CHALLENGES AND OBJECTIVES

1. 1. Establish a county-wide mechanism for shared resource allocation, multi-stakeholder vetting, and a communication process for the establishment of Crisis Care.

2. 2. Rapidly educate local, community, and hospital systems about the steps necessary for a systematic process to those unfamiliar with the prior Institute of Medicine/National Academies (IOM/NAM) or state frameworks.⁶

3. 3. Complete the above in an abbreviated timeframe (ie, several weeks) during an environment of rapid regulatory change and evolving science surrounding COVID-19.

4. 4. Communicate virtually due to COVID-19 isolation restrictions.

5. 5. Create Triage Teams and provide training tools for hospital systems.

TIMELINE

On March 11, 2020, when the World Health Organization (WHO) declared COVID-19 a pandemic and due to the accelerating concerns witnessed around the world, the San Diego County Medical Society and the San Diego Bioethics Commission engaged the County health officials regarding plans for the potential allocation of scarce resources during a surge of patients (Figure 1). By mid-March, it was determined that practical guidance from the federal government was unlikely, and that solutions and authority would need to be developed locally with community resources and values considered. The global scarcity of personal protective equipment (PPE) for health-care workers and limited severe acute respiratory coronavirus 2 (SARS-CoV-2) testing triggered conservation strategies in San Diego and served to highlight the need for Crisis Care preparedness. Therefore, various local leaders and San Diego-based experts from the Taskforce for Mass Critical Care partnered to draft a Community Standard of Care Consensus document for Crisis Care during COVID-19.

FIGURE 1 Timeline.

DEVELOPMENT OF HEALTH-CARE COMMUNITY COALITIONS

As originally described by Courtney et al. in 2009, the formation of Health-Care Coalitions is vital to respond to a mass critical care event and share resources in a coordinated manner.^{Reference Courtney, Toner and Waldhorn7} The San Diego area maintains collaborative relationships through health system disaster coordinators and the county; however, intensivists are not commonly involved in regional planning and meeting activities, and few physicians can leave patient care responsibilities to prepare for what may be a “never-event.”^{Reference Hanfling8} This has resulted in a lapse in knowledge of the formation of health-care coalitions, roles, responsibilities and the Incident Command System (ICS). Using some of the updated framework by the American College of Chest Physicians and the Society of Critical Care Medicine, multiple members worked simultaneously to engage various stakeholders.^{Reference Christian, Devereaux and Dichter9-Reference Maves, Downar and Dichter11} Following US national health-care preparedness guidance,^6,12 our approach also included coordination with the regional ICS. The San Diego ICS involves both an Emergency Operations Center (EOC) and a Medical Operations Center (MOC). Once it was determined that the County elected leadership and the Public Health Officer would be the declaration authority if state or federal declaration was absent for Crisis Care, health-care systems’ alignment rapidly formed.

STAKEHOLDERS NECESSARY FOR RAPID REGIONAL COALITIONS

A core group of 4 individuals was able to initiate the framework for coalition and workgroup formation (Figure 2). Organizers ensured representation from all health-care systems throughout the county. This framework includes:

• Administrative support from Regional Public Health/Government Authority

• Leadership from Professional Medical Society representatives

• Engagement of each hospital Chief Medical Officer and Chief Executive Officer during weekly (virtual) meetings and triage team training^{Reference Burkle13,Reference Devereaux, Dichter and Christian14}

• Selection and formation of Intensive Care Unit (ICU), Ethics, Triage, and Extracorporeal Membranous Oxygen (ECMO) workgroups designated by leaders from each hospital system, including the Veteran’s Administration (VA), Kaiser, UC San Diego, and the US Navy

• Formation of a Community Crisis Care Committee. Representing San Diego area’s Pulmonary, Critical Care, Hospitalists, Out-Patient, Emergency, and Pediatric Medicine, Behavioral/Wellness/Mental Health, Community Health Advocates, Clergy, Government, Hospital Administration, SDCMS Leaders, Medicaid, Nursing, Bioethics, Palliative Care, Hospice, Veterans, Homeless, and Legal Services. Several members represented more than 1 sector. This committee met weekly.

FIGURE 2 Organization Chart for Regionalization.

