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In response to COVID-19, many states revised, developed, or attempted to develop plans to allocate scarce critical care resources in the event that crisis standards of care were triggered. To our knowledge, no prior analysis has assessed this plan development process, including whether plans were successfully adopted. How did states develop or revise scarce resource allocation plans during the COVID-19 pandemic, and what were the barriers and facilitators to their development and adoption at the state level? Plan authors and state leaders completed a semistructured interview February to September 2022. Interview transcripts were qualitatively analyzed for themes related to plan development and adoption according to the principles of grounded theory. Thirty-six participants from 34 states completed an interview, from states distributed across all US regions. Among participants' states with plans that existed prior to 2020 (n = 24), 17 were revised and adopted in response to COVID-19. Six states wrote a plan de novo , with the remaining states failing to develop or adopt a plan. Thirteen states continued to revise their plans in response to disability or aging bias complaints or to respond to evolving needs. Many participants expressed that urgency in the early days of the pandemic prevented an ideal development process. Facilitators of successful plan development and adoption include: coordination or support from the state department of health and existing relationships with key community partners, including aging and disability rights groups and minoritized communities. Barriers include: lack of perceived political will to adopt a plan and development during a public health emergency. To avoid repeating mistakes from the early days of the COVID-19 response, states should develop or revise plans with community engagement and consider maintaining a standing committee with diverse membership and content expertise to periodically review plans and advise state officials on pandemic preparedness. [ABSTRACT FROM AUTHOR]

This article examines the use of nonconventional ventilators (NCVs) during the early days of the COVID-19 pandemic in New York. The study found that patients ventilated exclusively with NCVs had higher mortality rates compared to those using conventional ventilators. However, the study has limitations, such as the absence of emergent viral variants, evidence-based therapies, vaccination, and immunity in the population studied. The article also discusses the challenges of conducting research on nonstandard therapies during public health emergencies and suggests adaptive platform trials as a potential solution. Additionally, the text mentions the shortage of intensivists in ICUs and the increasing role of advanced practice providers in critical care. [Extracted from the article]

A priority system has traditionally been the protocol of choice for the allocation of scarce life-saving resources during public health emergencies. COVID-19 revealed the limitations of this allocation rule. Many argue that priority systems abandon ethical values, such as equity, by discriminating against disadvantaged communities. We show that a restrictive feature of the traditional priority system largely drives these limitations. Following minimalist market design, an institution design paradigm that integrates research and policy efforts, we formulate pandemic allocation of scarce life-saving resources as a new application of market design. Interfering only with the restrictive feature of the priority system to address its shortcomings, we formulate a reserve system as an alternative allocation rule. Our theoretical analysis develops a general theory of reserve design. We relate our analysis to debates during COVID-19 and describe the impact of our paper on policy and practice. This paper was accepted by Axel Ockenfels, behavioral economics and decision analysis. [ABSTRACT FROM AUTHOR]

When health professionals experience moral distress during routine clinical practice, they are challenged to maintain integrity through conscientious practice guided by ethical principles and virtues that promote the dignity of all human beings who need care. Their integrity also needs preservation during a crisis like the COVID-19 pandemic, especially when faced with triage protocols that allocate scarce resources. Although a crisis may change our ability to provide life-saving treatment to all who need it, a crisis should not change the ethical values that should always be guiding clinical care. Enduring ethical commitments should encourage clinicians to base treatment decisions on the medical needs of individual patients. This approach contrasts with utilitarian attempts to maximize selected aggregate outcomes by using scoring systems that use short-term and possibly long-term prognostic estimates to discriminate between patients and thereby treat them unequally in terms of their eligibility for life-sustaining treatment. During times of crisis and calm, moral communication allows clinicians to exercise moral agency and advocate for their individual patients, thereby demonstrating conscientious practice and resisting influences that may contribute to compartmentalization, moral injury, and burnout. [ABSTRACT FROM AUTHOR]

Background: Reports of poor outcomes among older adults with COVID-19 may have changed patient perceptions of Do-Not-Resuscitate (DNR) orders or caused providers to pressure older adults into accepting DNR orders to conserve resources. Objective: We determined early-DNR utilization during COVID-19 surges compared with nonsurge periods among nonsurgical adults ≥75 and its connection to hospital mortality. Methods: We conducted a retrospective cohort study among adults ≥75 years using the California Patient Discharge Database 2020. The primary outcome was early-DNR utilization. Control cohorts included nonsurgical adults <75 years in 2020 and nonsurgical adults ≥75 in 2019. Multiple causal inference methods were used to address measured and unmeasured confounding. Results: A total of 487,955 adults ≥75 years were identified, with 233,678 admitted during COVID-19 surges. Older adults admitted during surges had higher rates of early-DNR orders (30.1% vs. 29.4%, absolute risk differences = 0.7, 95% confidence interval [CI]: 0.5–1.0) even after adjusting for patient case-mix (adjusted odds ratio [aOR] = 1.02, 95% CI: 1.01–1.04). Patients with early-DNR orders experienced higher hospital mortality (15.5% vs. 4.8%, aOR = 3.96, 95% CI: 3.85–4.06). Difference-in-difference analyses demonstrated that adults <75 years in 2020 and adults ≥75 years in 2019 did not experience variation in early-DNR utilization. Conclusions: Older adults had slightly higher rates of early-DNR orders during COVID-19 surges compared with nonsurge periods. While the difference in early-DNR utilization was small, it was linked to higher odds of death. The increase in early-DNR use only during COVID-19 surges and only among older adults may reflect changes in patient preferences or increased pressure on older adults stemming from provider fears of rationing during COVID-19 surges. [ABSTRACT FROM AUTHOR]

