Crisis Planning Has Not Matched Experiences of Clinicians During Pandemic

Planning for resource limitation during the coronavirus disease 2019 (COVID-19) pandemic has fallen short, leaving clinicians struggling to make decisions, a new study found.

The study, published in JAMA Nework Open, included interviews with 61 clinicians in 15 U.S. states, including areas with high infection rates such as Seattle, New York City and New Orleans.

“Resource limitation in practice during the pandemic doesn't fit the theoretical mold,” Catherine R. Butler, MD, MA, acting instructor in the Division of Nephrology at the University of Washington School of Medicine, told Contagion®. “There have been substantial efforts to plan an approach to triage in crisis capacity settings in the US based on the Institute of Medicine's phased approach, which assumes a common understanding of what it looks like to hit crisis capacity. However, in real-world clinical settings during the pandemic, resource limitation substantially impacted care far before declaration of crisis capacity, leaving clinicians to make difficult allocation decisions at the bedside without any guidelines or framework to approach this.”

Clinicians and institutions anticipated shortages in resources based on the experiences of health care institutions elsewhere in the world as the pandemic emerged and followed frameworks developed by national organizations such as the Institute of Medicine. Plans for phased responses were developed, with a triage team responsible for rationing resources in a crisis.

“We began this project thinking that we would be studying the workings of triage teams, but they didn't end up being deployed,” Butler said. “I suspect that this was, in part, because clinicians were so highly creative and motivated to avoid categorically denying care to any one individual that they could find all kinds of ways to stretch resources thin without triggering the need to overtly ration care. The problem is that this 'stretching resources thin' meant offering care that was far far below what would have been considered usual standard of care.”

Led by investigators at the University of Washington, the study included clinicians from a variety of roles and settings, including those who had experience planning for resource limitations. Audio recorded interviews lasting 30 to 60 minutes were completed between April 9 and May 26. The interviews included open-ended questions. Online surveys to collect demographics and practice experience also were conducted.

Interviews were reviewed and coded. Three themes emerged: 1) planning for crisis capacity, 2) adapting resource limitation, and 3) multiple unprecedented barriers to care delivery. The study found that adapting to resource limitations proved to be more complex than planned, with clinicians making difficult decisions at the bedside.

“As much as we would like to separate patient-centered decision-making from considerations of resource limitation, these considerations often occur together, including before and after the pandemic,” Butler said. “Open acknowledgement of the impact of resource limitation on our clinical decisions is the first step toward having an honest community discussion about when this is and is not an appropriate part of care decisions.”

The study concluded that expanding crisis planning to address moral distress, promoting equity and optimizing care may be helpful.

“We need to develop a framework for approaching resource limitation during the pandemic that better reflects our real-world experience,” Butler said. “Perhaps members of triage teams can act as ethics consultants in the grey zones between usual care and overt triage when resource limitation is nonetheless impacting clinical decisions.”

Health officials have grappled with shortages of medications and equipment like ventilators to treat patients with COVID-19. Measures have been taken to preserve personal protective equipment and investigators examined whether PPE such as N95 masks could be reliably reused.