Tragic choices in intensive care during the COVID-19 pandemic: on fairness, consistency and community

Multiregional, multi-industry impacts of fairness on pandemic policies

The health and economic crisis caused by the COVID-19 pandemic highlights the necessity for a deeper understanding and investigation of state- and industry-level mitigation policies. While different control strategies in the early stages, such as lockdowns and school and business closures, have helped decrease the number of infections, these strategies have had an adverse economic impact on businesses and some controversial impacts on social justice. Therefore, optimal timing and scale of closure and reopening strategies are required to prevent both different waves of the pandemic and the negative socioeconomic impact of control strategies. This article proposes a novel multiobjective mixed-integer linear programming formulation, which results in the optimal timing of closure and reopening of states and industries in each. The three objectives being pursued include: (i) the epidemiological impact of the pandemic in terms of the percentage of the infected population; (ii) the social vulnerability index of the pandemic policy based on the vulnerability of communities to getting infected, and for losing their job; and (iii) the economic impact of the pandemic based on the inoperability of industries in each state. The proposed model is implemented on a dataset that includes 50 states, the District of Columbia, and 19 industries in the United States. The Pareto-optimal solutions suggest that for any control decision (state and industry closure or reopening), the economic impact and the epidemiological impact change in the opposite direction.

Rationing scarce healthcare capacity: A study of the ventilator allocation guidelines during the COVID-19 pandemic

In the United States, even though national guidelines for allocating scarce healthcare resources are lacking, 26 states have specific ventilator allocation guidelines to be invoked in case of a shortage. While several states developed their guidelines in response to the recent COVID-19 pandemic, New York State developed these guidelines in 2015 as "pandemic influenza is a foreseeable threat, one that we cannot ignore." The primary objective of this study is to assess the existing procedures and priority rules in place for allocating/rationing scarce ventilator capacity and propose alternative (and improved) priority schemes. We first build machine learning models using inpatient records of COVID-19 patients admitted to New York-Presbyterian/Columbia University Irving Medical Center and an affiliated community health center to predict survival probabilities as well as ventilator length-of-use. Then, we use the resulting point estimators and their uncertainties as inputs for a multiclass priority queueing model with abandonments to assess three priority schemes: (i) SOFA-P (Sequential Organ Failure Assessment based prioritization), which most closely mimics the existing practice by prioritizing patients with sufficiently low SOFA scores; (ii) ISP (incremental survival probability), which assigns priority based on patient-level survival predictions; and (iii) ISP-LU (incremental survival probability per length-of-use), which takes into account survival predictions and resource use duration. Our findings highlight that our proposed priority scheme, ISP-LU, achieves a demonstrable improvement over the other two alternatives. Specifically, the expected number of survivals increases and death risk while waiting for ventilator use decreases. We also show that ISP-LU is a robust priority scheme whose implementation yields a Pareto-improvement over both SOFA-P and ISP in terms of maximizing saved lives after mechanical ventilation while limiting racial disparity in access to the priority queue.

UK Healthcare Workers' Experiences of Major System Change in Elective Surgery During the COVID-19 Pandemic: Reflections on Rapid Service Adaptation

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic disrupted the delivery of elective surgery in the United Kingdom. The majority of planned surgery was cancelled or postponed in March 2020 for the duration of the first wave of the pandemic. We investigated the experiences of staff responsible for delivering rapid changes to surgical services during the first wave of the pandemic in the United Kingdom, with the aim of developing lessons for future major systems change (MSC).

METHODS

Using a rapid qualitative study design, we conducted 25 interviews with frontline surgical staff during the first wave of the pandemic. Framework analysis was used to organise and interpret findings.

RESULTS

Staff discussed positive and negative experiences of rapid service organisation. Clinician-led decision-making, the flexibility of individual staff and teams, and the opportunity to innovate service design were all seen as positive contributors to success in service adaptation. The negative aspects of rapid change were inconsistent guidance from national government and medical bodies, top-down decisions about when to cancel and restart surgery, the challenges of delivering emergency surgical care safely and the complexity of prioritising surgical cases when services re-started.