Ethical dilemmas exist with decision-making regarding resource allocations, such as critical care, ventilators and other critical equipment, and pharmaceuticals during pandemics. Triage artificial intelligence (AI) algorithms based on prognostication tools exist to guide these decisions; however, implicit bias may affect the decision-making process leading to deviation from the algorithm recommendations. Conflict within the ethical domain may be affected as well. A knowledge gap was identified within the Adult-Gerontology Acute Care Nurse Practitioner (AG-ACNP) curriculum regarding ethics in crisis standards of care (CSC) medical decision-making. Incorporating a CSC simulation looked to address this knowledge gap. A simulation-based learning (SBL) experience was designed as a critical access setting where CSC are in place and three diverse, medically complex patients in need of critical care present to the hospital where one critical care bed remains open. Given the complexity of the simulation scenario, a table-top pilot test was selected. Three AG-ACNP fourthquarter students in their critical care rotation volunteered for the pilot test. Students were provided with the topic, "ethics crisis standards of care" and the article, "A catalogue of tools and variables from crisis and routine care to support decision-making during pandemics" by M. Cardona et al. (2021), to read in advance. Students were provided with the triage AI algorithm (M. Cardona et al., 2021) utilizing prognostication tools to prioritize which patient requires the critical care bed. The expectationwas that implicit biaswould enter the decision-making process, causing deviation from the triage AI algorithm and moral distress. The debriefing session revealed that students deviated from the triage AI algorithm, experienced implicit bias, moral distress, and utilized clinical judgment and experience to care for all three patients. The pilot test results support that a CSC SBL experience addresses a critical knowledge gap in AG-ACNP education and an SBL experience incorporating ethical decision-making curriculum with standardized patients should be developed and trialed as the next step. [ABSTRACT FROM AUTHOR]

Background: The number of disasters occurring globally is increasing. Natural hazards, changing geopolitical situations, and increasing population densities may lead to an increased likelihood of a surge of patients requiring health care, some of whom might be requiring intensive care-level treatment. There is a dearth of literature on intensive care unit (ICU) practitioner's priorities regarding disaster preparedness and crisis standards of care., Objectives: This study aimed to understand what nurses working in ICUs within Australia prioritise regarding ICU disaster preparedness and the implementation of crisis standards of care., Methods: A modified three-round Delphi design was used for this study. A snowballing recruitment method facilitated the purposive sampling of ICU nurses, starting with members of the Australian College of Critical Care Nurses. Eligible participants were asked to rate statements according to their priorities when addressing disaster preparedness of the Australian ICU in which they work. Statements that achieved the 10 highest scores in the final round were tabulated to indicate the broader areas of disaster preparedness that the respondents considered priorities., Results: A total of 16 participants completed both round two and round three of this Delphi study. Out of 38 statements across six domains, 33 statements achieved consensus. Healthcare practitioner protection, wellbeing, and the management of space populated the top 10 priorities. These priorities included adequate personal protection equipment, services to support healthcare practitioners, and clear communication and debriefing pathways. Another key priority identified was the need for a clear plan on how the ICU footprint will expand to accommodate a surge of patients., Conclusion: Healthcare practitioner wellbeing followed by adequate plans for ICU expansion are key priorities of nursing staff working in ICUs within Australia. Understanding the priorities of those who work in the ICU gives a pragmatic insight into what is required to further develop the disaster preparedness of Australian ICUs., Competing Interests: Declaration of competing interests The authors have none to declare., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Disasters have the potential to cause a surge of patients, some of which may require admission to an intensive care unit. Due to the high resource requirements of intensive care units, standards of care may need to be altered during a disaster to treat more people with limited resources, a care model referred to as 'crisis standards of care'. The aim of this scoping review was to explore the practical considerations of implementing crisis standards of care in intensive care units during patient surges resulting from disasters. Guided by the Joanna Briggs Institute methodology, most of the 19 studies included in this review were qualitative in design, undertaken in developed countries and focused on COVID-19. Adequate space, human resources, and physical resources were required for standard patient care in ICUs. When unbalanced, contingency measures or crisis standards of care were implemented, and adjustment to ICU governance was required. During times of crisis standards of care implementation, healthcare practitioner wellbeing was impacted. Continued efforts to support the ICU workforce before, during and after a disaster are warranted. • Adequate space, human resources and physical resources are required for ICU care. • In a crisis, ICU governance adjustments support challenging and complex decisions. • During times of crisis, healthcare practitioner wellbeing can be impacted. • Continued efforts to support the ICU workforce throughout a disaster are needed. [ABSTRACT FROM AUTHOR]

Children make up approximately 25% of the population in the United States and are particularly vulnerable to the impact of disasters. The creation of federally-funded programs and advisory committees has had a positive impact on addressing the needs of children and families in disasters by identifying best practices, disseminating information, identifying gaps, and providing information with future investments that will contribute to expanding disaster science for children and their families., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)