Heal at Home: L.A. County Outlines Wrenching Moves to Ration Health Care If COVID-19 Hospital Crisis Worsenshttps://www.latimes.com/california/story/2020-12-19/los-angeles-county-coronavirus-hospitalization-surge-rationing?_amp=trueCalifornia on Friday broke a record for most coronavirus cases in a single day with 53,326, topping the high last set Wednesday, when 52,330 cases were reported. The record for the number of Californians hospitalized for COVID-19 has been broken for 20 days in a row, rising to 16,019 by Thursday, including 3,447 people in intensive care units. COVID-19 hospitalizations have multiplied sevenfold since late October. Available ICU beds in LA County have dropped to 0%
... “We have not hit an inflection point. It is still picking up faster. The number of people going into the hospitals is pretty much growing more and more every day. It’s not just getting bigger — it’s getting bigger faster,”... “With the continued rise in cases and the steep slope of the trajectory that shows no sign in bending, we’re essentially screwed,” ... “We’re afraid that California is heading towards New York spring status at this rate.”
With intensive care units full and projections showing big increases in hospitalizations through New Year’s Day, Southern California’s medical system is faced with the prospect of not being able to provide critical medical care to everyone who needs it, which would significantly increase the chances of patients dying as they wait for help.
Already, hospitals are juggling resources to keep up, placing the overflow of ICU patients in other parts of hospitals not designed for them, clearing out critical care wards of patients who can survive elsewhere and in some cases keeping patients on ambulances for as long as eight hours until space is available.
But much more wrenching choices could be ahead as the COVID-19 surge shows no signs of slowing down, and there is little hope for the arrival of an army of additional medical professionals who can greatly expand intensive care unit availability through the end of the year.
Many hospitals are preparing for the possibility of rationing care in the coming weeks as the number of patients exceeds their staffs’ abilities to care for them.
A document obtained by The Times outlining how to allocate resources in a crisis situation was recently circulated among doctors at the four hospitals run by Los Angeles County.
The guidelines call for a shift in mindset that is unfamiliar to many medical providers.Instead of trying everything to save a patient, their goal during a crisis is to save as many patients as possible, meaning those less likely to survive will not receive the same level of care they would have otherwise.
Doctors will no longer be pulling out all the stops to save a life but instead strategizing about how to keep as many people as possible from perishing.... “Some compromise of standard of care is unavoidable; it is not that an entity, system, or locale chooses to limit resources, it is that the resources are clearly not available to provide care in a regular manner,” the document reads.
... “We have enough beds, supplies, and equipment for now, but
we don’t have enough trained staff for the number of patients who need care. We have brought in new staff, retrained and redeployed staff from other areas of the system, and have requested additional resources from the state,” Ghaly wrote. “But these measures are not anticipated to be enough to meet the continuously escalating number of patients that are presenting across the county for care.”
Across the nation, it has already become harder to get admitted to the hospital with COVID-19 symptoms today than it was a couple of months ago, said Dr. Kirsten Bibbins-Domingo, UC San Francisco chair of the department of epidemiology and biostatistics.
This sets up the potential for a deadly Catch-22 already seen in hard-hit places in China, Italy and New York earlier in the pandemic — hospitals so crowded that people have to be extremely sick before they’re admitted, by which time, it may be too late to save them.
...Earlier in the pandemic, some less critically ill patients in hot zones were asked to return home instead of being admitted to an overcrowded hospital. Some people deteriorated at home and later died. Had they been admitted earlier, as would have been the case if the hospital were less crowded, they’d have a much higher chance of surviving.
... “When hospitals start to to get full … we subtly change our thresholds for admitting someone to the hospital,” Bibbins-Domingo said.... “So maybe last month, we might say, ‘Wow, you’re not getting enough oxygen. Let’s admit you to the hospital because we want to be more cautious.’ And when a hospital is full, that is a time when we might … say, ‘Well, why don’t we wait another day and see how you do?’”
Symptoms can worsen so quickly that it may be too late to seek help by the time a person realizes something is seriously wrong, or, having been turned away once, some sick patients may second-guess whether they should return to the hospital when they should.
A study published in the summer in the journal JAMA Internal Medicine found that patients admitted to hospitals with fewer ICU beds had a higher risk of death.
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2768602 The county memo said the shortages are unlikely to be of tools like ventilators but instead of highly trained staff, specifically respiratory therapists, ICU nurses and critical care physicians. Decisions would be made by an appointed triage officer.
For patients who receive a scarce resource, they will be given up to two days to see if it is helping, at which point they should be reassessed to determine whether the treatment should continue.
If the patient has not shown improvement or has gotten worse, the resource may be reallocated to someone else.“The ethical justification … is that in a public health emergency when there are not enough critical care resources for all, the goal of maximizing population outcomes would be jeopardized if patients who were determined to be unlikely to survive were allowed indefinite use of scarce resources,” the document states.
The chief medical officer of L.A. County’s flagship public hospital warned that although the county has not yet suffered catastrophic consequences, it “is now moving towards becoming the epicenter of the pandemic … and if we don’t stop the spread, our hospitals will be overwhelmed.”
“If you have a heart attack, if you get into a car accident, if you fall off a ladder, or have a stroke, we may not have a bed for you,” said Dr. Brad Spellberg, chief medical officer of L.A. County-USC Medical Center.
He added: “I’m not going to sugarcoat this: We are getting crushed.”
Poll