As recent outbreaks in India and Japan have demonstrated, getting the COVID-19 pandemic under control will take quite a bit more time and a lot more careful thought. Surges in infection rates and corresponding demands on health care resources will almost certainly recur as further variants of SARS-CoV-2 emerge before the globe can be vaccinated. Health care systems need to have plans in place for dealing with them. 

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The AMA and eight other national organizations—the American Association of Colleges of Nursing, Association of American Medical Colleges, American Hospital Association, American Nurses Association, American Organization for Nursing Leadership, John Hopkins Bloomberg School of Public Health Center for Health Security and the National League for Nursing—have thus issued a joint statement with a number of strategies to improve crisis standards of care implementation in future COVID-19 surges.  

Crisis standards of care are implemented when shortages in health care resources—such as clinical staff, hospital beds and medications—are so severe that conventional standards and processes are no longer sufficient to meet the need. 

“The prospect of once again facing decisions about whether to transition to crisis standards of care (CSC) calls for action now, while a relative lull in cases allows stakeholders to plan thoughtfully for such decisions,” says the statement, developed by the National Academy of Medicine. 

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The AMA has created an ethics resource page, “Crisis standards of care: Guidance from the AMA Code of Medical Ethics,” that offers expert guidance on allocating scarce resources during a pandemic. Drawing on numerous opinions from the Code, the page provides a comprehensive guide to help organizations ensure responsibility to patients during pandemics. 

Updating crisis standards of care “is especially important in light of painful lessons the pandemic has taught about the need for clarity and consistency across institutions and jurisdictions about invoking CSC and the disproportionate impact COVID-19 has had on historically minoritized and marginalized populations,” the statement says. 

The challenges of implementing crisis standards of care “can be compounded when they are put into practice through processes that similarly fail to embed considerations of equity,” the statement adds. 

The statement notes that changes have to be made in four key areas:  

  • How to declare a crisis in a community and have it applied fairly and consistently. 
  • Ways to provide greater clarity around professional liability during a crisis. 
  • Strategies for relieving frontline clinicians of gut-wrenching triage decisions. 
  • How to pivot when your staff don’t have the right skill sets for an emergent situation. 

For starters, it’s important to have agreed-upon thresholds for what is considered a crisis—in terms of both staffing and decision-making. Also essential are messages for physicians and the public to explain what will happen when thresholds are reached. 

Also, there are ways to clarify physicians’ liabilities, including by explaining the protections afforded by state and federal laws. Legal counsel in health systems should easily understand how important this is. 

Regarding triage, it’s important to ensure that a physician or other clinician facing a novel or uncomfortable allocation decision has a designated point of contact—someone outside of the career team—who can immediately give expert advice and raise the issue to incident management. 

The statement details how to deal with not having enough staff with adequate training to meet the needs of incoming patients—particularly in emergency and critical care—and how to reassign staff to new assignments without wrecking morale. It recommends providing them with a number of resources, including respite, behavioral health resources and monitoring and check-ins for adverse personal effects. 

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“The best time to address these issues is now, while they are top of mind,” the statement says. “Failure to capitalize on this opportunity means the continuation of a fractured system that could do much more to protect both patients and providers in times of crisis.” 

Find out more about how to implement crisis care standards when needed during COVID-19 or the next public health emergency. 

The AMA COVID-19 resource center offers frequent updates on clinical information, AMA guides and resources, advocacy and medical ethics related to the pandemic. 

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