Workgroup and Committee members were solicited by means of email requests to area hospital leaders and disaster experts. Once key members were identified, word rapidly spread regarding the County’s collaborative work and nearly every hospital in the region became engaged. Recommendations from workgroups were discussed with the Crisis Care Committee for feedback regarding fairness and elimination of bias. Throughout this week of planning, teams were informed by, and rapidly adapted to, national and international events as well as evolving ethical debates about scarce resource allocation.¹⁵ There was enthusiastic engagement from all stakeholders who attended videoconferences, frequently lasting over 2 h each. Plans and resource adaptation ideas were freely exchanged among institutions, reflecting the trust provided by leadership authorities toward the workgroups. Mutual trust, transparency, and respect are a necessary requirement for effective coalition development and cannot be understated. During this busy period of activity, short-notice meetings were frequent and at times neglected the hospital ICS (HICS). This early weakness was improved by use of redundant communication and providing advanced notification to workgroup members and executives of meetings.

TRIAGE OF SCARCE RESOURCES—TRIAGE TEAMS

To ensure resources are shared fairly in the setting of scarcity, it is essential that the triage process for patients requiring critical care resources be consistent across all hospital systems, and includes access to relevant subspecialty expertise. The goals of crisis care triage shift the standard practice of individual patient considerations to a broader population-based public health to extend scare critical resources to ensure the survival of the largest possible number of patients. Identifying patients who might need critical care resources and defining their individual risks for mortality become key to maximize the greatest good for the greatest number.^{15-Reference Christian17} The shift to population-based health triage as a concept is only used when a health system’s ability to surge has been maximized and exceeded.

To implement Crisis Care and triage of scarce resources, committee organizers established Triage Teams and created Job Action Sheets within HICS.¹⁸ The following principles were instrumental in the development and formation of Triage Teams.

1. 1. Health-care systems have triage officers with the following qualities: (a) critical care triage training to provide optimum allocation of resources; (b) situational awareness at both a regional and institutional level; (c) experience in care of the patient being triaged; (d) individual triage officers or teams consisting of a senior critical care physician and an acute care (critical care-experienced) physician or nurse be designated to make mass critical care triage decisions in accordance with previously prepared, publicly vetted, and widely disseminated guidelines.

2. 2. A vetted triage protocol (SD Crisis Consensus Care Draft document), rather than clinical judgment alone, will be used.

3. 3. Health-care systems will leverage technology in triage to augment clinical assessment in an effort to improve incremental survival and efficiency of resource allocation.

4. 4. The triage decision process will have an appeals mechanism in case of deviation from an approved process (which may be a prospective or retrospective review) or a clinician request for reevaluation in light of novel or updated clinical information (prospective).

5. 5. Intensivists should leverage telemedicine and other technologies when possible to assist those health-care systems with few or no intensivists to help with triage.

6. 6. There will be legal protections for providers conducting triage in a disaster as well as a psychological support system for triage officers and health-care providers. When legal protection is not possible, providers need to follow acceptable, consensus-based community standards of care pertaining to triage in mass critical care.

7. 7. Intensivists should work within their local and regional health-care system to determine the plan for augmentation of critical care resources to care for as many patients as possible. Resources should be shared across geographic regions to maximize lives saved.

8. 8. Triage is a dynamic process that may change rapidly based on available resources, knowledge of the disease process, patient volume, and acuity.

The biggest challenge in creating a triage algorithm was the substantial gap in the literature as to how to prognosticate accurately regarding COVID-19.^{Reference Fink19} Because triage is designed to be used on all patients, it was, therefore, essential to have subspecialty expert input (eg, from trauma, emergency medicine, neurocritical care, ethics, and medical intensivists) to ensure fairness for all clinical conditions is built into the triage algorithm. Nonstandardization of hospital medical record systems and variable personnel resources created additional challenges in creating a uniform and unbiased triage team. This was overcome by sharing technological solutions, providing written protocols, and training as an entire county system. All San Diego hospitals identified triage personnel that would be on-call, should a crisis level of surge be declared and crisis standard of care triage need to be implemented (Figure 3).

FIGURE 3 Triage Team Development and Education.

SITUATIONAL AWARENESS

To create a system that would permit Triage Teams to share information, decisions, and allocate resources, a transparent dashboard visible to all facilities in the region is required to facilitate real-time decision-making. This provides situational awareness and reduces the moral distress that may be experienced by health-care providers with creating and executing such processes.

