Delaware hospitals are in crisis.
ChristianaCare, Bayhealth, TidalHealth Nanticoke and Saint Francis announced in a joint statement on Monday that they all will be implementing Crisis Standards of Care. This means that the hospitals will, among other things, begin to prioritize care among patients and change how resources are distributed.
For ChristianaCare, it is the first time implementing such a drastic change in about 130 years.
For weeks, the hospitals have exceeded maximum capacity as Delaware sees an unprecedented number of hospitalizations during the latest surge in COVID-19 infections.
Under Crisis Standard of Care, the focus shifts to saving the most amount of lives over the needs of individual patients.
“Delawareans who need emergency care might not be able to get it,” Gov. John Carney said earlier this week. “That’s just a fact. It’s time for everyone to pitch in and do what works.”
Health officials continue to urge Delawareans to get vaccinated, wear masks and avoid large gatherings.
How did Delaware get here?
For nearly two weeks, the state watched hospitalizations climb, reaching new highs almost every day. This week, it crossed the 700 threshold.
At this time last year, when there was limited access to vaccines, hospitalizations hovered around 430.
The state is experiencing its toughest fight against the virus as the rate of weekly cases and the percent of positive tests are at their highest points.
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The omicron variant appears more transmissible than any previous strain. During the week of Christmas, health officials said, about 78% of lab-tested samples were of the omicron variant.
Over the past month, Gov. John Carney and state health officials have pleaded with Delawareans to take personal responsibility by getting vaccinated and wearing masks in indoor public settings. The governor reinstated the mask mandate for most indoor public places starting Tuesday morning.
“My hope was that we’d be able to accomplish it by voluntary compliance … that didn’t seem to work,” Carney said during a Tuesday briefing. “We were pushed to the limit with our hospitalization number and decided to pull out the stops.”
Hospitals have been struggling with staffing issues since the fall. Many nurses are leaving the bedside or finding better financial opportunities.
Some are leaving the profession altogether due to burnout and mental health issues and the nurses who stayed often had to care for many more patients than before.
Following the explosion of cases after Thanksgiving, emergency rooms became more crowded. Doctors and nurses began caring for an unprecedented number of COVID-19 patients, about 70% of whom are unvaccinated. Hospital leaders began sounding the alarm about capacity issues.
It reached a breaking point.
What does Crisis Standards of Care really mean?
This kind of care is only done in extreme emergencies, when resources are depleted. Hospitals have already exhausted other options, including delaying non-urgent medical procedures.
Health systems, state officials said, are experiencing capacity levels of 117% on average. At ChristianaCare and Beebe, that number is 130%.
This is the first time in ChristianaCare’s history that it is operating under a Crisis Standard of Care.
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“We’ve been steeped in this pandemic,” said Dr. Ken Silverstein, chief physician executive, ”we’ve been planning for these surges, we’ve been adjusting and adapting our capacity. We’ve put contingency strategies in place.
“But we’ve reached the point where we are overwhelmed with the demand for our services.”
The hospitals will be following guidelines set by both the National Academy of Medicine and the Division of Public Health. In April of 2020, weeks into the pandemic, Delaware created a document that includes medical, logistical and ethical guidelines for if and when this emergency situation occurs.
It outlines the common factors that could lead to implementing Crisis Standards of Care, which could also be triggered from a natural disaster or another drastic emergency. For health care facilities, they can include:
- Non-patient areas used for patient care
- There is an “insufficient number of trained staff working” or staff are working jobs they are not trained for
- There is a lack of critical supplies, resulting in an allocation of lifesaving measures
- Care is not consistent with usual standards
Overall, the decisions made under Crisis Standards of Care focus on getting the best outcome for a group of patients as opposed to focusing on individuals.
“We have to make clinical prioritization decisions,” Silverstein said, “who’s eligible, who is in the greatest need, who will benefit most from those medications?”
How will patients be affected?
This decision will affect all types of hospital patients. And it will likely do so in different ways.
Due to staffing issues among ChristianaCare’s dietary team, not every patient will be able to get a hot meal, Silverstein said. So staff is prioritizing patients.
Nurses delivering medications to patients on a schedule will now decide who will be receiving pills on time and who have to wait a bit longer.
The same can be applied to monoclonal antibodies, a treatment for high-risk COVID-19. This medication is in short supply. Staff will have to decide who gets it first.
It’s likely hospital staff will have to make even tougher, wrenching decisions when it comes to life-saving treatment. The state guidelines note how patients should be triaged, providing a scoring rubric.
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“Triage should be guided by the acute severity of the patient’s current medical condition,” the document reads, “the epidemiology of the disease and the current status of any underlying medical diseases that may hinder recovery.”
These decisions, according to the document, should be based on “individual assessments of each patient’s potential for survivability to discharge.” Health care workers should not factor in a patient’s quality of life before hospitalization, or predict future quality of life.
“Based on the event, allocation of treatments may prioritize the number of patients who will recover over the number of life-years saved,” the document reads.
Hospital leaders are urging residents to only come to the emergency room if they are experiencing a medical emergency – not to get a COVID-19 test. The wait times in the ERs are so long, patients are being treated in hallways.
The section chief of critical care for ChristianaCare, in a video aired before the governor’s Tuesday briefing, noted how the hospital has set up an “extra” intensive care unit. He said, at the time of shooting the video that it was operating at about 170% of normal.
“Everyone’s really tired,” he said. “It’s a very busy weekend. Exhausting”
He then took a breath and said: “No end in sight.”
Contact Meredith Newman at (302) 256-2466 or at mnewman@delawareonline.com. Follow her on Twitter at @MereNewman.
