COVID-19 Crisis Standards of Care April 2020 We expect to face a - PowerPoint PPT Presentation

COVID-19 Crisis Standards of Care April 2020

We expect to face a shortage of critical care resources in the near future Est. of BMC COVID-19 cases over next 60 days ICU cases 200 150 Surge capacity 100 Standard capacity 50 0 -20 0 20 40 60 80 § BMC will take all available options to expand capacity and distribute burden among other hospitals § We remain in communication with medical centers in Boston and statewide § There is need for an internal resource allocation framework aligned with state guidance and consistent with other hospitals 2

BMC may reach a point where “crisis standards of care” justify significant rationing of lifesaving interventions Crisis Standard: Shift from focusing on the individual autonomy of patients to the overall public good is warranted § Move to maximizing survival at community/societal level § DPH may make official declaration 3

We anticipate several stages of institutional response as resource shortages become increasingly severe We are here Stage 1 Stage 2a Stage 2b Stage 3 Stage 4 Prepare for surge Manage surge Avoid crisis Manage crisis Exhausted standards care standards care capacity § Bed escalation plan § Surge expansion: § Leverage regional § Implement crisis § Simplified triage resources: standards of care protocol ̶ Staff § Centralized staffing ̶ Vents ̶ Pandemic ̶ Beds oversight § Consider triage team ̶ Supplies ̶ Vents unorthodox 24/7 § Preserve vents approached (e.g., ̶ Supplies § Manage demand ̶ Begin priority split vents, short- across orgs § Activating critical scoring § Proactive term vents for long care triage advanced directive ̶ Close trauma § External term use) outreach ̶ Communication ̶ State CSOC ̶ Divert EMS approach § More frequent ̶ Citywide/State § Staff Pandemic reassessment § Extend State ̶ Triggers for prioritization Triage officer advocacy on stage 3 resources § Staff Appeals Officer Goal Ready to treat as Organized Avoid crisis Make ethical many patients as expansion of standards of care decisions, alleviate possible at BMC capacity and anywhere until truly provider burden prepare for surge needed regionally Triggers Fewer than 6 Beyond normal Dynamic in <3 vents Scale of demand conventional vents ICU/vent/staff response to makes existing Market capacity resource constraints triage protocols tapped out impractical 4

Broadly accepted guiding principles have informed the approach we will take over the course of the pandemic Three core tenants should underlie any decisions... Commitment to treat patients, not to abandon them - even in Duty to care 1 the face of some risk Fairness in 2 Benefits and burdens imposed are shared uniformly and providing care fairly Certain resources may be preferentially directed to slow Duty to steward 3 spread of the disaster resources Must be balanced against duty to care and attention to equity And the process itself should be… Clear and open communication to stakeholders Transparent 1 Treating all patient groups alike; nondiscrimination Consistent 2 Proportional Burdens should serve important hospital/patient/community need 3 Accountable Decision makers should be accountable for utilizing best evidence 4 5

Our crisis standards of care guidelines are evidence-based and aligned with what we anticipate the State will approve and recommend Ethical Goal: Do the greatest good for the greatest number, based on two considerations a) saving the most lives and b) saving the most life-years ▪ Strong emphasis of non pursuit of heroic interventions (normal Non-heroic 1 standard of care but emphasized now) in patients with low Interventions survival likelihood (e.g., unwitnessed cardiac arrest) ▪ Patients assigned score based on prognosis for short-term and 2 Priority Score long term survival ( additional details following ) ▪ Patients raw priority score places them into 3 priority groups 3 Priority Group (Red – highest, Orange – intermediate, Yellow – lowest) ▪ ‘Tiebreaker’ criteria determine order within priority group – first 4 Tiebreakers by age (lower higher priority) then random lottery ▪ Primary/triage team will use clinical judgment to determine if 5 Reassessment continued benefit at 72 hours and every 48 hours thereafter* *Review times may change based on accrued data about clinical course of COVID-19 6

