Life and death decisions during a pandemic: Healthcare risk managers in the front lines

Crisis standards of care (CSC) plans should be developed before a disaster such as COVID-19 strikes, but they can be fine-tuned even in the midst of the crisis, a senior risk management consultant said recently.

CSC is when healthcare systems, which already operate at or near capacity in Canada and other countries around the world, are so overwhelmed by a catastrophic public health event like a pandemic that it becomes impossible for them to provide the normal or standard level of care. In these situations, as with the coronavirus pandemic, formal declarations by government entities occur to recognize healthcare systems are in crisis operations that may last for some time.

“That’s why crisis standards of care plans, which should be developed before disaster strikes, are so critical,” said Krishna Lynch, senior healthcare risk management consultant at Zurich North America, during a Zurich podcast Apr. 1. “They help avoid situations where providers are required to make allocation or triage decisions, [such as] whether to take a ventilator away from a patient who isn’t improving to help save another patient who might.”

These choices “represent the last resort in crisis care,” said Lynch, who is clinically trained and has over 20 years of healthcare experience. She was speaking during a Risk Insights: Coronavirus podcast series, this one focusing on healthcare facilities and CSC.

Paramedics transfer a patient to the emergency unit at Verdun Hospital, Tuesday, April 14, 2020 in Montreal. THE CANADIAN PRESS/Ryan Remiorz

The goal of CSC is to take steps to slow “dire life-or-death conundrums,” Lynch said. “What happens when you don’t have enough medical and care resources to save everyone?” she asked. “How do you decide who gets what? Do you save the most lives possible by giving more care to people who need it most? Do you favour certain groups, such as the old or the young? What if two COVID-19 patients need a ventilator and only one is available?”

In extreme cases, some people will not receive all the treatment they need. “The question then becomes how to deliver the best care possible under the worst possible circumstance.”

But even if a healthcare organization hasn’t created a robust CSC, it’s worth fine-tuning in collaboration with your incident command system and local and governmental entities, even in the midst of this crisis, Lynch said. The goal is to contemplate strategies that may maximize care during a pandemic as the surge of COVID-19 patients increases.

For example, hospitals may need to manage staffing issues should healthcare workers get sick themselves; this may include pulling in administrators with medical training back into patient care, or asking families to help with feeding and personal hygiene. From a supply standpoint, facilities may consider sterilizing and reusing disposable equipment. Or to manage the demands of crisis care, hospitals may need to optimize space limitations by putting patient beds in hallways, conference rooms, and use operating rooms for urgent cases only.

Lynch said the surge capacity of many hospitals to accommodate a pandemic is being affected by the disruption and availability of healthcare workers, medical equipment, inadequate numbers of ventilators, and insufficient hospital beds, personal protective equipment and medication. “Why? Because of the interconnectedness of our global economy and the nature of supply chains, which have been compromised by this pandemic,” Lynch said.

“The COVID-19 pandemic is unprecedented,” she said. “It will require an unprecedented level of integrated planning, coordination and follow-through among many disciplines and agencies, including state, provincial and local governments, emergency medical services, healthcare coalitions, healthcare organizations and healthcare providers in the community.”