How hospitals allocate scarce resources [PODCAST]

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“We are grateful to be avoiding the need to use draconian measures for resource allocation. We have been afforded the blessing of lead-time here in Los Angeles and have the chance to learn from other parts of the world, as well as other areas within the United States. We are preparing our personal protective equipment, re-organizing team structures and hospital workflow, taking new precautionary measures, and expanding the skillset of providers to maximize manpower. In case resource utilization reaches capacity, frameworks are in place to guide decisions in the most ethical and morally appropriate manner possible, and such frameworks remain available in future disaster scenarios. While we as health care providers address COVID-19 from the frontlines, there are still many ways the public at large can contribute to the battle against this pandemic that we all face, though the storm seems to slowly be calming.”

Alexander Connelly is an internal medicine physician.

He shares his story and discusses his KevinMD article, “A Los Angeles response to the pandemic.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Alex Connelly. He’s an internal medicine physician, and he wrote the KevinMD article “A Los Angeles response to the pandemic.” Alex, welcome to the show.

Alexander Connelly: Thank you. Thank you for having me here.

Kevin Pho: So we’ll get into your article in a little bit, but I was wondering first if you could share your story and your journey to where you are today.

Alexander Connelly: Of course. So I started out working with AMR, which is an ambulance company here in the LA County area and San Bernardino County area in California, and that was the beginning of my first interest in medicine. That was my first exposure, being out in the field, and it was my springboard for going into medical training. I’m working in internal medicine now, but I was trying to decide between internal medicine and emergency medicine, and I had really good experiences with emergency medicine through medical school. One thing that really stuck with me, that I really enjoyed learning about, was disaster medicine and the concept of triage.

Moving forward to where I am now as an attending, that concept seems to be coming to the forefront again. I’m working as an academic hospitalist, and I’m seeing many of these patients in the hospital who are coming in with COVID. One thing that we saw in Italy was that resources became overwhelmed fairly quickly at the start of the pandemic. Nobody really understood the disease, and nobody really was ready to take on the burden of ventilator support that was needed up front. That was something that we were worried about for the United States when things started out on the East Coast and then migrated to the West Coast. I think with the time that we’ve had in Los Angeles, we didn’t feel quite the full brunt of that force.

So my involvement in the past couple of months has really not been as bad as I thought it would be, because I think we had a little bit of time to prepare. As I said, I think that lead time has helped us out quite a bit. But the article that I wrote, just to give a little bit of detail about it, is about what systems we have in case our resources were to become overwhelmed. Specifically with the COVID-19 pandemic, what would we be able to do if there was such a widespread burden of disease that our ICUs, our intensive care units, were becoming overwhelmed, or our capacity was being reached, or there weren’t enough ventilators available, or intra-aortic balloon pumps, or CRRT renal replacement therapy for patients in renal failure?

Some of the thinking from this really made me think back to my EMS days and what I learned about emergency medicine in medical school, because that’s where I was really exposed to this concept of triage. I think there are some analogs between the triage system that’s used in the field and in emergency medicine and what we potentially would have to deal with in the re-emerging COVID pandemic.

What I’m referring to, for people who aren’t familiar with it, is that in emergency medicine there’s a tag system that’s used whenever you’re in a situation where essentially your local resources are overwhelmed by whatever disruption is happening, or whatever hazard is affecting the community or the region. It can be in the form of earthquakes, tsunamis, terrorist attacks, or widespread illness, and this is also a battle concept as well.

The way that this works is there are different colors that are attributed to different patients. Let’s say there was a mass casualty event, and you have first responders, police, and paramedics all coming out to the scene. You need to be able to quickly determine who you can help, who can wait for help, who needs immediate help, and who might not benefit from those resources. The way that you can go about doing that is a tagging system. A red tag is a level one, for people who are in immediate danger and need immediate treatment, but there’s some hope that you are going to be able to get them better. Yellow is essentially that they’re really not doing well, but they’re not in immediate danger. Green is somebody walking around after a building collapse whose arm got scraped up, but they’re otherwise doing well. And a black tag is if they are either deceased or their injuries are so severe that even if you were to immediately treat them, you don’t expect them to move forward with their survival.

