Crisis Care Guidelines

1. GUIDELINE STATEMENT

   The Crisis Care Guideline is an extension of the surge-capacity plan. Crisis care standards will only be executed if critical care capacity is overwhelmed despite all surge-capacity efforts.

2. PURPOSE

   To ensure a framework is in place when the hospital moves from contingency care to crisis care. The framework is based on saving lives and saving life years, by ensuring care access to all patients based on objective medical knowledge.

3. FRAMEWORK
   1. Triggers/Thresholds for Activation of Crisis Care
      1. Consider the following triggers for appropriate implementation of the Crisis Care Guidelines:
         • Critically limited resource(s) and infrastructure are identified (e.g., staffing).
         • Surge capacity is fully employed within health care facilities (and regionally) if capacity/space is the limited resource.
         • Maximum efforts to conserve, substitute, adapt, and re-use are insufficient if supplies are the limited resource.
         • Patient transfer or resource importation is not possible or will occur too late for bridging therapies (such as bag-valve ventilation or other temporizing measures) to be considered.
         • Necessary resources have been requested from local, regional health officials (as applicable), and affiliated entities.
         • A state of emergency has been declared, or other health powers (as applicable) have been activated.
         • Regional, state, and federal resources are insufficient or cannot meet demand.
   2. Framework of Resource Triage Team (RTT)
      1. The facility has created a Resource Triage Team to determine the appropriate allocation of healthcare resources.
      2. The RTT will include acute care physicians, nurse(s) and administrator(s).
      3. The RTT will eliminate bias and discrimination when making triage decisions.
      4. The RTT or designee will accompany the treating physician to communicate triage decisions to patients and families.
      5. The RTT or designee will attend all patient and family appeals to the triage decision.
         • If resources permit, palliative care clinicians, social workers, and/or chaplains are to provide emotional support to patients and families.
      6. The hospital will ensure a framework is in place to address appeals, when necessary through the Resource Triage Committee.
   3. Ethical Considerations should be incorporated into decision-making regarding allocation of healthcare resources to:

      1.To achieve benefit for populations of patients, doing the greatest good for the greatest number.

      • To create meaningful access for all patients who are eligible for ICU services during ordinary circumstances remain eligible, and there are no exclusion criteria based on age, race, disability (including weight-related disabilities and chronic medical conditions), gender, sexual orientation, gender identity, ethnicity (including national origin and language spoken), ability to pay, weight/size, socioeconomic status, insurance status, perceived self-worth, perceived quality of life, immigration status, incarceration status, homelessness, or past or future use of resources.
      • To ensure that all patients receive individualized assessments by clinicians based on the best available objective medical evidence.
      • To ensure that no one is denied care based on stereotypes, assessments of quality of life, or judgments about a person based on the presence or absence of disabilities or other factors.
      • To diminish the impact of social inequalities that negatively impact patients’ long-term life expectancy by keeping in mind historic disparities and inequalities
   4. Allocation of Resource Process
      1. All patients requiring emergency stabilization either in the Emergency Department or on the hospital floor will receive stabilization treatment before any resource allocation decision is made. Scarce resource(s) may be provided during the stabilization process with the understanding that the resource may be withdrawn after the allocation process is performed.
      2. Patients will be assessed for conditions present in Table 2. Patients with conditions listed in Table 2 may not be eligible for allocation of ICU care or ventilator use.
      3. Treating physicians will identify all patients who require the use of scarce resources. Examples of patients who require ICU level of care or ventilator use is provided in Table 1.
      4. A disease severity score will be calculated for each patient requiring a scarce resource. Currently, the score that is being used is the SOFA score (Table 3) or mSOFA score (Table 4). Table 5 compares the differences between the two scores.
      5. The patient will then be assigned to a priority group based on his/her disease severity score. Table 6 shows the prioritization groups by SOFA or mSOFA score. The priority group assignment should be noted clearly in the patient’s chart or electronic medical record by the RTT.
      6. The availability of the scarce resource will determine how many eligible patients will receive (or continue to receive) the resource. Patients in group 1 will receive the resource first, followed by patients in groups 2, 3, and 4. Patients with the highest score within the priority group will receive resources before patients with a lower score in the same priority group
      7. Patients and/or their agent/surrogate will be notified of the decision.
      Table 1: Medical Criteria supporting consideration of ICU care or Ventilator Use

