Surge may spark ‘rationed’ care

If 90% of icu beds are in use, triage system is an option

IMAGE/WASHOE COUNTY: The area's COVID-19 Threat Meter is just a click away from the severe level of virus cases.

If the region’s intensive care hospital beds reach 90% occupancy over the holidays, a “scoring” system to determine which COVID-19 patients get what kind of treatment is ready to be activated.

“We’re in a process where these systems are in place, but I’m not saying that (rationing care) is being done now,” said Dr. John Hess, a family physician at Saint Mary’s Health Network Reno. He said if cases and hospital capacity continue to surge in the coming weeks and patients stack up beyond the system’s ability to handle them, hospitals would have to use triage protocols.

“Fortunately we didn’t see a massive spike after Thanksgiving and I think that’s because people listened,” he said.

Sharp spike in cases feared

Hess, other local doctors and Reno city officials spoke at a media briefing Dec. 22. They said half of all patients in local ICU beds were being treated for the virus and the current COVID-19 surge in cases is predicted to continue. On Dec. 21, when hospital capacity was at 85%, an additional 238 virus cases and eight more related deaths were reported in Washoe County.

UPDATE: By Dec. 29, hospital capacity had dropped to 80%. On that date, there were 14,086 active cases in Washoe County and a total of 460 deaths since March. December has been the county’s deadliest month of the pandemic and officials said the county’s “threat meter,” in the image above, will probably remain in the “red” zone at year’s end.

If the surge continues to build in January and hospitals are overwhelmed, the tiered scoring system could be used to make treatment decisions.

The scoring protocol is now being used as an assessment method for all patients, not just those who have tested positive for the virus that causes COVID-19. The next step would be to use those scores as a means of ranking patients in order to make decisions about treatment, Hess said.

A critical time for precautions

Speakers at the media briefing implored residents to observe the pandemic restrictions, including remaining at home whenever possible, avoiding gathering with people outside of one’s own household, frequently washing hands and wearing masks, as well as maintaining social distancing in public. Predictive models indicate the first weeks of the new year may herald a worse spike in infections.

PHOTO/FRANK X. MULLEN: Renown Regional Medical Center set up 700 beds as an overflow area on one floor of its parking structure in November and has the capacity to add another 700 patient stations if needed. Hundreds of patients have used the facility since then.

“We were at a very high positivity rate for weeks and we saw some improvement last week, but now we’re right back up there,” said Reno Councilwoman Naomi Duerr. She noted that the area’s COVID-19 risk meter is in the red zone “and just a tick away from the purple (severe level).” The ICU bed occupancy rates also are high and doctors, nurses and other hospital staff members are exhausted, she said.

“They need to rest,” Duerr said. “They’ve performed extremely well, but they are running out of gas and they need to refuel.”

‘Scores’ access mortality risk

Hess said a procedure called SOFA (Sequential Organ Failure Assessment Score) would be used as a means of rationing care if hospitals become overwhelmed. It’s an alternative to treating patients on a simple first-come, first-served basis when staffing is inadequate, and ICU beds, ventilators and other critical-care equipment are in short supply.

SOFA is based on an assessment of patients’ organ dysfunction and potential for life-ending organ failure. That system assigns points to such factors as a patient’s vital signs, laboratory reports and other clinical information. If all local hospitals can’t cope with a massive increase in patients, decisions about what kind of care a patient receives would then be made by a panel of three doctors assigned to analyze the data. The method doesn’t take identities, demographics or other variables into consideration and “is objective and unbiased,” Hess said.

Emergency triage plans weren’t generally necessary in the first wave of U.S. COVID-19 cases in the spring and summer. But health care systems all around the country have SOFA and similar triage protocols in place in case the spread of the contagion outpaces health care facilities’ ability to keep up with the demand for intensive care.

A ‘battlefield situation’

Those policies have sparked new conversations among bioethicists about the use of such protocols and whether other indicators, such as patients’ ages, their likelihood or survival if they receive the care that is in short supply, the ongoing trajectory of the patients’ conditions and other factors also should be part of assessments. In addition, some experts question whether the use of such triage plans is a valid option in pandemics, according to several medical journal articles.

One consensus: rationing care for critical patients is an option that no one wants to use.

“It’s a battlefield situation,” Hess said. “We need to be prepared in the event (capacity) tips over if this (COVID-19 case) surge continues.” He said the specter of an overwhelming wave of cases is particularly worrisome during the holiday season, when people want to gather with relatives and friends.

Reno Mayor Hillary Schieve said the arrival of the vaccine has given Nevadans a ray of hope after months of bad news, but she urged people not to let their guards down over the holidays. “People are tired,” she noted, but social distancing, wearing masks and other precautions must continue to avoid a disastrous surge.

 Some patients delay care

Dr. Bayo K. Curry-Winchell, of Saint Mary’s Health Network, said patients often aren’t sure when to seek urgent care. During the pandemic, patients have been advised to avoid going to hospital emergency departments and urgent care facilities unless they are having severe symptoms.

We’ve had some patients who were delaying care. At the beginning of the pandemic, patients would come in and seek care (when they had symptoms). Now, there is so much fear and anxiety about seeking care, coming into contact with COVID patients, and contracting the virus.”

— Dr. Bayo Curry-Winchell, of Saint Mary’s Health Network.

Lately, she said, some patients have waited until symptoms have gotten critical before seeking help. Some of them are immediately transferred to a hospital. She said one of her recent patients told her she feared getting the virus in a hospital if she didn’t already have it. In addition, that patient was concerned about whether anyone could visit her if she was admitted to a facility.

‘Will I walk out?’

 “And the third thing she was worried about was just heart-breaking,” Curry-Winchell said. “She asked ‘if I go in to the hospital, will I walk out?’”

Dr. Bayo K. Curry-Winchell,

 Curry-Winchell said a decision about whether to go to an urgent care facility should be made based on the patient’s assessment of their medical history and current symptoms.

“It’s a little different for everybody,” she said. “If you have co-morbidities such as hypertension or COPD, that really elevates when you should actually seek care.” Severe symptoms include “if you have a fever that’s not responding to Tylenol or ibuprofen,” extreme fatigue, such as “not being able to walk from your bedroom to your front door,” or a complete loss of appetite. Those are indications that people should seek care as soon as possible, she said.

Accessing pre-existing conditions

Fingertip pulse oximeter

Hess agreed that underlying medical conditions should always be a factor in deciding whether to go to a care facility. He said people older than 65 with underlying health conditions should seek care if they think they may have the virus.

Shortness of breath also is a red flag. People who have an oximeter meter should get to an urgent care facility if their oxygen levels drop below 92 or “certainly if their oxygen level goes to 90” or below, Hess said. A fingertip pulse/oximeter, which usually costs less than $20, is “certainly a good thing to have,” he said, because it may be hard for patients to determine when their oxygen levels become critical.

Shortness of breath

“Shortness of breath is a critical symptom no matter what your age,” Hess said. “If you are having trouble breathing, you should get to a hospital.”

In addition, he said, people who have tested positive, but aren’t exhibiting symptoms, or folks experiencing mild symptoms should stay away from other people. He mentioned an example of a Reno business owner who felt sick but kept going to work. Several employees of his business contracted COVID-19, he said.

“If you are sick, you need to stay home,” Hess said.

NOTE: This story was updated on Dec. 29 with the most recent COVID-19 totals.

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