The reason that I think this ties into things that we need to think about for the COVID pandemic is essentially exemplified by what we saw in Europe. We saw a country being completely overwhelmed, resources being overwhelmed, and the country being devastated in the process. When I originally wrote this article, I wrote it and submitted it and started seeing the numbers decline, and I was relieved. I was happy that it felt like my article was going to be completely irrelevant, but now we’re starting to see those numbers change a bit.

We went from seeing, in early April, an area peak of 33,000 cases per day for us, and our numbers started dwindling down since then overall for the country. But on June 23, we finally got back to that peak level, and as of yesterday, actually, we’ve almost doubled that daily case load, up to 57,000 cases. What does this mean? Globally, this has translated into a little over half a million deaths, and this is based off of the data that we know, right? This is based off of, as best as we can determine, the number of deaths that has been attributable to COVID. There may be more, there may be less, but that’s the number that we’re working with.

What I wrote about in the article is, if we do end up in a resource shortage situation, how do we go about allocating resources? It brings us back to this concept of triage, in the sense that there will be people who are doing well, who don’t necessarily need additional resources. They’re like the walking well, as we’ll call them. On the other side of the spectrum, we will have other individuals who have multiple medical comorbidities, who may have end-stage renal disease, who may have liver disease, heart failure, or other forms of end-organ dysfunction. This may decrease their overall probability of survival. With that being known, if we were to be in a situation where we have a certain number of ventilators for a certain number of people, and the number of people that need them exceeds what we have, we may have to utilize that form of a triage concept, not speaking specifically to the hospitals within which I work, but for the county, for the country, for other cities that may be more burdened.

We have certain regions that are more burdened than others, and there may be different societal factors playing a role in that. I think what that ultimately means is that there should be some familiarity with these concepts among major regional hospitals for different areas, in case that needs to be used. It seemed like that might not be as worrisome before, but now, to see the transition in the numbers that we have in such a short time frame, just in this past 7 to 10 days, as well as seeing how much congregation has been happening in the public, I think it’s really bringing this type of issue and this type of concept back into the spotlight. The better we understand it, the better hospitals can start to develop systems for preparing in this manner: discussing with emergency medicine colleagues and with the ICU, figuring out how you can accumulate additional resources to try to offset some of that burden as much as possible, and shuttling resources to the areas that would most benefit from them.

I’m by no means an expert on this topic, but what I should have mentioned at the beginning is that my interest in this came from the development of a resource allocation committee within our hospital. So this was a new concept for me, but it does seem to make sense. If you have limited resources, and we have to make a decision between who’s going to benefit from those resources, we do ultimately want to make sure that you’re providing a limited number of ventilators to the people who are most likely to survive with that ventilator support. It’s unfortunate that there are many people who end up on the vent and pass away, and sometimes it can be after weeks and weeks of care. If we’re in a situation where resources are burdened, and if there’s a way of distinguishing who those patients might end up being, who are less likely to survive, then that may overall help us from a population viewpoint.

Hopefully we don’t get to that point. Hopefully we’re able to mitigate those numbers. There are always changes being made from higher up with respect to local policies to try to stem the tide again, now that we’re seeing this re-emerge. But again, there’s going to be a little bit of a delay. Anytime we make a change, we’re going to have a delay in what we see within the community in terms of emergence of disease. Anytime we make a change to try to stem that tide again, we’re going to see a delay, because cases are already blooming.

So I think that’s the point that we’re at right now. I think we need to see what the trajectory of the current expansion of the virus is at this point in time, and see how else we can stem the tide. And really, ultimately, the main thing for us to do, I think, at this point, with the numbers that we see now, is to really reinforce stay-at-home orders: unless there are essential reasons to go out, staying at home, really good personal hygiene, continuing social distancing, and wearing masks. I’m not wearing my mask right now while I’m here inside, but I’m definitely wearing it whenever I’m outside the door.