      Requires invasive mechanical ventilation	Refractory hypoxemia (SpO2<90% on non-rebreather mask at flow of ≥15 LPM) Respiratory acidosis with pH < 7.20 on arterial blood gas Clinical evidence of respiratory failure Inability to protect airway
      Requires vasoactive support for hypotension or unstable rhythm	Systolic blood pressure < 90 mmHg with clinical evidence of shock (end-organ failure) refractory to volume resuscitation Unstable bradyarrhythmia refractory to electrolyte replacement Unstable tachyarrhythmia requiring vasoactive drip or cardioversion
      Requires intensive neurologic monitoring or intervention	Acute neurologic condition (e.g. intracranial/intraventricular hemorrhage, subarachnoid bleed with unsecured aneurysm, traumatic brain injury, or ischemic stroke with mass effect or acute hydrocephalus, severe CNS infection) with Glasgow Coma Scale < 13 Status epilepticus refractory to initial antiepileptic therapy Spinal cord injury at or above C5 with ASIA-A and B
      Requires intensive interventions for trauma or major surgical condition	Polytrauma within 24 hours of presentation Post-operative condition with significant instability (e.g., open abdomen)

      Table 2: Medical Criteria supporting lack of benefit from ICU care or Ventilator Use

      Catastrophic cardiac arrest	Out-of-hospital unwitnessed arrest Out-of-hospital witnessed arrest without ROSC after ≥30 mins of ACLS without shockable rhythm In-emergency-department or in-hospital witnessed arrest without ROSC after ≥30 mins of ACLS without shockable rhythm
      Catastrophic burns	American Burn Association expected mortality ≥90%
      Catastrophic trauma (general)	Trauma Injury Severity Score predicting ≥90% mortality Traumatic brain injury with Glasgow Coma Score motor response ≤ 2 at presentation
      Catastrophic trauma (neurologic)	Traumatic subdural hematoma that results in >1.5cm of midline shift with loss of (near) all brainstem reflexes Any sized traumatic epidural hematoma that has resulted in evidence of uncal herniation and brainstem infarction with loss of brainstem reflexes Gunshot Wound to Head: Transtentorial - Bullet track passes through the ventricle from one hemisphere to the other Severe Traumatic Brain Injury with GCS 3 with fixed and dilated pupils after return of circulation with MAP> 65 or radiographic and clinical evidence of brainstem injury with fixed and dilated pupils in the absence of hydrocephalus Spinal Cord Injury: Atlanto-occipital dislocation with brainstem hemorrhage
      Catastrophic irreversible neurologic injury	Anoxic brain injury clearly present at time of presentation Catastrophic ischemic stroke at time of presentation with HIAT-2 score 8-10 Catastrophic ischemic stroke at 24-hour re-evaluation with mortality > 90% based on nomogram below Ischemic stroke with left-sided (dominant) hemispheric stroke in complete MCA distribution or right-sided hemispheric stroke in complete MCA distribution with age > 80 Brainstem infarcts that would result in locked-in syndrome Catastrophic status epilepticus due to one of the irreversible brain injuries listed in Table 2 · Catastrophic status epilepticus after 72h without response to therapy will be considered a form of irreversible brain injury but not considered at time of presentation Intracranial hemorrhage > 100 cc in any hemisphere, Brainstem hemorrhage > 2 cm or cerebellar hemorrhage with loss of brainstem reflexes Ruptured aneurysm in patient with Hunt-Hess score of 5 whose exam cannot be explained by reversible factors (seizure, hydrocephalus, or medication)

