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Coronavirus-Are we ready to talk about rationing care?

Disasters   (5,420 Views | 71 Replies)

dinah77 has 8 years experience as a ADN and specializes in Tele, OB, public health.

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Alright, I'm gonna be the soulless monster who brings it up......

Have those of us in critical care/inpatient started to think of the possibility that rationing care will occur?

IF this spread gets bad, and large numbers of people need vents, we will have to start triaging and rationing 

There is a woeful lack of vents  overall and there will be even fewer numbers of nurses available to manage those ventilated patients

Which means, rationing, and choosing who gets that care

If we follow the utilitarian model, of who will benefit the most from that care, the elderly, especially those with comorbidities are poor candidates to get those spaces, particularly when we look at numbers of that demographic who survive  being intubated and return to a somewhat normal life (it's shockingly few, FYI)

Links here to support my last statement- would love to hear some thoughts from others

https://www.sciencedaily.com/releases/2010/03/100302162247.htm?fbclid=IwAR1c_TR50jkAbEM2n0v4BPnRAaLAge2u69i6QZnZhJV0HL2uSMxUZUe2P0o

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1127042/

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MunoRN has 10 years experience as a RN and specializes in Critical Care.

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I think I've mentioned it before you're not the first 'soulless monster'.  

Unless it's trajectory drastically changes, there's not going to be options other than drastic care rationing.  Vents, rooms, and staff are the major limiting factors.

The key is going to be to figure out who will likely survive without aggressive care, and who likely won't survive despite aggressive care, so that our limited resources are focused on this who will most likely actually benefit without wasting it on those who could have gotten by without it.  

So far, mortality risk appears to increase linearly with age, so a starting point would be that the younger should get vents before the older patients, but then that gets tricky because why put a young patient on a vent who would probably survive without one.  

Then those sticky situations that will arise, what happens if all your vents are in use and someone comes in more likely to benefit from the vent than someone already on one, it would seem you would need to take that patient's vent away and give it to the patient more likely to benefit.

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Hoosier_RN has 20 years experience as a MSN and specializes in LTC, home health, hospice, ICU, ER, dialysis.

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I agree, you are not soulless. It's a reality that we need to face. In the event that the coronavirus worsens or warrants, or any other catastrophic situation presents, tough choices will need to be made. There's no nice way around it. I just hope that it doesn't come to that any time soon

Edited by Hoosier_RN

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I believe there is an untapped resource in the community - licensed nurses who, for their own reasons, are not currently working as nurses, but who would like to work in a hospital during a crisis to help out if they could receive the necessary training.  A number of those nurses could reasonably be expected to have kept their licenses and continuing education current and may have retained much of their nursing knowledge/proficiency.  Sufficiently training suitable nurses to take care of ventilated patients could help alleviate the shortage of nurses able to care for ventilated patients.  

Other options exist besides "care rationing."

Edited by Susie2310

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dinah77 has 8 years experience as a ADN and specializes in Tele, OB, public health.

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But remember, nurses are only part of the equation. There is a finite number of ventilators and beds 

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Wonder if the ventilator manufacturers have considered ramping up production.

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5 Followers; 37,410 Posts; 100,331 Profile Views

5 hours ago, Susie2310 said:

I believe there is an untapped resource in the community - licensed nurses who, for their own reasons, are not currently working as nurses, but who would like to work in a hospital during a crisis to help out if they could receive the necessary training.  A number of those nurses could reasonably be expected to have kept their licenses and continuing education current and may have retained much of their nursing knowledge/proficiency.  Sufficiently training suitable nurses to take care of ventilated patients could help alleviate the shortage of nurses able to care for ventilated patients.  

Other options exist besides "care rationing."

There are many, many nurses, self included, who would jump at the chance to work in the acute care setting if given the proper training and available support. Just don’t throw these resources out with the garbage once the crisis has subsided. Consider that experience when these people apply for positions in the future.

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Hoosier_RN has 20 years experience as a MSN and specializes in LTC, home health, hospice, ICU, ER, dialysis.

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5 hours ago, dinah77 said:

But remember, nurses are only part of the equation. There is a finite number of ventilators and beds 

And medications, supplies, etc. And even nurses wanting to work during what may become a very grueling experience may be in limited supply in some areas, as the hours may be unstable, assistance may be limited, etc

2 hours ago, caliotter3 said:

Wonder if the ventilator manufacturers have considered ramping up production.

I think that they would, not sure that most facilities are going to invest in a whole lot more though

Edited by Hoosier_RN

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Nurse SMS has 9 years experience as a MSN, RN and specializes in Critical Care; Cardiac; Professional Development.

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Yeah, nurses to work the situation is part of the equation, but there are limits on beds, vents, meds, protective gear and the like. I have a girlfriend (nurse) from China who sent on video - it was horrific. If it gets anything like that here we are in for an education as Americans.

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adventure_rn is a BSN and specializes in NICU, PICU.

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21 hours ago, Susie2310 said:

I believe there is an untapped resource in the community - licensed nurses who, for their own reasons, are not currently working as nurses, but who would like to work in a hospital during a crisis to help out if they could receive the necessary training. A number of those nurses could reasonably be expected to have kept their licenses and continuing education current and may have retained much of their nursing knowledge/proficiency.  Sufficiently training suitable nurses to take care of ventilated patients could help alleviate the shortage of nurses able to care for ventilated patients.

16 hours ago, caliotter3 said:

There are many, many nurses, self included, who would jump at the chance to work in the acute care setting if given the proper training and available support. Just don’t throw these resources out with the garbage once the crisis has subsided. Consider that experience when these people apply for positions in the future.

Very reasonable idea in theory, tricky in practice.

People keep talking about having adequate training and support--there won't be time or resources for adequate training and support when the system is already stretched to the point of breaking. Everybody who is working will be expected to be relatively self-sufficient (much like travel nurses).

If a patient is sick enough to be intubated/ventilated, then they're critically ill; critical care requires several months of orientation, and the orientation process itself actually slows down the workflow in the ICU (since the preceptors need to take on easier assignments and go more slowly while they train the newer nurses). I can work way more quickly and take on a heavier patient load on my own than when I'm first orienting a new-to-specialty nurse; with new-to-specialty orientees, I'm only able to provide about 2/3-3/4 of the 'maximum' amount of care that I could usually provide solo, since I'm spending the other 1/4-1/3 of the time teaching (attending to the orientee instead of the patient).

It's one thing to incorporate 'critical shortage' community nurses back into hospitals if they already have several years of recent acute care experience in the specialty where they'd be working. However, training nurses without acute care experience to care for ventilated patients seems entirely impractical. 

Honestly, I think that it makes more sense for acute care nurses already working in the hospital to 'float up' to their highest acuity capacity, meaning that all of the step down nurses who have floated to ICU need to help staff the ICU, all of the floor nurses who have floated to step-down need to help staff step-down, etc.

Once we've done that, if nurses from the community want to come in and help out, they can be oriented to straightforward tasks like med passes, vitals, performing LDAs, etc. I don't say that because I think those nurses are only qualified to do those tasks; rather, it takes several months to train a non-acute-care nurse to take a full patient load, but it would take a couple of days to train them to pass meds, grab vitals, and perform LDAs. Meanwhile, this would allow the existing staff to focus on the tasks that community nurses haven't necessarily been trained for. I'm a peds/neonatal ICU nurse; there have been times that I've floated to the adult ICU because they were desperately short, and my job was to function as a CNA assisting with bed baths because that's what I'd already been trained to do in nursing school, and that's where I was the most useful.

An emergency is arguably the worst time to be training people with limited acute care background to take critically-ill, vented patients. Rather, everybody needs to step in and perform the maximum skill set for which they have already been trained.

I actually think that the bigger problem will be a critical shortage of RTs. They already tend to be stretched quite thin (even at baseline), and there really isn't anybody who can step in and replace them. That makes it even scarier to consider nurses without extensive ventilator experience caring for intubated patients; when we don't have enough RTs around, the ICU nurses need to feel comfortable knowing how to troubleshoot the vent when it malfunctions (and there are plenty of newer ICU nurses who don't).

