Crisis Standards of Care: Lessons from New York City Hospitals’ COVID-19 Experience

New York City suffered an unprecedented surge of novel coronavirus disease 2019 (COVID-19) patients from April to June 2020 associated with extraordinary use of critical care resources and high case fatality ratios. Hospitals were overwhelmed and conventional standards of care were unable to be maintained, forcing hospitals and healthcare workers to adjust the way that care was provided in order to do the most good for the greatest number.

The purpose of this project was to convene a forum in which critical care physicians from a number of hospitals across New York City could frankly discuss their experiences with implementation of crisis standards of care (CSC). The Johns Hopkins Center for Health Security, in collaboration with New York City Health + Hospitals, convened a virtual working group in October 2020 consisting of 15 New York City intensive care unit (ICU) directors. The following major themes emerged from the discussion:

• Prepandemic CSC planning did not always align with the realities and clinical needs of the pandemic as it unfolded.
• The COVID-19 surge response was effective but often chaotic.
• Interhospital collaboration was an effective adaptive response.
• Situational awareness, especially related to information about patient load and resource availability, was a challenge for many clinicians.
• Multiple CSC challenges had to be overcome, especially around decision making for triage or allocation of life-sustaining care.
• Healthcare workers were profoundly psychologically affected by dealing with CSC issues amid the extraordinary surge.

Looking ahead, the following themes and suggestions were expressed:

• Going forward, there was a sense that CSC planning needs to be more operational and that clinicians need to be more involved.
• Clinicians must be taught that CSC fundamentally involves making the best decision one can when in an unfamiliar situation that involves risk to the patient or provider; such decisions are not limited simply to ventilator triage or other formal triage processes.
• More research is needed to understand what future guidance for CSC planning is needed. Discussions between clinicians and their legal advisors are needed in the planning process to resolve differences in understanding of what is and is not legal in the CSC context.
• In a crisis, a clear formal declaration that a CSC context exists at the hospital, hospital system, healthcare coalition, and jurisdictional levels is needed. This should include specific clinical guidance about the scope of the declaration—that is, which resources or processes it applies to and which it does not. CSC plans must factor in that a formal declaration from the state may not be made in time, and plans must be made for how to proceed without it.  ...
• ...