CONCLUSION

Success in the rapid reorganisation of elective surgical services can be attributed to the flexibility and adaptability of staff. However, there was an absence of involvement of staff in wider system-level pandemic decision-making and competing guidance from national bodies. Involving staff in decisions about the organisation and delivery of MSC is essential for the sustainability of change processes.

[Frequently asked questions (FAQ) in risk communication about COVID-19: creation and significance as an inter-institutional rapid reaction tool]

In der Ergänzung des Nationalen Pandemieplans zur Bewältigung der COVID-19-Pandemie ist festgelegt, dass die Bundeszentrale für gesundheitliche Aufklärung (BZgA) über die Internetseite www.infektionsschutz.de Informationsmaterial zum Coronavirus SARS-CoV‑2 für die Allgemeinbevölkerung zur Verfügung stellt. Dieses soll insbesondere Antworten auf häufig gestellte Fragen (FAQ) sowie Verhaltensempfehlungen zur Prävention beinhalten.

Dieser Artikel beschreibt, wie die Ad-hoc-Erstellung von Informationsinhalten in Form von FAQ erfolgt und welche Bedeutung diese in der Krisenkommunikation haben. Dabei wird der Wandel der FAQ vom einfachen Informationsangebot zum interinstitutionellen Krisenreaktionsinstrument (Rapid Reaction Tool) im Rahmen einer agilen Kommunikation zum Coronavirus deutlich. Im Sinne einer kongruenten und tagesaktuellen Informationsbereitstellung ist eine enge Zusammenarbeit zwischen den Institutionen erforderlich. Die Arbeits- und Abstimmungsprozesse sowie verschiedene Vorgehensweisen bei der Aktualisierung werden vorgestellt.

Aus den beschriebenen und bewerteten Arbeitsprozessen können theoretische Implikationen für die Krisenkommunikation und das Krisenmanagement – insbesondere die Zusammenarbeit zwischen verschiedenen Institutionen – abgeleitet werden. Auch können sie von anderen Institutionen als Beispiel für „gute Praxis“ aufgegriffen und ggf. weiterentwickelt und auf andere Kontexte übertragen werden.

Study protocol for the online adaptation and evaluation of the 'Reboot' (Recovery-boosting) coaching programme, to prepare critical care nurses for, and aid recovery after, stressful clinical events

Background

Critical care nurses (CCNs) are routinely exposed to highly stressful events, exacerbated during the COVID-19 pandemic. Supporting resilience and wellbeing of CCNs is therefore crucial to prevent burnout. One approach for delivering this support is by preparing critical care nurses for situations they may encounter, drawing on evidence-based techniques to strengthen relevant psychological coping strategies. As such, the current study seeks to tailor a Resilience-boosting psychological coaching programme [Reboot] for CCNs, based on cognitive behavioural therapy (CBT) principles and the Bi-Dimensional Resilience Framework (BDF), and (1) to assess the feasibility of delivering Reboot via online, remote delivery to CCNs, and (2) to provide a preliminary assessment of whether Reboot could increase resilience and confidence in coping with adverse events.

Methods

Eighty CCNs (n=80) will be recruited to the 8-week Reboot programme, comprised of two group workshops and two individual coaching calls. The study uses a single-arm before-after feasibility study design and will be evaluated with a mixed-methods approach, using online questionnaires (all participants) and telephone interviews (25% of participants). Primary outcomes will be confidence in coping with adverse events (the Confidence scale) and resilience (the Brief Resilience Scale) measured at four time points.

Discussion

Results will determine whether it is feasible to deliver and evaluate a remote version of the Reboot coaching programme to CCNs, and will indicate whether participating in the programme is associated with increases in confidence in coping with adverse events, resilience and wellbeing (as indicated by levels of depression).

