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It’s Time for a Post-Mortem on COVID Crisis Standards of Care

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It’s Time for a Post-Mortem on COVID Crisis Standards of Care

Ever since the threat of an avian flu pandemic in 2006, governments, hospitals, and professional associations have been preparing for the next “big one.” New York State was a leader in pandemic preparation, having developed its Ventilator Allocation Guidelines in 2007, with updates in 2015. And yet, when the COVID tsunami hit New York City in early 2020, overwhelming the healthcare system, New York failed to revise and officially activate its guidelines, despite pleas from professional and institutional stakeholders, leaving hospital staff without guidance. Without state sanctioned activation, individual hospitals and their staff struggled to make difficult triage resuscitation decisions, in some instances without benefit of legal protection. Nevertheless, decisions at the bedside had to be made. Because as Matthew Wynia, MD, MPH, noted early on: “No one would want to be accountable for making these decisions. They’re tragic decisions, which is why they roll downhill. Right? From powerful person to less powerful person to the person who can’t say I refuse to make that decision. That’s how they end up in the lap of the bedside doctor.”

Throughout the nation, hospitals in urban and rural areas also experienced unprecedented surges in COVID and had to make difficult decisions at the bedside because they had no choice. Very little is known about these decisions. In 2022, it is time to find out.

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Crisis Standards of Care

Crisis standards of care (CSC) are officially invoked by state governments when sustained demand far exceeds available hospital staff, equipment, and space. Hospitals operating at this level of capacity, i.e., crisis capacity, may be at significantly higher risk of patient morbidity and mortality. In response, CSC plans typically call for expansion of hospital capacity and for coordinated, if not centrally directed, regional sharing of resources and transfer of patients if necessary. To facilitate staffing, competency, and credentialing, regulations are relaxed. If these measures fall short, CSC allows for triage — the prioritization of access to life-sustaining treatments (e.g., ventilators) — aimed at saving the most lives possible. Accordingly, patients who have the greatest chance of survival with intervention receive higher priority than both those with the highest likelihood of survival without medical intervention and those with the smallest likelihood of survival even with medical intervention.

To protect the fiduciary relationship of the physicians and nurses treating the patient, triage decision making, which is supposed to be a transparent process based on publicly available criteria, should be carried out by an independent triage officer or triage team. In many states, triage is a three-step process:

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  1. Initial screening of patients and possible denial of aggressive treatment based on exclusion criteria (e.g., medical conditions that result in immediate or near-immediate mortality even with aggressive therapy) or simply by positioning such patients so low on the priority list it is clear they would never receive scarce resources
  2. Risk assessment based on best available objective criteria, such as the Sequential Organ Failure Assessment (SOFA) score, and other physiological data to determine ICU admission priorities
  3. Periodic reassessment of progress at regular intervals

In New York City, hospitals dramatically expanded hospital and ICU capacity to meet the sustained surge in demand. For example, Montefiore Health System in the Bronx quadrupled its ICU beds from 120 to 475, an extraordinary expansion in capacity. In those hospitals experiencing the most extreme surges, the quality of care no doubt was diluted by an overstretched and, in many instances, inadequately trained (in critical care) staff. Decidedly, it was an “all hands on deck” approach. Could it have been any other way with cases doubling every 3 days, staff getting sick and dying because of lack of PPE, and refrigeration trucks augmenting hospital morgues? The pressure on the staff must have been unimaginable.

Morbidity and Mortality Rounds

A 2022 summary report from the Assistant Secretary for Preparedness and Response of HHS showed wide variation in the ways states and individual hospitals implemented or failed to implement their CSC plans, if they had one. Among the key findings: only 9 states declared CSC; in 15 states, crisis care apparently occurred but no official declaration was made; and many hospitals declared CSC in the absence of state action. In some states, with or without a declared CSC, executive orders provided for hospital expansion and the relaxation of credentialing requirements. John Hick, MD, et al. in their assessment of lessons learned from COVID, found that the formal CSC plans often failed to meet the needs of the situation on the ground. Also, healthcare providers often suffered from severe moral distress related to bedside rationing decisions.

