Ten years ago, state health officials gathered to plan for what they knew was inevitable: a long-term health emergency such as a pandemic gripping the state and stressing the medical system like little before it.
Those meetings turned into the state “Standards of Care” plan, a blueprint for how to deal with crises like the COVID-19 virus.
The document calls for drastic measures: moving the most critically ill patients out of ICU to make room for pandemic victims who have a better chance to live; focusing less on individual patient care and more on stopping the spread of disease; suspending some privacy safeguards and even re-allocating potentially life-saving equipment such as ventilators from one patient to another.
A key feature was planning ahead: statewide discussions needed to happen to standardize how hospitals would make those decisions, if the situation called for it.
A decade later, state officials and health experts began discussions to update the plan. And then a pandemic actually arrived — and the planning came to a halt.
“We have been working with [the state Department of Public Health] more recently, over the last few months before this all broke, on helping them to identify what, if any, next steps would be most useful,” said Yale New Haven Health Director of Emergency Management Jim Paturas. The department “realized that they needed to have that 2010 crisis standards of care plan looked at again for a number of reasons.” A group was also convened in Washington, D.C. this fall to discuss the issue, he said.
“Nothing has been done with that yet, because then all of this broke. We have been spending our time just trying to wrestle with all the response and recovery issues,” Paturas said.
Whether any of the paper’s recommendations were carried out in the last 10 years remains unclear, and the state public health department has been silent on the plan.
The 2010 paper came together over the course of two years, completed by a working group of almost two dozen people, mostly doctors and lawyers. They discussed how best to prepare for a “‘perfect storm’ of an overwhelming demand for services accompanied by a critical shortage of resources.”
Rather than address needs for specific items or resources, it details how decisions should be made in a shortage, the values that should be considered in those decisions and the legal boundaries and statutes around providing “population-based care instead of individual-based care.”
Doing so would require formalized procedures for distributing personnel, equipment, supplies and access to care, with a utilitarian approach for “the greatest good (utility) for the greatest number.” That should be handled in a unified, statewide approach, according to the working group. DPH said at the time that a discussion was underway to encourage that.
The group also called for a statewide approach to ICU triage, in a scenario where demand for ICU space outpaced space, with patients prioritized “based on the probability of their survival.” One possible assessment tool was the Sequential Organ Failure Assessment, used to predict mortality. “It has been suggested,” the group wrote in the report, that in a crisis situation, patients with the highest SOFA scores should receive palliative care to free up critical care units for patients with higher likelihood of survival.
The working group didn’t recommend that hospitals necessarily use that specific triage tool, but said the same tool should be used across facilities “to provide a consistent response for the public and to minimize ‘hospital shopping.’”
They also urged hospitals and the state to consider burdens for healthcare workers, and to take steps to address them in advance of the crisis, including housing and medical care for themselves, rather than waiting until the situation became acute.
In a February 2010 press release, DPH said the document “will be used as the framework for an ongoing discussion over the next year with health care providers and the public to determine how scarce resources will be allocated and standard practices will be modified during such emergencies.” But asked about outcomes of that discussion, and whether standardized approaches were selected, the department did not respond to questions over the last week and said no one was available to discuss it.
DPH and the Connecticut Hospital Association also did not respond to questions about the plan, providing only a general statement about hospital preparedness.
“Hospitals routinely plan and drill for public health crises. They draw experience from past crises to improve planning and work with each other, and the state and federal governments to improve preparedness. In responding to the current COVID-19 pandemic, hospitals have begun implementing those plans,” CHA said in a statement. “Those actions include eliminating non-essential surgeries and procedures, expanding critical care capacity to accommodate COVID-19 patients, and reassigning staff to high need areas. Hospitals are coordinating this action with each other and in close partnership with the state. The past preparation is helping to guide these efforts.”
Hartford HealthCare Chief Clinical Officer Dr. Ajay Kumar called the paper a “really good, solid foundation,” but said he was unaware of it until asked about it this week. Many of the decisions outlined in the document were addressed in the system’s own incident command and planning, he said.
The state isn’t yet at a point where the crisis standards need to be put into action, Paturas said. Connecticut hospitals are using ‘contingency care,’ an intermediate measure between standard operations and a crisis, he said: decisions are being made that wouldn’t in normal circumstances, like canceling elective procedures and sharing ventilators between patients, but care is not yet being rationed.
Kumar said he doesn’t anticipate that the state will reach a point where crisis care becomes necessary, based on current models. That’s due in part to efforts that have been made across hospital systems to increase capacity, and to share resources with each other to avoid rationing care.
He said coordination began with CHA and clinical leaders in early March. On March 30, Gov. Ned Lamont assembled the Governor’s Health System Response Team, chaired by the CEOs of Hartford HealthCare, Nuvance Health and Yale New Haven Health. Their task, as Lamont announced, echoed the goals of the decade-old report: determining how to allocate space and people.
“We have been planning for this for months,” CHA President Jennifer Jackson said at the time, including sharing best practices for patient care. “Now that we move into this next phase, where we’re going to see increasing numbers of patients, what we expected, what we planned for, this step that the governor is taking is an important one in continuing to cement and enhance the collaboration that we already enjoy.”
The systems would typically be competitors, but are instead visibly working together, Paturas said.
Asked whether the communication could have begun earlier, both he and Kumar avoided casting judgment in hindsight.
“We could all be Monday morning quarterbacks and throw the blame,” Paturas said.
In the aftermath of the coronavirus, the current collaborations will likely continue into future planning, they said.
“It has to be a combined, concerted effort,” Kumar said. “I would imagine the same philosophy and thinking will prevail for a long long time to come.”