Allocation of Scarce Resources in a Pandemic: A Systematic Review of US State Crisis Standards of Care Documents

Abstract

The aim of this systematic review was to locate and analyze United States state crisis standards of care (CSC) documents to determine their prevalence and quality. Following PRISMA guidelines, Google search for "allocation of scarce resources" and "crisis standards of care (CSC)" for each state. We analyzed the plans based on the 2009 Institute of Medicine (IOM) report, which provided guidance for establishing CSC for use in disaster situations, as well as the 2014 CHEST consensus statement's 11 core topic areas. The search yielded 42 state documents, and we excluded 11 that were not CSC plans. Of the 31 included plans, 13 plans were written for an "all hazards" approach, while 18 were pandemic influenza specific. Eighteen had strong ethical grounding. Twenty-one plans had integrated and ongoing community and provider engagement, education, and communication. Twenty-two had assurances regarding legal authority and environment. Sixteen plans had clear indicators, triggers, and lines of responsibility. Finally, 28 had evidence-based clinical processes and operations. Five plans contained all 5 IOM elements: Arizona, Colorado, Minnesota, Nevada, and Vermont. Colorado and Minnesota have all hazards documents and processes for both adult and pediatric populations and could be considered exemplars for other states.

Legal Immunity for Physicians During the COVID-19 Pandemic

“…Numerous hospitals and physicians have therefore sought crisis standards of care (SOC), which are permissible changes in SOC in an emergency, given shortages of staff and supplies, 4 and statues granting immunity from criminal and civil lawsuits in treating COVID-19 if such shortages exist, assuming providers follow these standards, act in good faith, are not negligent, and do not intentionally harm patients.…”

“…However, only five states have included all five elements. 4 In 18 states, the standards were specific only to pandemic influenza.…”

A Systematic Narrative Review of Comprehensive Preparedness Strategies of Healthcare Resources for a Large Resurgence of COVID-19 Nationally, with Local or Regional Epidemics: Present Era and Beyond

“…Describing approaches falling under six predefined domains, 33 articles specifically focused on preparedness strategies of healthcare resources for the pandemic ( Table 1 ). 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 The final list of selected publications included 3 original articles, 9 commentaries, and 21 review articles. All but six articles were published between 2019 and 2020.…”

A proposal for selective resuscitation of adult cardiac arrest patients in a pandemic

“…The sequential organ failure assessment (SOFA) score is part of proposed guidelines for ethical ventilator allocation during a public health emergency 16 . Multiple states have draft guidelines published online on resource allocation of ventilators, but there are sparse data on the efficacy of these guidelines 17–19 . During the 2009 H1N1 influenza pandemic, a hospital in the United Kingdom found that ventilator guidelines may have led to overtriage and withdrawal of ventilator support, but H1N1 influenza affected the young more heavily than the current COVID‐19 pandemic 20 .…”

“…Michigan has helped define criteria that are ethically unacceptable to consider when allocating ventilators to patients 13,17 . Similarly, health care personnel should not use these characteristics in deciding whom to attempt cardiac arrest resuscitation on due to their inherent lack of fairness and potential for abuse or discrimination.…”