The ICU workgroup identified the following areas requiring development:

1. 1. A system to track and report resources in real-time at a countywide level

2. 2. A resource allocation process that is harmonized across multiple hospital systems

3. 3. Harnessing electronic health record systems to facilitate triage scoring

4. 4. Identifying infrastructure for communication regarding this triage process within and across hospital systems

5. 5. Just-in-Time education processes for hospital staff, providers, patients/families, and the public regarding triage

Since March 2020, each hospital has provided data regarding staff, patient census, PPE, and ventilator supply to the County Emergency Medical Services electronic data collection system (Resource Bridge module of Image Trend product). Although each hospital had no visibility of other hospitals’ data, each had seen the aggregate county-wide data during this pandemic and previous surge conditions from influenza and fire seasons. Using the currently available Emergency Medical Services (EMS) data, we created a data workgroup that requested a red-yellow-green display of Staff, Stuff, and Structure to visualize resource capacity. This permits the MOC and Crisis Care Committee Members to determine at a glance if the supply of resources is adequate, or to quickly focus on areas that are low or critically low. Unique to this pandemic, hospital triage officers, CEOs, and CMOs requested to view others’ data, as well as share their own in real time. To achieve the mission, they insisted not only to know the status of their own hospital’s resources, but also to be aware when their neighboring hospital was beginning to run low, so they could prepare to share their own resources.

EDUCATION AND TRAINING

Tabletop exercises are commonly used by emergency management for face to face simulated education of staff roles and responsibilities during disasters. As it pertains to triage education, a tabletop exercise allows the creation of a nonthreatening environment where new triage officers (Figure 3) can rehearse their roles, ask questions, and troubleshoot potential problems with the triage protocol. Unique to COVID-19, hospital leadership and clinicians involved in triage during a pandemic will need just-in-time education and training long before any triage protocol is implemented. It is important to prepare triage officers to understand the rationale and ethical principles in triage, provide training opportunities to implement the triage protocol, and to have a process in place for real-time revision of the protocol as understanding of the disease unfolds. Our education and training was complicated by the need to train triage officers from many different hospitals while maintaining social distancing. Therefore, we used a web-based platform for video and audio conferencing.

In preparing triage officers from area hospitals, San Diego conducted virtual tabletop exercises using Zoom. Our training objectives were to review the regional criteria for transitioning from first-come-first-served patient care to a triage process during crisis standards of care, review the roles and responsibilities of triage officers, practice using the triage protocol in 5 case scenarios, and to use feedback from the case scenarios to further refine the triage protocol. Using Zoom’s virtual break-out rooms, San Diego County successfully conducted tabletop exercises for more than 70 participants at a time, representing all San Diego acute care hospitals and integrated health systems. In addition to a successful training exercise, this permitted the identification of a challenge within the triage protocol, which was able to be remedied through a small modification by the Triage Tool workgroup. The exercises facilitated greater exposure of the triage protocol to the intended audience and resulted in a better instrument.

COMMUNICATION WITH THE PUBLIC AND WITH PATIENTS/FAMILIES

To achieve the ethical responsibility of transparency, a subgroup was formed from the Crisis Care Committee to create a communication plan for the public in the event of scarce resource allocation. The goal of this endeavor was to mitigate fear, encourage continued social distancing, and offer assurance to the public that the county and community was actively involved in planning for contingency and crisis. This subgroup created a handout for distribution to patients/families if admitted to a hospital when Crisis Standards are invoked. In executing the ethical duties of distributive and procedural justice, the goal of this undertaking is to ensure that every person admitted to any hospital in the county will receive the same information and be subject to the same allocation criteria regardless of the particular hospital^{Reference Li-Vollmer20} (see an example in the Appendix). Due to the separation of patients from family members for safety during COVID-19, the challenge of providing information to patients and family members has been considered and will require duplication of staff efforts and multi-media publication efforts.

SUCCESSFUL AND CONTINUED MITIGATION

As a result of the collaborative process in formation of clinical workgroups, hospital systems communication, and working within the SD County Incident Command System, the Crisis Care Committee and health-care coalitions have been able to assist with the initial allocation of remdesivir provided by means of the federal government²¹ and to provide a neighboring county that evacuated over 500 patients with protocols based upon the work done in San Diego. As COVID-19 cases accelerated in Southern California, the ECMO workgroup activated, sharing protocols and agreements. The hospital systems’ coalitions, led by hospital chief medical officers and chief executive officers have now assumed the responsibilities for Crisis Care in San Diego following release of California State guidelines in late June 2020.^{Reference De Jong, Chen and Lo22} The work done by the Crisis Care Committee of San Diego laid the foundation for resource sharing which has mitigated scarce resource situations.