaration in January 2022 to alleviate and protect health care systems, found here. SB40 explains in part: 

“The declaration of a local disaster emergency shall activate the response and recovery aspects of any and all local and interjurisdictional disaster emergency plans which are applicable to such county or city, and shall initiate the rendering of aid and assistance thereunder.” 

However, boards of county commissioners also had authority to determine which measures to take, even if they’re “less stringent” than the governor’s declaration.

In Missouri, no emergency or disaster declaration was issued by Gov. Mike Parson. However, he did issue waivers. Parson approved in March 2020 a “reciprocity waiver,” which would “provide more flexibility and alternative delivery methods for professionals in other states to provide care in Missouri,” according to a release.

However, Parson announced that Missouri’s State of Emergency would end Dec. 31, 2021 here.

The lack of legal protections for health care workers has been top of mind for the past two years, as outlined in this KCUR report from April 2020

Across the board, experts said transparency and collaboration – among politicians and public health leaders – was key for health care systems in the Kansas City region to succeed both internally and to help treat the community. 

“Even though maybe we didn’t say, ‘today, we implement crisis mode,’ we went into a crisis mode.”

Carole thomas, vice president, kansas city care clinic

This was part of the issue for the Kansas City area, said Carney, who is on the committee responsible for updating the standards of care document in Kansas. 

“Kansas and Missouri (are) really good stark examples. In the state of Missouri, we had a governor who said, ‘I will never declare a crisis standard’,” Carney said. Instead, Parson deferred responsibility to overwhelmed acute care systems and the resources they had available to navigate the pandemic. 

He explained that Kansas Gov. Kelly, on the other hand, understood the responsibility of implementing crisis standards and was willing to enact them should the time come. Kelly’s motive was to protect the frontliner workers. 

“When crisis standards go into effect, there are immediate protections given to the hospitals,” Carney said. Gov. Kelly instead declared a disaster, offering at minimum support and protections. 

Local experts have long pressed on the need for government leaders’ direction in crisis situations. They also urge the information to be shared across counties.

That sentiment is supported by a government assessment of COVID-19 response that reads in part:

“In addition to hospital capacity and resource data, it is essential that (Massive Open Online Courses) MOCCs and healthcare coalitions, especially those that cross jurisdictional boundaries, share common definitions and reporting criteria for public health data.” 

The key, Carney said, is the need for communication.

Communication Breakdown and Confusion

What may be less known is how the federal government punted to state governments to manage ever-changing health care resources and procedures when COVID-19 hit. 

Before that, there was a plan prompted by the influenza outbreaks that informed much of the crisis standards followed or looked to now.  

After the 2012-2013 flu, the idea was emergency stockpiles would be replenished to prepare for the next disaster. But that didn’t happen. 

Additionally, federal officials leaned on state officials to take care of a worsening pandemic. 

“The states were like, ‘Whoa, we don’t have stockpiles. We don’t create stock piles. We don’t move stuff from one state to another interstate. Commerce is not our thing. Interstate transportation issues and federal response is not our thing. That’s not what we do,’” Carney said. 

“The governors and the federal government, and everybody had a big fight about it and people were dying in the droves.” 

The focus for bioethicists and hospital leaders now is on drafting updated crisis standards, considering all that’s been learned the past two years and adjusting to help stabilize the health care system as well as its workforce. 

For bioethicists like Carney and Rosell, their work is ongoing as they consult with leaders in health care and public health. 

“While we have a little breather, we need to think about what could be done, what happened, as we’re doing here,” Rosell said. “What could we do differently? Coming back to that initial ethics principle of preparation: Be prepared.”

Guidelines like this would have helped during Olavarria Kaufman’s ER visit last December. She recalled:

“Everybody was running around frantic, like they usually are but this was times 300. People were running everywhere,” she said. “(And) the ambulance, they were bringing folks in and they had nowhere to put them. So it was scary.”

Catherine Hoffman covers community affairs and culture for Kansas City PBS in cooperation with Report for America.  The work of our Report for America corps members is made possible, in part, through the generous support of the Ewing Marion Kauffman Foundation. Vicky Diaz-Camacho covers community affairs for Kansas City PBS. Cody Boston is a video producer for Kansas City PBS.

Correction: A previous version of this article reported that only three states formally invoked Crisis Standards of Care (CSC). As of January 2022, five states have implemented CSC. The article has been updated to reflect that change. In addition, Terry Rosell’s last name was misspelled near the end. It is Rosell, not Rossell.

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