Crisis Standards of Care: What this could mean for New Mexico, Texas, and Amarillo

Local News

SANTA FE, N.M. (KAMR/KCIT) – The New Mexico Department of Health (NMDOH) announced Monday that the state’s healthcare system would begin working through Crisis Standard of Care (CSC) guidelines because of the intense volume of COVID-19 patients draining healthcare resources. This put New Mexico among states such as Idaho, Alaska, and Montana in which health leaders have approved healthcare rationing since September.

DOH Acting Secretary David Scrase, M.D., credited the need for CSC guidelines to COVID causing New Mexico hospitals and health care facilities to carry “an unmanageable burden.” The guidelines, he said, are the state offering “clarity and support” while healthcare providers make difficult choices about who gets what care, with the goal of saving as many lives as possible.

How will this impact day-to-day life in New Mexico? What if you need to call an ambulance, or go to a hospital?

While Dr. Scrase said that patients should still seek the care they need, CSC guidelines modify hospital and healthcare facility procedures.

People are likely to wait longer for care under CSC, not just in hospitals but at urgent care centers. Nurses also will likely see more patients than normal, and patients are likely to be sent home from the hospital as soon as possible and rely on in-home medical equipment during recovery. In Amarillo, some of these have already been seen, with previous weeks of excessive wait times in crowded ER’s and dozens of regional patients waiting for critical care.

More information is likely in the coming days for how specific areas and hospitals will change procedures under CSC, but New Mexico published a CSC plan as recently as 2018 that may help prepare communities for what to expect.

CSC guidelines from New Mexico detailed a “Clinical Concept of Operations” for CSC leadership to consider when these standards are needed, impacting topics such as:

  • Emergency Medical Services (EMS)
  • Hospital and Acute Care Facilities
  • Supply Shortages

Emergency Medical Services (EMS) and other pre-hospital care are expected to have guidance from NMDOH to have consistent care guidelines across the state. First responders may use one of the triage systems in place for the state in order to prioritize care; “START” for adults, “JumpStart” for children, and other situations possibly calling for “Alternate Triage, Treatment, and Transport Guidelines.”

Patients may initially be categorized using Immediate, Delayed, Minimal, Expectant (IDME) systems:

Hospitals and acute-care facilities may need to expand to different out-of-hospital care and establish triage sites under CSC to handle a high number of patients.

Primary Triage might happen at a hospital’s ER, a clinic, or another healthcare “access” point, for people who are not brought in by EMS services. Care would be prioritized using the START and JumpStart guidelines, similar to EMS.

Secondary Triage would happen after patients are first seen and after immediate medical interventions. A medical expert would then help prioritize who will have use of the operating room, computerized tomographic (CT) scans, burn care, and other trauma resources.

Tertiary Triage focuses on which patients will be admitted to the ICU. In that situation, patients are likely to be graded on “inclusion criteria” and a Sequential Organ Failure Assessment (SOFA) score to decide who has priority for ICU care. Those with a higher SOFA score generally have a lower mortality rate even among critical patients, so SOFA scores that are lower are given a higher priority:

Scopes of Practice might also be expanded during CSC situations, which means a person who is a licensed healthcare professional might be allowed to handle procedures and processes that they’re capable of but not necessarily licensed for. For instance:

  • EMT’s or PA’s might be supervised by a medical resident beyond their first year of residency in their healthcare facility.
  • A resident beyond their first year may “function to the best of their ability” in their healthcare facility.
  • New Mexico RN’s meeting requirements might perform procedures in facilities where they have privilages.
  • An out-of-state, licensed healthcare professional in good standing might be approved to practice in New Mexico by the board during CSC response.

Supply shortages, along with space and staff shortages are among the assumptions made when planning a CSC response, according to NMDOH. Steps made by healthcare leaders to adapt to these shortages might include:

  • Substitution: Using an “essentially equivalent” facility, professional, drug, or device for one that might usually be available
  • Adaptation: Using a facility, professional, drug, or device that is not equivalent but provides “the best possible” care
  • Conservation: Using lower dosages or changing practices when possible – such as minimizing the use of oxygen by using air for nebulizers, etc.
  • Optimizing Allocation: Giving resources that are left to patients who have a greater need, or “whose prognosis is more likely to result in a positive outcome” with limited resources

Could this happen in the Amarillo area?

In short – yes, but it may not look the same as it does in New Mexico. Some care rationing has already become commonplace during the pandemic, such as hospitals postponing elective surgeries or physicians switching to online visits.

Other rationing comes with far more dire images. In September in Idaho’s St. Luke’s Health System, patients were being ventilated by hand — with a nurse or doctor squeezing a bag — for up to hours at a time while hospital officials worked to find a bed with a mechanical ventilator, said chief medical officer Dr. Jim Souza. Idaho, specifically, also has a “Universal Do Not Resuscitate Order” for all adults once there are not enough ventilators to go around.

In Amarillo, a number of “elective” procedures have been limited because of the strain the healthcare system has seen from COVID-19. These don’t necessarily mean optional, but surgeries that can be scheduled in advance: having kidney stones removed, removing a mole or wart, or sometimes these are included under surgeries or treatments for conditions like cancer.

For the moment, facilities such as the BSA Health System said that surgeries are reviewed on a daily basis for decisions about what can and cannot be delayed. With hospitalizations from COVID-19 slowly seeing some decreases in the area, BSA said its capacity situation has somewhat started to improve.

However, even in the most recent COVID-19 briefing, BSA’s Dr. Lamanteer noted more COVID-19 patients needing ICU care than there was ICU space available, leaving multiple patients outside of their needed unit.

For Texas, there was no statewide Crisis Standard of Care policy as of 2021. There was a “Tactical Guide” related to the Texas Public Health and Medical Emergency Management plan for 2012-2016, but there has not been a policy in place outside of guidelines established from region to region.

Among the most easily found and referenced were the Southwest Texas Regional Advisory Council’s Hospital and ICU Pandemic Crisis Guidelines, updated in early 2021 in collaboration with the US Department of Health and Human Services and the Office for Civil Rights. The update to the Southwest region’s guidelines came due to the argument that the policies did not protect people with disabilities and older adults from being categorically excluded from care.

Both Texas and Arizona had complaints issued against them in 2020 by a coalition of national disability and civil rights advocacy groups that alleged that the plans were discriminatory against not only those with disabilities and older adults, but also people of color. While the Southwest guidelines were updated, these cover Trauma Service Area P served by Southwest Texas RAC – the Amarillo area is under Trauma Service Area A and served by the Panhandle RAC.

On the morning of Oct. 19, the Amarillo area COVID-19 dashboard reported 89% of Potter and Randall Counties’ adult hospital beds were in use, and 82% of the total ICU capacity. If the Amarillo area saw a COVID-19 spike in the coming months severe enough to warrant extreme care rationing, it is not clear what guidelines the Panhandle RAC would follow. MyHighPlains.com has reached out for clarification from the Texas Department of State Health Services, and will update this story as it develops.

It remains to be seen whether an influx of New Mexico patients will be sent into neighboring Texas areas for healthcare due to the current crisis, or how long those crisis standards will be in place. However, health officials from a local and national level have continued to encourage all who are able to get vaccinated against COVID-19, and practice mask wearing and social distancing in the collective effort to stop the spread.

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