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
This conversation makes me sad but it is one that we should be having. As a previous poster said, America is in for a rude awakening and that has been coming for quite a long while.
Specializes in rural, camp, telephone triage, abstraction.
Just thinking out loud here...what about a form of team nursing? It's been over 3 years since I've worked in hospital, even longer since I took care of a vented patient. BUT I know my way around the place and could definitely still make myself useful in critical care, maybe helping someone with current experience take on a larger patient load than usual. I'm sure there are others like me that would be willing to help however we can, but I'm guessing bureaucracy would somehow interfere. ?
Some of us private duty home care nurses are experts with trachs and vents. I'll probably be too busy with my own patients, but retired private duty nurses could help . . . if the bureaucracy allowed it.
Specializes in NICU, PICU, Transport, L&D, Hospice.
9 hours ago, dinah77 said:
This is true but I think it will be easier to start with who is definitely not a good candidate
The CDC used to have regional meetings where these sort of things were discussed and developed and planned for with health professionals from the region.
... 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? ...
Thank you for addressing the elephant in the room.
On 3/10/2020 at 1:00 AM, dinah77 said:
This is true but I think it will be easier to start with who is definitely not a good candidate
And it very well might be the 29-week neonate. Are you as willing to withhold or withdraw support from this patient as you are the 65 year old?
The 29 well premie is likely using a machine that would not work well on the 65 year old...
Not necessarily. Until recently my facility used the Servo I for all ventilated patients, regardless of age. Recently, we bought several Drager ventilators, the majority of which were the v500 ventilator,suitable for use in patients of all ages.
The question remains, if you compare likely outcomes, and the 65 year old is likely to have the best outcome, should he or she receive the treatment?
Specializes in NICU, PICU, Transport, L&D, Hospice.
11 minutes ago, chare said:
Not necessarily. Until recently my facility used the Servo I for all ventilated patients, regardless of age. Recently, we bought several Drager ventilators, the majority of which were the v500 ventilator,suitable for use in patients of all ages.
The question remains, if you compare likely outcomes, and the 65 year old is likely to have the best outcome, should he or she receive the treatment?
I've been out of the NICU for many years...
The CDC used to participate with hospitals in those mental exercises before there was an actual pandemic threat...
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
We already do ration care. I think you need to step back from this hysteria about 20 whole people in the us supposedly passing from corona (no evidence to support that corona was the primary, single cause of death, either)....And take a look at how many people do and have died from just flu a and b....And how many of those we sent home with a dose of Tamiflu or admit and bed them in multi patient rooms.
We already dispo people from ICU, extubate and push to step down...When they are not completely stable. How many rapids I have gone to in step down and med surg bc some patient was turfed for the bed. How many codes I have gone to for the same reason.
We are rationing care already. Let's not even go into medicare and medicaid, the uninsured and under insured, the ones that are unfortunate enough to be on those old model HMO plans....
Corona is not going to overwhelm the healthcare system. We are doing that to ourselves every day already.
This reminds me of one of the most succinct lines in any movie I've seen---one that reels people back into reality from all of the alarmist and wild speculation and fear---it's from "Contagion".
An army officer is speaking to the CDC guy played by Lawrence Fishburn and he is anxious and fearful and has a very "Militarized" way of thinking (because this is what he is trained to do---see threats in everything, always, everywhere)-
Officer: "Is it possible to weaponize bird flu?"
Laurence Fishburne: "No one needs to try, because the birds are already doing that."
We're living in an age where everyone wants everything to be done, no matter what. Teevee has told the average american that drastic and extreme measures can and will be taken on everyone. This simply is not true--not in theory and certainly not in practice. However...We have the lawyers and the average american being so willing to sue---the doctors do pretty much everything that a patient or family demands, to avoid these outcomes.
Therefore, we are rationing---because those patients that should have been dispo'ed and should have been booted out because they simply know what buzzwords to say to be admitted---take up beds from those who should be there.