Prioritization of ICU beds with renal replacement therapy support by court order and mortality in a Brazilian metropolitan area

The shortage of intensive care unit (ICU) resources, including equipment and supplies for renal replacement therapy (RRT), is a critical problem in several countries. This study aimed to assess hospital mortality and associated factors in patients treated in public hospitals of the Federal District, Brazil, who requested admission to ICU with renal replacement therapy support (ICU-RRT) in court. Retrospective cohort study that included 883 adult patients treated in public hospitals of the Federal District who requested ICU-RRT admission in court from January 2017 to December 2018. ICU-RRT was denied to 407 patients, which increased mortality (OR 3.33, 95% CI 2.39–4.56, p ≪ 0.01), especially in patients with priority level I/II (OR 1.02, 95% CI 1.01–1.04, p ≪ 0.01). Of the requests made in court, 450 were filed by patients with priority levels III/IV, and 44.7% of these were admitted to ICU-RRT. In admitted patients, priority level III priority level I/II was associated with a low mortality (OR 0.47, 95% CI 0.32–0.69, p < 0.01), and not. The admission of patients classified as priority levels III/IV to ICU-RRT considerably jeopardized the admission of patients with priority levels I/II to these settings. The results found open new avenues for organizing public policies and improving ICU-RRT triage.

'We weren't checked in on, nobody spoke to us': an exploratory qualitative analysis of two focus groups on the concerns of ethnic minority NHS staff during COVID-19

OBJECTIVE

To gain exploratory insights into the multifaceted, lived experience impact of COVID-19 on a small sample of ethnic minority healthcare staff to cocreate a module of questions for follow-up online surveys on the well-being of healthcare staff during the pandemic.

DESIGN

A cross-sectional design using two online focus groups among ethnic minority healthcare workers who worked in care or supportive roles in a hospital, community health or primary care setting for at least 12 months.

PARTICIPANTS

Thirteen healthcare workers (11 female) aged 26-62 years from diverse ethnic minority backgrounds, 11 working in clinical roles.

RESULTS

Five primary thematic domains emerged: (1) viral vulnerability, centring around perceived individual risk and vulnerability perceptions; (2) risk assessment, comprising pressures to comply, perception of a tick-box exercise and issues with risk and resource stratification; (3) interpersonal relations in the workplace, highlighting deficient consultation of ethnic minority staff, cultural insensitivity, need for support and collegiate judgement; (4) lived experience of racial inequality, consisting of job insecurity and the exacerbation of systemic racism and its emotional burden; (5) community attitudes, including public prejudice and judgement, and patient appreciation.

CONCLUSIONS

Our novel study has shown ethnic minority National Health Service (NHS) staff have experienced COVID-19 in a complex, multidimensional manner. Future research with a larger sample should further examine the complexity of these experiences and should enumerate the extent to which these varied thematic experiences are shared among ethnic minority NHS workers so that more empathetic and supportive management and related occupational practices can be instituted.

Ethical Guidance for Hard Decisions: A Critical Review of Early International COVID-19 ICU Triage Guidelines

This article provides a critical comparative analysis of the substantive and procedural values and ethical concepts articulated in guidelines for allocating scarce resources in the COVID-19 pandemic. We identified 21 local and national guidelines written in English, Spanish, German and French; applicable to specific and identifiable jurisdictions; and providing guidance to clinicians for decision making when allocating critical care resources during the COVID-19 pandemic. US guidelines were not included, as these had recently been reviewed elsewhere. Information was extracted from each guideline on: 1) the development process; 2) the presence and nature of ethical, medical and social criteria for allocating critical care resources; and 3) the membership of and decision-making procedure of any triage committees. Results of our analysis show the majority appealed primarily to consequentialist reasoning in making allocation decisions, tempered by a largely pluralistic approach to other substantive and procedural values and ethical concepts. Medical and social criteria included medical need, co-morbidities, prognosis, age, disability and other factors, with a focus on seemingly objective medical criteria. There was little or no guidance on how to reconcile competing criteria, and little attention to internal contradictions within individual guidelines. Our analysis reveals the challenges in developing sound ethical guidance for allocating scarce medical resources, highlighting problems in operationalising ethical concepts and principles, divergence between guidelines, unresolved contradictions within the same guideline, and use of naïve objectivism in employing widely used medical criteria for allocating ICU resources.

