Colorado officials set guidelines for prioritizing patient care in case of coronavirus surge

Colorado health officials agreed on guidelines to determine how health care resources should be allocated if hospitals see supply and equipment shortages during a surge of coronavirus patients.

Colorado’s cases of COVID-19 are expected to peak in the coming weeks, and the guidelines, adopted during a Sunday meeting of the Governor’s Expert Emergency Epidemic Response Committee, are intended to ensure fairness and equity among patients by setting objective statewide standards for care.

The crisis standards set up a four-tier system for health care institutions in deciding who receives care and who doesn’t during a shortage.

“We hope we don’t have to use these crisis of care standards, but the truth is with COVID-19 and how quickly it has been spreading, it could quickly overwhelm the hospital system and ICU beds and ventilators,” Jill Hunsaker Ryan, executive director of the Colorado Department of Public Health and Environment, said during Sunday’s remote meeting.

Under the guidelines, patients would first be assigned an objective score based on the severity of their condition and their likelihood of survival, according to a draft of the guidelines shown during Sunday’s remote meeting. Those with the lowest scores would have top priority for receiving critical care.

If two patients have the same score but care is only available for one, then the process moves to the second step, which gives priority to children, health care workers and first responders. If patients are still tied, then the third tier kicks in, which gives priority to pregnant women, considers the number of life years that could be saved and prioritizes patients who are the sole caregiver to children or others.

If patients make it through those three tiers without one receiving clear priority over the other, then the final step is to hold a random lottery to determine who should receive the care, according to the draft document, which was finalized during Sunday’s meeting. A complete copy of the standards was not immediately available.

The updated standards have not been activated, but could be if hospital beds fill up and the health care system is overwhelmed.

Anyone excluded from the priority care would still receive the best possible care within the triage standards, the document stated.

“This is an organized umbrella approach to try to make this fair across the board,” said Dr. Stephen Cantrill, an emergency medicine doctor and committee member. “Otherwise, you have individual providers making the game up as they go along, without having to think quietly about it. That’s the major reason to do it.”

The comprehensive 22-page document, of which only parts were shown publicly during Sunday’s meeting, prohibited health care workers from making decisions about care based on gender, sexual orientation, race, religion and other non-health related factors. The draft document also says decisions should not be made based on a person’s status or position.

“It becomes a very slippery slope,” Cantrill said in response to a question about whether certain people, like Gov. Jared Polis, should receive priority. “Where do you draw the line? We thought it was cleaner to say none.”

The standards also determine that the triage decisions should be made by a triage team that is separate from the medical team providing bedside care to the patient, and creates a framework for removing a ventilator from one patient who is not improving to give it to a patient with a higher likelihood of survival.

The committee also considered and passed crisis standards for personal protective equipment and for emergency medical services.

Despite the grim considerations discussed by the 19-member committee Sunday, Rachel Herlihy, the state epidemiologist for the Department of Public Health and Environment, offered some positive news to the group as well.

Colorado has seen an approximate 40% reduction in the transmission of COVID-19 as a result of the state’s early social distancing measures, like the prohibition of large gatherings, the closing of dine-in service at bars and restaurants, and school closures, she said.

The effect of the statewide stay-at-home order has not yet been reflected in that reduction, she said, and should slow the spread even further. The effect of the stay-at-home order will likely be identifiable by mid-week, Herlihy said.

“We are seeing a flattened curve here in Colorado,” she said. “But the question is still out about whether it is flat enough.”

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