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
I wasn't really thinking. Retired nurses are older nurses, who are now high risk for complications from this coronavirus. They should probably stay home.
True, but if one of them starts caring for my nearly bed bound 85 lb mother with Alzheimer's, I'll return to ICU knowing that she and my dad are fine.
I fear for nurses struggling with lack of ppe already. I fear for my family when I do get called go ICU (I'm perdiem in a hospital) I fear we'll need knowledge nurses to lead the next generation of new grads when this is over.
Specializes in Medical and general practice now LTC.
As I mentioned in another thread...
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Okay guys enough is enough. The thread is not political but about people stealing equipment from a hospital for what is obviously personal gain. Any more political posts after this warning will be removed. As mentioned in a previous post there is a political forum in the breakroom please feel free to post political discussions there and not here
...this thread is about rationing. Posts that are political have been removed from view. Please keep to topic
Governor Inslee indicated that although private companies are gearing up to manufacture PPE, and ventilators, they are also charging exorbitant prices for these items. The governors are trying to get Trump to use his power to lower the prices on these items.
The reason that some countries' death toll is higher is because their hospitals are overrun. If they are overrun then the normal crew of chronically ill patients will be bypassed. Only the very ill will be treated, and thus the death toll for all illnesses will go up.
The point of keeping the curve down is to prevent a run on hospitals. Right now my hospital has low census (or did), and this is probably people staying away from the hospital. Some of these people will inevitably die at home. Some scientists have claimed that people stayed away from the hospital during the Ebola epidemic as well.
I've never had a vent patient so I have a question for those of you familiar with using a vent. I've seen more than a few news clips of various politicians quite angrily yelling about the need for more vents. So if a ton of new vents are manufactured and delivered how will the hospitals that receive them room and staff them? Do they need to convert regular beds to vent rooms? What is the learning curve for operating a vent? Is it something that a bunch of nurses can be trained to operate safely in a short amount of time?
I ask because I truly don't know how complicated this would be. I mean, what good are the vents if there is nowhere to put them and too few nurses that know how to use them?
Specializes in Critical care, tele, Medical-Surgical.
On 3/10/2020 at 5:55 PM, Kitiger said:
Even if we can come up with enough nurses, there is still the problem of not enough vents.
New York State came up with guidelines in 2015. Part of the planning process was to develop guidance on how to ethically allocate limited resources (I.e., ventilators) during a severe pandemic while saving the most lives. I am praying they don't have to use them.
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VENTILATOR ALLOCATION GUIDELINES
As part of our emergency preparedness efforts, the Department, together with the New York State Task Force on Life and the Law, is releasing the 2015 Ventilator Allocation Guidelines, which provide an ethical, clinical, and legal framework to assist health care providers and the general public in the event of a severe influenza pandemic...
Specializes in Vents, Telemetry, Home Care, Home infusion.
Disaster Ethics as part if Emergency Preparednes is often discussed and formal plans created at the corporate level to guide decisions made by staff.-How many staff nurses ever read their facilities Disaster Response Plan?
Having been on a hospital and later home health disaster planing + ethics committees, I've helped with desktop modeling and policy creation so familiar with crisis standards
Tracie -the Healthcare Emergency Prepareness Information Gateway has online collection of Crisis Standards of Care articles.
The provision of medical care under catastrophic disaster conditions requires considerable pre-event planning, along with the recognition that the delivery of healthcare services will likely change due to the potential scarcity of required resources. Beginning in 2009, ASPR has focused significant attention on “crisis standards of care,” spearheaded by the issuance of three reports by the Institute of Medicine of the National Academies. Work performed under this topic area provides a roadmap for medical decision-making during catastrophic events. Coordination of emergency response system planning is critical to successful health and medical outcomes under chaotic “crisis” conditions, which limit patient morbidity and mortality in an environment of collective rather than individual priorities. The standards of care proposed under the delivery of such conditions must represent a “reasonable” approach to healthcare service delivery merging public health, ethical, and medical care demands, albeit under unique and challenging conditions.
Note that many state plans use Sequential Organ Failure Assessment (SOFA) score thresholds (e.g., >11) to make decisions. Based on findings highlighted in articles from 2010 to present, this is not ethically justifiable. This Topic Collection includes plans that have adjusted their criteria to a comparative use but also notes this limitation for a few otherwise excellent plans. For current frameworks, access Christian et al. (2014) and the ASPR TRACE document SOFA Score: What it is and How to Use it in Triage. https://files.asprtracie.hhs.gov/documents/aspr-tracie-sofa-score-fact-sheet.pdf
Specializes in Vents, Telemetry, Home Care, Home infusion.
Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement
The 11 suggestions highlighted in this article can help those involved in large-scale pandemics or disasters with multiple critically ill or injured patients (e.g., front-line clinicians and hospital administrators) make more informed decisions about critical care triage. https://journal.chestnet.org/article/S0012-3692(15)51990-9/fulltext
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... 11. Triage process:
11a. We suggest tertiary-care triage protocols for use during a disaster that overwhelms or threatens to overwhelm resources be developed with inclusion and exclusion criteria.
11b. We suggest the inclusion criteria for admission to intensive care.
11c. We suggest patients who will have such a low probability of survival that significant benefit is unlikely be excluded from ICUs when resources are overwhelmed.
11d. We suggest consideration be given to excluding patient groups that have a life expectancy < 1 year.
11e. We suggest if a physiologic (nondisease-specific) outcome prediction score can be demonstrated to reliably predict mortality in a specified population upon screening for ICU admission, it is reasonable to use this to exclude admission for patients with a predicted mortality rate > 90%. Similarly if a disease-specific score can be demonstrated to reliably predict mortality when used in the same manner for patients with the disease, we suggest it is reasonable to use this to exclude admissions for patients with a predicted mortality rate of > 90%.
11f. We suggest each patient's condition be reassessed after a suitable time period (eg, 72 h) by the triage officer or triage team. If at that point the patient meets the criteria for exclusion from ICU, consideration should be given to withdrawal of therapy. If in the future a score is demonstrated to reliably predict high mortality when the patient is assessed during ICU stay, this should be used in preference to or as a supplement to clinical judgment.
I've never had a vent patient so I have a question for those of you familiar with using a vent. I've seen more than a few news clips of various politicians quite angrily yelling about the need for more vents. So if a ton of new vents are manufactured and delivered how will the hospitals that receive them room and staff them? Do they need to convert regular beds to vent rooms? What is the learning curve for operating a vent? Is it something that a bunch of nurses can be trained to operate safely in a short amount of time?
I ask because I truly don't know how complicated this would be. I mean, what good are the vents if there is nowhere to put them and too few nurses that know how to use them?
Asking the real questions!
A vent can go into any room with wall air and o2. That's not a big problem.
There is a learning curve for nurses and physicians. Theoretically, anesthesia providers who are not in the OR right now can manage prescribing settings and following ABGs to adjust settings. (Settings include rate, pressure, volume, and mode. Some modes provide a lot of support to mimic natural breathing, some allows the patient to do most of the work naturally, and some provide extra pressure and are very different to natural patterns.) Maybe they can even alleviate some of the critical care nurse's role in that assessments and evaluation if non critical care nurses are stepping in. The nurse still needs to know when and how to suction (oh, so much sticky suctioning) and how to maintain the patient's comfort and cooperation. The nurse will need to recognize normal and abnormal response to the vent and when to alert a provider that a change in setting might be available. It's imperative to prevent and assess for lung barotrauma and pneumonia. Remember, there's a finite number of RRTs as well and even a seasoned ICU nurse depends on them.
Read a book called "Five Days at Memorial" about a hospital that was impacted by the flooding following Katrina. Staff forced to make some heart-wrenching life/death decisions we are discussing. Then to add insult to injury, one of the docs involved in those decisions was arrested and charged with murder. Hope we don't see any of that with this situation.
Read a book called "Five Days at Memorial" about a hospital that was impacted by the flooding following Katrina. Staff forced to make some heart-wrenching life/death decisions we are discussing. Then to add insult to injury, one of the docs involved in those decisions was arrested and charged with murder. Hope we don't see any of that with this situation.
I read that book for my medical ethics class for my MPH program January of 2019
we also had a discussion about how to ration care if “there is a global influenza pandemic that requires rationing of of ventilators- how do you choose who gets one?” creeps me out how relative that Is now ?
I read that book for my medical ethics class for my MPH program January of 2019
we also had a discussion about how to ration care if “there is a global influenza pandemic that requires rationing of of ventilators- how do you choose who gets one?” creeps me out how relative that Is now ?
I've read the book as well. It's sad, but if things get much worse, we will need to make tough choices
CampyCamp, RN
259 Posts
True, but if one of them starts caring for my nearly bed bound 85 lb mother with Alzheimer's, I'll return to ICU knowing that she and my dad are fine.
I fear for nurses struggling with lack of ppe already. I fear for my family when I do get called go ICU (I'm perdiem in a hospital) I fear we'll need knowledge nurses to lead the next generation of new grads when this is over.