by Joyeeta G Dastidar, MD
In New York City, the epicenter of the COVID-19 pandemic in the country with a quarter of the nation’s cases, hospitals prepared for ventilator shortages. This included the development of ventilator allocation guidelines and, in some institutions, appointments of triage allocation committees to help determine who would get a ventilator if there was an inadequate supply of ventilators. While there was much debate and discussion over triage guidelines, ultimately in New York City, due to a lack of supportive legislation at the state or federal levels, resource allocation guidelines and committees were not utilized. As with other New York City hospitals, we too doubled or tripled the number of ICU beds available in order to accommodate the surge of COVID-19 patients with respiratory failure requiring ventilators. We did this by repurposing various areas of the hospital to build “mini-ICUs” where there were none.
At first blush, this seemed great. By not withholding ventilators from anyone, even those deemed unlikely to survive, every patient and family’s wishes for maximal care was accommodated as is standard operating procedure outside of pandemics. But what of quality of care and how that was affected by the significant increase in the volume of hospitalized patients? What if using inappropriate resources such as ventilators and ICUs for dying patients led to worse outcomes for those who would survive? The extent of the increase in hospital and ICU beds was not based on the interest in quality of care of our patients, but out of necessity borne out of a lack of government backing to prioritize resources to help those likely to survive, as well as a delayed ability to redistribute patients out of acute care settings.
What were some means utilized to alleviate staffing shortages? Medical students on track to start residency on July 1 graduated early so they could go into practice months in advance. This was helpful, with the caveat that these were doctors at the very beginning of training, needing considerable support and oversight. We repurposed doctors not accustomed to taking care of acutely ill hospitalized patients from outpatient clinics and procedure suites whose operations were temporarily suspended. Intensivists and other doctors, along with nurses, nurse practitioners, and physician assistants flew into our city from all over the country. Despite all these measures, staffing remained spread thin. Doctors and nurses were covering 2 to 3 times as many patients they were accustomed to taking care of.
Studies have found that excessive workloads, long working hours, and frequent call duties – factors that were all exacerbated during the pandemic – contribute to physician burnout. Studies have also shown that physician burnout leads to a decrease in quality of care. Similarly, as nursing to patient ratios increase, there is a deterioration of quality of care, and delays in completing tasks required for patient care. One study looking specifically at quality of care in ICUs found statistically significant declines in quality of care as occupancy rates, work hours, and nursing to patient ratios increased. During a pandemic, some of this decline is expected. By definition, crisis standards of care acknowledge that the quality of care suffers. That was the basis for New York State Governor Cuomo’s legislation protecting healthcare workers from civil liabilities during the COVID-19 pandemic. But even during a pandemic, there is likely benefit in prioritizing quality over quantity of care within the constraints of disaster medicine.
Field hospitals were set up in athletic fields, run by military veterans and medics, to help offload patients over the most acute phase of their illness and clearly on the path to recovery. The field hospitals were functional soon after the peak of COVID-19 hospitalizations in the city.6 Other field hospitals including at the Javits Center and a U.S. naval ship were there in theory, but grossly underutilized due to systems issues. These were measures that accommodated the surge as best as they could. Others have advocated well – based on similar experiences with the COVID-19 pandemic in New York City – for the need to have governmental legislation regarding cardiopulmonary resuscitation (CPR) and ventilator allocation in place for any future pandemics. While making decisions on who receives critical care is controversial, a more palatable issue, and one that affects a greater number of patients, is how to better distribute patients to address the volume issue and improve quality of care for all. Doing this on a large scale requires logistic and financial support from the government.
The best way to see if quality of care suffered – given the increased rate of infection and death among people of color as well as those with lower income and larger household size – would be to compare outcomes with a city with similar demographics but lower volume of cases. In the meantime, given the association between COVID-19 and being socially disadvantaged, redistribution of patients from overcrowded hospitals to improve quality of care can also be seen as ethical from the standpoint of social and distributive justice. Redistribution would help elevate the quality of care for more vulnerable populations to at least be on par with care in those whose local hospital is not beyond maximum hospital and ICU bed capacity with attendant high patient-clinician ratios.
The horse is out of the barn for New York City, now on the downslope of the curve and no longer stretched beyond maximal ventilator and ICU bed capacity. However, there are many areas in the country behind that curve as compared with New York City, and the prospect remains of a second peak, possibly worse than the first. Even within the constraints of crisis standards of care, there is room for improvement. New York City hospitals did not have control over the need to implement care in whatever fashion was possible to rise to the occasion. They did have a role in the redistribution of patients, and city, state, and federal government should play a more active role in that job, ensuring any hypothetical increase in available beds created translates to real beds that can offload hospitals.
In addition to outcomes studies to better guide future care, many of which are underway and a few of which are completed, much is needed on the side of governmental guidance and legislation beyond matters of CPR and ventilator allocation. Things that may help if this virus makes an encore appearance, as well as in areas of the world not as far along in the curve, include setting up field hospitals proactively, well before the peak. This would offload the burden of hospitalization of those who are stable and improving, giving clinicians in area hospitals the ability to focus on caring for those who are acutely and critically ill. If having such field hospitals up and running from the onset of a second peak still doesn’t allow for management of hospitalized patients at standard care ratios, redistribution of patients to areas less burdened by the disease could be another thing to consider. These changes will be especially crucial in states such as New York with recently enacted legislation to prevent discharge of patients with COVID infections back to nursing homes where the virus can run rampant and quickly cull its vulnerable residents. Without a redistribution plan in place, hospitals would quickly fill up with patients who are no longer acutely ill and are awaiting clearance to return to their nursing home.
All of this requires anticipatory planning not only on the institutional level, but also coordination and support at the state and federal levels as well. This goes well beyond the more often discussed and equally important matters of adequate personal protective equipment, ventilators, widespread testing and contact tracing capabilities. Convalescent patients requiring ongoing hospitalization and fully recuperated patients awaiting a return to a nursing home would proactively be transferred to less acute care settings such as field hospitals starting well before the peak of the viral curve. Acutely or critically ill patients from oversubscribed medical centers could be triaged farther afield to other hospitals with greater capacity to care for them. With these measures in place, we would be more capable of balancing quantity and quality of care. While important regardless of other legislation, in the absence of legal backing for institutions and physicians to weigh in on propriety of end-of-life and critical care, as well as the inability to transfer COVID patients back to the nursing homes they came from, these geographic reallocation mitigation strategies will be even more crucial with a second peak of infection.