      Table 3: SOFA Score - If there is more than one value for an organ system generated during a 24-hour period, the highest value is used to calculate the SOFA score
      

      Variable	0	1	2	3	4
      PaO2/FiO2 mmHg	>400	≤400	≤300	≤200	≤100
      Platelets, x 103/µL (x 106/L)	>150 (>150)	≤150 (≤150)	≤100 (≤100)	≤50 (≤50)	≤20 (≤20)
      Bilirubin, mg/dL (µmol/L)	<1.2 (<20)	1.2-1.9 (20 – 32)	2.0-5.9 (33 – 100)	6.0-11.9 (101 – 203)	>12 (> 203)
      Hypotension	None	MABP < 70 mmHg	Dop ≤5	Dop > 5, Epi ≤0.1, Norepi ≤0.1	Dop > 15, Epi > 0.1, Norepi >0.1
      Glasgow Coma Score (GCS) *	15	13 – 14	10 - 12	6 - 9	<6
      Creatinine, mg/dL (µmol/L)	< 1.2 (<106)	1.2-1.9 (106 – 168)	2.0-3.4 (169 - 300)	3.5–4.9 (301 – 433)	>5 (> 434)

      Sequential Organ Failure Assessment (SOFA) score SOFA Scale
      Dopamine [Dop], epinephrine [Epi], norepinephrine [Norepi] doses in ug/kg/min SI units in brackets
      Adapted from: Ferreira FI, Bota DP, Bross A, Melot C, Vincent JL. Serial Evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 2001; 286(14): 1754-1758.
      *GCS should not add points to the SOFA score when a patient cannot articulate intelligible words, even if this condition is due to a pre-existing speech disability or chronic ventilation. Clinicians should use clinical judgement to adjust SOFA scores downward where appropriate to account for chronic baseline levels of physiological functional impairment not caused by COVID-19, including for any temporary elevation of a score of score element caused by any patient disability to access a regularly used stabilizing device or treatment (such as CPAP or BiPAP unit, dialysis, or specific medications).

      Table 4: The mSOFA score eliminates the need for the platelet count, replaces bilirubin measurement with physical presence or absence of jaundice or scleral icterus, and allows for the peripheral oxygen saturation to be measured instead of the PaO2.

      Modified Sequential Organ Failure Assessment (MSOFA) Score

      Organ System	0	1	2	3	4
      Respiratory SpO2/FiO2	>400	≤400	≤315	≤235	≤150
      Liver	No scleral icterus or jaundice			Scleral icterus or jaundice
      Cardiovascular, hypotension	No hypotension	MAP <70 mm Hg	dopamine≤5 or dobutamine any dose	dopamine>5 epinephrine≤0.1 norepinephrine≤0.1	dopamine>15 epinephrine>0.1 norepinephrine>0.1
      CNS, Glassglow Coma Score	15	13-14	10-12	6-9	<6
      Renal, Creatinine mg/dL	<1.2	1.2-1.9	2.0-3.4	3.5-4.9	>5.0

      MAP=mean arterial pressure

      dopamine, dobutamine, epinephrine, and norepinephrine doses in micrograms per kilogram per minute

      CNS=central nervous system

      Table 5

      Comparison of the SOFA and M-SOFA Scores

      Organ System	SOFA score	MSOFA score
      Respiratory	PaO2/FIO2 ratio	SpO2/FIO2 ratio
      Coagulation	Platelet Count x 103/µL	Not Scored
      Liver	Biliburin level, mg/dL	Scleral icterus or jaundice
      Cardiovascular	Hypotension or vasopressors	Same as SOFA score
      Central Nervous System (CNS)	Glasglow Coma Score (CGS)	Same as SOFA score
      Renal	Creatinine mg/dl or urine output	Same as SOFA score

      PaO2/FIO2 ratio: partial pressure of arterial oxygen divided by the fraction of inspired oxygen

      SpO2/FIO2 ratio: arterial oxygen saturation measured by a pulse oximeter divided by the fraction of inspired oxygen

