The COVID-19 pandemic has seen crisis standards of care created and implemented in emergency departments across the United States, from waiting rooms converted into treatment spaces to patients back-transferred from urban hospitals with oxygen shortages to rural centers. While some of these documents have been successful, others have been problematic.

A paper published in NAM Perspectives last summer on crisis standards of care and COVID-19 noted that the authors were unable to share specific details some colleagues relayed as some of these clinicians suffered “professional retribution for raising these issues or being willing to have open and honest discussion of the tactics that were implemented.”¹ It cited improvements needed in the areas of equity and allocation of resources; graduated changes across the care continuum in staffing, dialysis, and respiratory support; and prior crisis standards-of-care work and its contributions during COVID-19.

In the emergency department at the University of Florida Health Jacksonville, instituting crisis standards of care has meant treating patients in waiting rooms with vertical beds as well as forming a Hospital Incident Command Center (HIC) that opened in February 2020 and has remained open since, according to Kelly Gray-Eurom, MD, a professor and assistant dean for quality and safety. 

“During the initial phases of the first surge, the HIC’s team met via Zoom every day at 9 a.m.,” she says. “The team was large and multidisciplinary so communications and planning could be robust.” These team members included all members of the hospital’s C-suite, the dean, medical disaster officer (an emergency physician), patient safety officer, nursing leaders from all areas of the hospital, pharmacy, supply chain, infection prevention and control, media relations as well as representatives from housekeeping and laundry. 

The State of Alaska had a crisis standards-of-care document in development years before the COVID-19 pandemic, but it wasn’t approved until March 2020 when it looked increasingly clear they may need it, according to Anne Zink, MD, chief medical officer for the state and an emergency physician at Mat-Su Regional Medical Center in Palmer, Alaska. The state convened a group of clinicians to adopt a document close to The Minnesota Framework but with edits to adjust for things such as the fact that Alaska does not have a burn unit. The state updated the document last August and is currently in the process of updating it again. But, as helpful as that document has been, it was by no means a panacea. “Those documents cover what happens when you run into things,” Dr. Zink says. “They do not address what happens when you run out of people.” 

Nursing Shortages