And protecting populations that are at risk. So if you have elderly in the family, trying to avoid seeing them. And little ones in the family, anybody who might be immunocompromised, transplant patients, all the people who tend to be at higher risk for burden of disease from coronavirus: just being mindful of who those people are and protecting them as much as you can.

Kevin Pho: Let’s talk about who allocates those scarce resources. So we’ve arrived at a point where we do have to allocate things like ventilators. Who are the people that comprise that committee who makes those decisions?

Alexander Connelly: Right. So this committee, at least within our institution, comprises a number of different individuals. It has people like myself who are coming in from personal interest. I have rotated among other hospitals within the group in terms of managing the hospital floor COVID patient population, so that’s where our role plugs in. But we also have our critical care faculty. We have administrative personnel for the hospital. We have nurses involved, case managers, social workers, and also a palliative care team. And we also involve personnel from our ethics committees as well, to be able to help guide what that may look like.

And again, this has not been something that we’ve had to formally implement. It seems like we’ve been able to manage everything that’s in front of us at this time. So there are no scares there right now. It’s more of a preparatory phase, just in case.

Kevin Pho: Sure. And hypothetically speaking, if the committee makes a decision that the attending may not agree with, is there any recourse to appeal those types of decisions?

Alexander Connelly: Right. There is an appeals process, and it’s delineated. Obviously, since we haven’t been in a situation of needing to exercise these tools yet, we haven’t been able to fully explore what that looks like. Anytime you have a new process, until you truly go through all the steps of the process, you learn how you have to modify it and adjust it. But there is a process for bringing a case back up and having it reviewed by alternative individuals from outside of that particular group, who are, again, not associated with that patient’s direct care.

And that’s one other thing I forgot to mention earlier: In that type of decision-making, the clinician who is involved in patient care in the situation is generally left out of that decision-making process. That allows a little bit more impartiality to this, and I think it also takes away some of the burden of what that type of decision could carry for people who have to be involved in it on the front line of care.

So to answer your question, yes, there’s a process for it. I think all the right individuals are there. There’s an appeals process in case there are disagreements, especially from family, because that’s a hard thing. If you were to be in that situation, and you have your elderly loved one who has multiple medical comorbidities, and you have two people and you’re trying to decide on a single ventilator, it’s hard to be involved in a decision that might not provide the support for your loved one. But there are systems in place for being able to address that.

Kevin Pho: Sure. We’re talking to Alex Connelly. He’s an internal medicine physician. He wrote the KevinMD article “A Los Angeles response to the pandemic.” Alex, what’s one thing that you know now that you wish you knew back before the pandemic started?

Alexander Connelly: Well, I think the thing that I wish I knew now, just to answer your question a little differently, was, shortly after the pandemic started, what to expect moving forward. I didn’t realize how much the concept of social distancing impacted the spread of disease. I’m a fairly junior attending and don’t have very much exposure within medicine prior to these past two years. I haven’t been around for seeing very many explosions of disease in the community, and for seeing the way that different social determinants, different social factors, can impact the spread of a disease. I think I didn’t really truly see what weight that could carry, what impact that could carry, especially with those changes that we’ve seen over the past week.

Because essentially, thinking back, like I said, I basically had a false reassurance after writing this article, thinking that things seemed to be getting better, and not really noticing that this is actually just the calm before the storm, now that we’ve allowed pockets of virus throughout the community and then suddenly let the dogs back out of the bin. That might not be the best terminology, but you know what I mean. You finally set everybody loose. The community is like a ticking time bomb.

Kevin Pho: And my final question: What’s your take-home message for the KevinMD audience?

Alexander Connelly: My take-home message is continue social distancing, continue personal hygiene, stay at home, and protect those around you. Be very cognizant of the fact that this virus, I like the analogy that I recently heard about doing craft projects with glitter. If you have 10 people at a table and one person’s doing a project involving glitter, how many projects have glitter on them? I think that’s the way we truly need to think about this virus. It’s so widespread in the community right now. We have to take this more seriously than we ever have before.

Kevin Pho: Sure. Alex, thank you so much for sharing your insight, and thank you for being on the show.

Alexander Connelly: Yeah, of course. Thank you so much for your time.

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