Rationing in the Pediatric Intensive Care Unit-ethical or unethical?

Rationing in health care is controversial, and even more so in pediatrics. Children are an inherently vulnerable group because they are reliant on their parents and caregivers to make decisions in their best interests and have no political voice. Historically, there has been general acceptance of the need to ration healthcare at a systems level, however there is controversy over whether healthcare professionals should be involved in rationing at the bedside. The COVID-19 pandemic has highlighted that bedside rationing is unavoidable, at least in times of extreme resource scarcity. Internationally, there has been significant ethical analysis and guideline development to guide intensive care rationing decisions in the event that resources are overwhelmed. This paper explores the principles underlying distributive justice in healthcare rationing and discusses how these were operationalized in ethical guidelines for the COVID-19 pandemic. In fact, rationing is unavoidable and occurs constantly in everyday nursing and medical ICU practice, often in mundane and uncontroversial ways. Some argue that these everyday decisions are not true rationing decisions, but resource allocation, or stewardship decisions. We argue there are no clear lines between resource allocation and rationing decisions, rather that they occur on a spectrum. These everyday rationing decisions are particularly susceptible to personal biases that are often implicit. Due to the subtle and constant nature of most everyday rationing decisions, specific guideline development will rarely be practical or appropriate. However, it is possible to develop other processes to improve decision making. There are a variety of strategies we recommend for this including, encouraging reflective practice; developing explicit frameworks that promote collaborative decision making; being transparent about resource allocation and rationing decisions with colleagues, patients, and families; and promoting a workplace culture of speaking up and accessing support in identifying and managing everyday rationing decisions.

[Public trust in institutions in the first half of the Corona pandemic: findings from the COVID-19 Snapshot Monitoring (COSMO) project]

Hintergrund

In der Coronaviruspandemie nehmen 2 Institutionen eine zentrale Rolle in der evidenzbasierten Einordnung des Geschehens für Politik und Bevölkerung ein. Das Robert Koch-Institut (RKI) koordiniert die Pandemiebekämpfung, erstellt fundierte Empfehlungen für medizinisches Fachpersonal, die Medien sowie die Bevölkerung und berät die Politik. Die Bundeszentrale für gesundheitliche Aufklärung (BZgA) informiert die Bevölkerung und Institutionen.

Ziel der Arbeit

Mit dem COVID-19 Snapshot Monitoring (COSMO) wird beobachtet, ob und wie sich das Vertrauen in Institutionen über die Pandemie verändert. Es wird untersucht, welche Bevölkerungsgruppen Vertrauen zeigen und wie dies mit Einstellungen, Risikowahrnehmung und Verhaltensweisen zusammenhängt.

Material und Methoden

In Querschnittstudien werden seit März 2020 die Risikowahrnehmung, das Verhalten und die Akzeptanz von Maßnahmen sowie das Vertrauen in Institutionen mit etwa N = 1000 Befragten pro Erhebung untersucht.

Ergebnisse

Das Vertrauen in RKI und BZgA war generell hoch, sank aber über den Verlauf der Pandemie. Höheres Vertrauen ging für beide Institutionen mit höherem Alter der Befragten, höherer Bildung, höherer Risikowahrnehmung und höherer Akzeptanz von Maßnahmen einher.

Verhaltensweisen wie Abstandhalten und Händewaschen wurden häufiger gezeigt. Männer und chronisch Erkrankte zeigten geringeres Vertrauen.

Diskussion

Die Ergebnisse zeigen, dass Vertrauen weiter gefördert werden sollte. Dies könnte u. a. erreicht werden, indem in der Entwicklung und Begründung von Strategien und Maßnahmen auch die Sichtweise der Bevölkerung (z. B. durch COSMO) berücksichtigt wird. Kommunikationsstrategien und Handlungsempfehlungen sollten darauf abzielen, Personen mit hoher Risikowahrnehmung zu unterstützen und zu entlasten.