The priority score uses an objective set of clinical indicators to evaluate patients and guide overall resource allocation Priority Score* = Sum of A+B Specification Point System 1 2 3 4 (A) Prognosis for SOFA** score SOFA score SOFA score SOFA score short-term survival (</=8) (9-11) (12-14) (>14) Major comorbid (B) Prognosis for Severely life- long-term survival conditions with limiting (medical assessment substantial conditions; death of comorbid impact on long- likely within 1 conditions) term year survival Major Comorbidities Life Limiting Comorbidities • • Moderate dementia Severe dementia • • Malignancy with a < 10 year Cancer tx w/ palliative intent • expected survival NYHA Class IV heart failure • NYHA Class III heart failure OR Severe chronic lung • disease with evidence of frailty Moderately severe chronic lung disease (e.g., COPD, IPF) • Cirrhosis with MELD score • ESRD in patients < 75 ≥20, ineligible for transplant • • Severe multi-vessel CAD ESRD in patients older than • Cirrhosis with history of 75 decompensation • *Lower score indicated better survival and therefore increased access to resources 7 • ** SOFA includes: Pa02/FiO2 ratio, creatinine, platelets, bilirubin, GCS and MAP

A pandemic triage response structure will make resource allocation decisions and support frontline teams Communication to stakeholders and incident command § Pandemic Triage § Oversight and staffing of pandemic triage teams Committee § Apply triage algorithm to make individual allocation decisions Pandemic Triage § Work directly with clinical teams to apply crisis standards of care Team (Pager: 8888) § 24/7 availability of senior MD/RN dyads § Hear appeals from clinical teams in real-time Appeals Officer § Make appeal decisions on technical criteria only (Pager: 5075) Senior Physician Leader (rotating) § 8

The Pandemic Triage Response Teams will continually review and reassess critical care resource allocation For pending withdrawal: Prioritization § Notify primary team Prioritization performed by pandemic triage § Notify family officer/team § List for palliative care Patient 1 Criteria Explanation Patient 2 Criteria Explanation Patient 3 Criteria Explanation No Patient 4 Criteria Explanation Patient 5 Criteria Explanation Supportive Care only Patient 6 Criteria Explanation Patient 7 Criteria Explanation Patient 8 Criteria Explanation Patient 9 Criteria Explanation Patient Priority vs. other ICU requires Recovery ICU patients? vent Yes ICU/vent Those requiring urgent Reassess after 72 hrs, support will be placed on a then dynamically holding vent while assessment takes place 9

During this time we will deploy enhanced patient and employee supports Palliative Care Enhanced Support Employee Support Dedicated ED Support § 24/7 real-time or scheduled Psychological First Aid Support (12 volunteer clinicians § In situ ED palliative care team supporting 2 already existing on-call clinicians) § BMC Pocket Card for symptom management § BMC Chaplains service is now available 24/7 Clinical Resources by phone § EPIC Comfort Measures COVID19 Order Set § BH clinicians rounding and meeting with frontline teams (in-person & virtually) § COVID19 Palliative Care Toolkit § Employee Assistance Program (EAP) and § Virtual consultation and coaching EAP Clinician (Beth Milaszewski, Izzy ICU/Inpatient Berenbaum) § Code status/goals of care for high risk inpatients § Doctor on Demand (no co-pays for employees § MD consultation to support ICU workflows during Pandemic) § Continued GIP services Outpatient § Primary care patient outreach per MOLST form § Telemedicine COVID script 10

During this incredibly difficult time, BMC will be guided in all decisions by our core values § This is unlike any time in any of our careers § It will be incredibly difficult and painful and we will not be able deliver care in the way that we want to § We have to believe that we are doing the best we can § We will be guided by the values of this organization that have been our foundation for over 160 years § Thank you for all you are doing for our patients as we get through this unprecedented time 11