      Table 6

      Principle	Specification	Priority Group*
      		1	2	3	4
      Current Overall Clinical Status	Prognosis for acute survival (SOFA score, mSOFA, or other severity of illness score#)	SOFA score < 6 Or mSOFA<6	SOFA score 6-8 Or mSOFA 6-8	SOFA score 9-11 Or mSOFA 9-11	SOFA score ≥12 Or mSOFA ≥12

      Resolving “Ties” Between Patients with the Same Disease Severity Score

      A “tie” can occur if there are not enough resources for patients who have been given the same SOFA or mSOFA score during prioritization. In the event of a tie, priority may be given to patients without severe life-limiting comorbidities. Comorbid conditions should only be considered if the condition will impact near-term survival. The following conditions are listed in the California Crisis Care Guidelines as examples of severe life-limiting conditions:

      • Minimally conscious or unresponsive wakeful state from prior neurologic injury
      • American College of Cardiology / American Heart Association Stage D heart failure
      • World Health Organization Class 4 pulmonary hypertension
      • Severe chronic lung disease with FEF1 < 20% predicted, FVC < 35% predicted
      • Cirrhosis with a model for end-stage liver disease score > 20
      • Metatstatic cancer with expected survival < 6 months despite treatment

      Refractory hematologic malignancy (resistant or progressive despite conventional initial therapy)

      If the “tie” is not resolved by consideration of severe comorbidities, a lottery (i.e. random allocation) should be used to break the tie.

      Reassessment and Reallocation of Scarce Resources

      After initiation and/or allocation of treatment, patients should receive a time limited trial of therapy that is determined by the natural history of the disease and the physician’s clinical interpretation of the trajectory of the patient’s clinical course. Trial duration of therapy should be defined as early as possible and adjusted as data about the particular disease state emerges. Patients receiving scarce resources, such as ICU care or mechanical ventilation, who experience significant clinical decline at the end of the trial period may have the resource withdrawn after notification of the patient and/or family. Reassessment and re-allotment may occur prior to the end of the trial period if the patient sustains a rapid and substantial decline in their condition such that their risk of mortality is significantly increased. The reassessment process should occur by the following steps:

      1. Patients will be periodically assessed during the course of their treatment at pre-determined times. During re-assessment, the patient’s disease severity score will be re-calculated and the patient placed in the appropriate prioritization group.
      2. If the patient’s prioritization score indicates removal of the scarce resource, the RTT will promptly notify the attending physician of the decision.
      3. The patient and/or the patient’s agent/surrogate will be notified of the decision.
      4. The scarce resource will be withdrawn and clinically indicated alternative forms of intervention will be provided.

      Notification of decision

      The Crisis Care Guidelines will be available to interested parties.  After assessment or reassessments decisions are made the RTT and treating physicians will communicate to the patient’s family or designated party the outcome.

   5. Appeals Process for RTT Decisions

      If a patients’ family or clinician challenges a triage decision, the patient’s family or clinician should be able to appeal the decision of the RTT 

      1. The appeal will need to be addressed in real time.
      2. For the initial triage decision (i.e., initiation of ventilation), the only permissible appeals are those based on a claim that an error was made by the RTT in the calculation of the priority score.
      • The RTT will verify the accuracy of the priority score by recalculating it.
      • The RTT designee or treating physician should be prepared to explain the calculation upon patient’s or family’s request.
      3. For the withdrawal of existing mechanical ventilation from a patient who is already receiving it, elements of this appeal process could include:
      • The individuals appealing the triage decision should explain to RTT the grounds for their appeal. Appeals based on objection to the overall allocation framework may not be granted.
      • The RTT should explain the basis for their triage decision.
      • Appeals based on considerations other than disagreement with the allocation framework should immediately be brought to a committee that is independent of the RTT and of the patient’s care team (Resource Triage Committee).
      • The appeals process must occur quickly enough that the appeals process does not harm patients who are in the queue for scarce critical care resources currently being used by the patient who is the subject of the appeal.
      • The decision of the Resource Triage Committee will be final.
      • Periodically, the Resource Triage Committee should retrospectively evaluate whether the review process is consistent with effective, fair, and timely application of the allocation framework.
4. Crisis Care should be suspended immediately once critical resources are no longer scarce.