Patients who come to the er "With a plan" every week so that they can get to the front of the 80 deep waiting room and a 3 day stay. Patients that come to the er for prescription refills because they sold the last one to buy meth or used it all up early so they come with "Vague" symptoms and force us to do 12-24 hour long workups with expensive tests like cts and mris. Patients who are dumped by family because they "Just want a break" and make up all sorts of vague complaints to keep aunt mildred from coming home for a long weekend.
These patients hold us up from providing care to people who actually need it. This would not be a worry---rationing care to the critically ill---if the sword of damocles wasn't held over our heads every single day in the form of lawsuits.
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.
Utilizing nurses from the community to provide basic care is a very good idea, as is the idea of floating staff upwards to their highest level of acuity. But if a situation arises where there is a significant shortage of nurses, and even these plans are not sufficient, then I think it will be necessary to consider another option, and I think it is sensible to plan for this now.
As far as utilizing nurses in the community who are not currently practicing or who are practicing in other roles, the nurses would ideally need to have acute care training that they have kept reasonably current - much can be accomplished with sufficient good quality continuing education, even though the value of continuing education is sometimes overlooked or downplayed by nurses themselves.
We are talking about helping in a crisis situation. In a crisis situation things are done that are not normally done because the conditions are not normal. Frankly, if I or my loved one were critically ill and had the choice of receiving care from a nurse who was brought in from the community who had reasonably/somewhat current acute care knowledge (even if they weren't currently practicing as a nurse), and the nurse was able to receive enough (not necessarily an ideal amount) of training to enable them to provide care for patients of critical acuity utilizing ventilators (it is quite possible that individual nurses in the community who are not currently practicing may already have some knowledge of critical care and care of ventilated patients and will not require extensive training) or no care at all during a severe illness such as that caused by the Coronavirus, I would choose to receive care from that nurse for myself or my family.
There are also nurses who practice in home settings who have knowledge of the use of ventilators in the home and have acute care backgrounds. If some of these nurses wished to help out in the hospitals, I can't see how it would be impossible to train them in a reasonably short time to take care of hospitalized ventilated patients.
If a staffing crisis of nurses who are trained to take care of ventilated/critically ill patients exists or is imminent, it seems sensible to me to begin investigating availability of nurses in the community and making contact with them and assessing their training/education to determine what resources would be necessary to enable them to provide care for ventilated/critically ill patients. Again, if the choice if between the patient receiving no care at all, or care by a nurse who is not as well trained as a currently practicing ICU nurse, I personally will choose the latter for myself or my family.
The point is to look for solutions. There are always reasons for not doing something. In crisis situations it is necessary to look for alternative solutions. Of course, crisis circumstances mean that some things will be done differently.
Of course, crisis circumstances mean that some things will be done differently.
I don't think your idea is too bad, considering that even if people "float up" as has been suggested, there will still be a need for all the floating up to be replaced all the way down the line. I agree with you that there are plenty of areas in which a trained nurse could be put into action even if not currently working in acute care.
But another thing that would become mandatory (hopefully) if we were to face a crisis would be that we'll have to let go of the rather luxurious iteration of "lean" that employers have been able to demand, wherein resource restriction (crappy staffing) miraculously does not stem the tide of low-value initiatives, low-value documentation requirements, petty discipline and fear mongering.
Where does the rationing of care end? Will you ration the nursing care of my hospice patient? How is one life valued above another and thus receives more care? No human being has the right to determine human value or privilege - only God can do that. A pre-born baby who is unable to vocalize their needs/wants has just as much rights as my late stage demented patient who cannot vocalize his/her needs/wishes either. Do not play God....you won't win.
twinmommy+2, ADN, BSN, MSN
1,289 Posts
This conversation makes me sad but it is one that we should be having. As a previous poster said, America is in for a rude awakening and that has been coming for quite a long while.