On 3/7/2020 at 9:40 PM, MunoRN said:

Then those sticky situations that will arise, what happens if all your vents are in use and someone comes in more likely to benefit from the vent than someone already on one, it would seem you would need to take that patient's vent away and give it to the patient more likely to benefit.

In theory, that's arguably how it should work. In practice, though, I don't think providers will feel comfortable withdrawing on one person just so that they can use the vent for another. This comes back to the clinical ethics question of 'killing vs. letting die;' research shows that providers feel far greater moral distress over actively removing life support ('killing') than they do not providing it in the first place ('letting die'). Therefore, in practice, I highly doubt providers will actually remove life support on someone less likely to benefit (I.e. 'kill them') to help somebody who is more likely to benefit.

This is just my opinion, but I think providers would feel much more personal responsibility (like they were 'playing God') if they withdrew on one person to help another than if they just shrugged and said they couldn't intubate/ventilate the younger, healthier person due to a supply shortage (I.e. removing personal responsibility since there's nothing they can do about the shortages). The former places the moral burden on the provider (I.e. 'I killed one person to save another') than the latter (I.e. 'they died due to a supply shortage, there's nothing I could do.') Yes, rationing makes sense, but I simply don't see providers actually enforcing that kind of practice, since by actively removing someone's life support they'd knowingly be 'doing harm.'

Now, if we're between two non-intubated patients who need a vent, one who is more frail and the other who is more robust, then I could definitely imagine the latter patient getting priority. However, I doubt we'd extubate and essentially kill the former to save the latter.

I do wonder if this will make providers push harder than usual for the vulnerable/immoncompromised/elderly patients to have DNRs and DNIs before we have to intubate. We may also see providers initiating withdrawal of care conversations more quickly with these families than they normally would. Providers might feel better about 'letting these people die' a little sooner than they usually would to prioritize equipment for younger, healthier patients. We may see a decline in providers even offering intubation or 'heroic measures' to those families. They might also be a bit more cavalier about extubating patients who aren't quite ready yet (although extubating somebody who isn't ready, giving away their vent, and then not having the capacity to reintubate them would put them at risk for a law suit if that person dies...)

Edited by adventure_rn

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adventure_rn is a BSN and specializes in NICU, PICU.

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Also wanted to add...

It would also be tremendously difficult to determine an algorithm to prioritize who gets the vents because the determining factors are so complex. In many hospitals, all patients of all conditions (including children) use the same vents. We aren't just comparing one coronavirus patient against another; we're comparing all intubated patients (including babies, children, and all adults, from trauma to a ruptured appendix to coronavirus to cancer), since they all use the same vent. Who is to say that a 29-weeker preemie is more or less deserving than a 21-year-old with severe pneumonia due to coronavirus? How do we compare patients with vastly different outcomes and medical conditions? We can't immediately develop an algorithm for rationing that is both fair and all-inclusive, especially one that works for all patients in all care areas (from ED to NICU to the adult floors). I could easily envision attendings on two different floors getting into an enormous pissing match over whose patient 'deserves' the ventilator more.

Edited by adventure_rn

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dinah77 has 8 years experience as a ADN and specializes in Tele, OB, public health.

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1 hour ago, adventure_rn said:

Also wanted to add...

It would also be tremendously difficult to determine an algorithm to prioritize who gets the vents because the determining factors are so complex. In many hospitals, all patients of all conditions (including children) use the same vents. We aren't just comparing one coronavirus patient against another; we're comparing all intubated patients (including babies, children, and all adults, from trauma to a ruptured appendix to coronavirus to cancer), since they all use the same vent. Who is to say that a 29-weeker preemie is more or less deserving than a 21-year-old with severe pneumonia due to coronavirus? How do we compare patients with vastly different outcomes and medical conditions? We can't immediately develop an algorithm for rationing that is both fair and all-inclusive, especially one that works for all patients in all care areas (from ED to NICU to the adult floors). I could easily envision attendings on two different floors getting into an enormous pissing match over whose patient 'deserves' the ventilator more.

This is true but I think it will be easier to start with who is definitely not a good candidate 

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