REFERENCES

1. Portions of this document was developed by Sara B. Edwards, Grace Oei, Arnold Tabuenca, and Raul Coimbra of Riverside University Health Systems medical Center.  We are deeply appreciative for use of their materials.
2. Berlinger N, Wynia M, Powell T, et al. Ethical Framework for Health Care Institutions & Guidelines for Institutional Ethics Services Responding to the Coronavirus Pandemic. The Hastings Center. March 2020. https://www.thehastingscenter.org/ethicalframeworkcovid19/
3. Christian MD, Devereaux AV, Dichter JR, et al. Introduction and executive summary: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014;146:8S-34S.
4. California SARS-CoV-2 Pandemic Crisis Care Guidelines. California Department of Public Health. June 2020. https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/COVID-19/California%20SARS-CoV-2%20Crisis%20Care%20Guidelines%20-June%208%202020.pdf
5. Devereaux AV, Dichter JR, Christian MD, et al. Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. Chest 2008;133:51S-66S.
6. Disaster Management and Emergency Preparedness Course. American College of Surgeons Committee on Trauma Disaster Subcommittee. Second Edition, 2016
7. Grissom CK, Brown SM, Kuttler KG, et al. A modified sequential organ failure assessment score for critical care triage. Disaster Med Public Health Prep 2010;4:277-84.
8. Hick, J. L., D. Hanfling, M. K. Wynia, and A. T. Pavia. 2020. Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2. NAM Perspectives.Discussion paper. National Academy of Medicine. Washington, DC. https://doi.org/10.31478/202003b
9. Khan Z. et.al. An assessment of the validity of SOFA score based on triage H1N1 critically ill patients during an influenza pandemic. Anaesthesia. 2009; 64. 1283-1288.
10. Maves RC, Downar J, Dichter JR, et al. Triage of Scarce Critical Care Resources in COVID-19 An Implementation Guide for Regional Allocation: An Expert Panel Report of the Task Force for Mass Critical Care and the American College of Chest Physicians. Chest 2020;158:212-25.
11. New York State Task Force on Life and the Law and New York State Department of Health. Ventilator allocation guidelines. November 2015. https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf.
12. University of Pittsburgh: Allocation of Scarce Critical Care Resources During a Public Health Emergency. March 2020. https://ccm.pitt.edu/sites/default/files/UnivPittsburgh_ModelHospitalResourcePolicy_2020_04_15.pdf
13. Ventilator Document Workgroup, Ethics Subcommittee of the Advisory Committee to the Director, CDC. Ethical Considerations for Decision Making Regarding Allocation of Mechanical Ventilators during a Severe Influenza Pandemic and other Public Health Emergency. July 2011. https://www.cdc.gov/about/advisory/pdf/VentDocument_Release.pdf
14. QxMD Software Inc. Calculate by QxMD. ©2020 QxMD Software Inc, December 2020. Version 8.12.0. qxmd.com, https://apps.apple.com/us/app/read-by-qxmd/id574041839
15. United States, Congress, State of California—Health and Human Services Agency, and Sonia Y. Angell. California SARS-CoV-2 Pandemic Crisis Care Guidelines, California Department of Public Health, 6AD, pp. 1–40.
16. White, Douglas B. “A Model Hospital Policy for Allocating Scarce Critical Care Resources: Available Online Now.” Department of Critical Care Medicine, University of Pittsburgh, 3 Apr. 2020, ccm.pitt.edu/?q=content%2Fmodel-hospital-policy-allocating-scarce-critical-care-resources-available-online-now.

    Initiated:          1/6/2021

    Reviewed:      

    Approved: