After numerous warnings, Utah hospitals are preparing to ration care.
With soaring numbers of coronavirus cases, Utah hospitals have seen their ICUs reach dangerously high occupancy levels and have been forced to do the unthinkable: prepare to ration care. Under the Utah Crisis Standards of Care, protocols for deciding who gets ICU space or ventilators aim at doing the greatest good for the greatest number. In other words, some patients will have to be sacrificed to make room for others with better prospects of survival. It is hoped that the chilling guidelines will persuade Utahns to be more vigilant about limiting the spread of the virus.
Video Spotlight: Shortage of ICU Resources in Utah
This post is based on The Salt Lake Tribune article, Utah’s Hospitals Prepare to Ration Care as a Record Number of Coronavirus Patients Flood Their ICUs, by E. Alberty and S.P. Means, October 25, 2020, and the YouTube video, A Utah Infectious Disease Doctor on His State’s Coronavirus Crisis , by PBS NewsHour, October 26, 2020. Image source: Pordee_Aomboon / Shutterstock.
1. What are the factors contributing to the high occupancy rates of ICUs? Why is it difficult to increase ICU capacity?
Guidance: The primary factor is a high increase in demand caused by spikes in coronavirus cases. Other factors include limited capacity in terms of beds, equipment, and qualified personnel. To make matters worse, ICUs are currently understaffed because nurses cannot work due to illness, infection in the family, or burnout. The time it takes to put on and take off personal protective equipment between patients and to transfer patients has further limited the time available for care. Although ICU bed capacity can be increased by repurposing existing beds and opening overflow units, the number of doctors and nurses with the proper qualifications to administer intensive care cannot be increased at will.
2. Why is 85% occupancy considered full capacity utilization in ICUs? Why is the statewide ICU capacity of 590 beds considered overly optimistic?
Guidance: The spokesman for Utah’s Division of Emergency Management said, “If we are at 85%, we are basically at 100%.” Because of variability in capacity, an ICU cannot be operated at full capacity. Staffing levels change over time, and different patients require different levels of care and resources (service time). The ICU capacity of 590 beds includes beds in small hospitals. Smaller hospitals can provide intensive care, but they are ill equipped to handle coronavirus patients who are referred to larger hospitals whose combined capacity amounts to 460 beds.
3. What are the protocols for deciding who gets ICU space? How do they relate to queuing concepts?
Guidance: The protocols involve a 4-step process: 1) make sure that patients using the resources want them (e.g. end-of-life discussions); 2) transfer patients to a regular hospital bed if their condition is not improving; 3) if ICU capacity is fully utilized, transfer patients who are not improving out of the ICU and give priority to pregnant women and younger patients; and 4) change the cutoff for improvement based on daily demand for ICU beds.
Because capacity is constrained, the protocols aim at decreasing the demand placed on the system. If nothing was done, queues of patients waiting for ICU space would keep on growing. The priority system (queue discipline) adopted in the guidelines provides the basis for deciding who gets ICU space and who does not.