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What was it really like for doctors, nurses, and other healthcare professionals on the front lines? A qualitative study from Elizabeth Chuang, MD, MPH, and colleagues designed to identify potential problems in implementing model guidelines, based on the National Academies of Medicine Crisis Standards of Care and the New York State Ventilator Guidelines, found doctors and nurses to be conflicted over the ethics of triage, raising concerns about their actual performance in a pandemic. Robert Truog, MD, MA, reconsidering the soundness of the Massachusetts CSC, concluded that the basic approach was flawed and impossible to implement and that if time-limited trials of ventilators were used as a precursor to withdrawal, they would likely face backlash from politicians. Similar obstacles with regard to the implementation of CSC protocols were found in Arizona as part of a system simulation exercise (Patricia Mayer, MD, personal communication).

It is time for hospitals to hold the equivalent of morbidity and morbidity rounds to examine the formal (state or hospital) and informal/ad hoc responses to COVID surges involving triage.

We need a postmortem, and we need to start with questions.

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What do we know about the CSCs and their processes? Were the state CSC triage guidelines, or the ones adopted by hospitals, helpful or too cumbersome to be useful? Were formal triage guidelines used at all? To what extent were triage decisions made in the ER and were CSC exclusion criteria useful, if they existed? What was the utility of SOFA and other scoring systems? Who actually oversaw the response to the COVID surge and triage (e.g., Incident Command System), if anyone, and with what effectiveness? In the places that formally activated triage protocols (some facilities in Alaska, Tennessee, and Idaho for instance) did they keep records? What were their results, and did they indeed save more lives using a protocol?

What do we know about outcomes? To what extent did patients die who would have survived under normal conditions? Did salvageable patients die because ICUs were already filled with dying patients because staff were unwilling or unable to withdraw life-sustaining treatment to make way for others?

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What do we know about staff? To what extent did staff feel their decision making was supported legally and ethically? Did medical teams even recognize the care being provided as triage? Did teams consider or try to deal with racial inequities? How many staff were bullied, threatened, or harassed after the “heroes” label went cold? How many quit? Committed suicide? What were the reactions and consequences to teams using formal triage processes versus those triaging ad hoc?

What do we know about patients and families? How much did patients or families know about the limitations in “stuff, space, and staff”? How are families coping now when they lost loved ones they weren’t allowed to see?

What is the public perception of CSC and triage? How does the public feel about states that did not activate CSC (including New York and Texas) when TV footage was filled with dying patients, morgue trucks and body bags, and literally everybody assumed somebody was making decisions?

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And what lessons were learned? Specifically, what could have been done differently? How can we improve next time (and there will be a next time) — unless we have information about what happened this time? Failure to learn from this experience dishonors those who died as well as those who served. We need answers.

Martin A. Strosberg, PhD, is emeritus professor of healthcare policy, and bioethics at Union College and Clarkson University in Schenectady, New York. Patricia Mayer, MD, is a palliative care physician and the director of clinical ethics at Banner Health based in Phoenix. Daniel Teres, MD, is a critical care physician and clinical instructor in public health and community medicine at Tufts University School of Medicine in Boston.

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How to Feel Hopeful, Even When It’s Really, Really Hard

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How to Feel Hopeful, Even When It’s Really, Really Hard

And for those with mental illnesses, such as depression or anxiety, cultivating hope and resilience can be key to managing their symptoms, Dr. Tedeschi says. In depression, for instance, a persistent feeling of hopelessness is often a defining symptom. In the case of anxiety, fear is one of the driving factors. “In both cases, they’re drawing the conclusion that things are out of their control and things aren’t going to work,” Dr. Tedeschi says. Figuring out a way to become more hopeful, even—or especially—when life is difficult, is usually a necessary component of treatment.

Being hopeful can help you build resilience.

Putting in the work to be hopeful has other psychological benefits too. In particular, hope helps build resilience, which “is the ability to either recover quickly from events that are challenging, or traumatic, or a crisis or to be relatively unaffected by these events,” Dr. Tedeschi explains.

But resilience isn’t just being able to withstand a difficult situation. “It has to do with living a fuller life,” Lillian Comas-Diaz, PhD, a psychologist specializing in trauma recovery and multicultural issues, tells SELF. “Resilience is a way of coping with adversity and being able to get some knowledge from that adversity,” which might help you improve your coping mechanisms for the future.

From there, it’s easy to see how hope, optimism, and a generally more positive outlook might develop with resilience. It works like a feedback loop, Dr. Tedeschi says: “If you have success in managing these situations, you become more optimistic about how you’re going to do in the future,” he explains. And as you develop some optimism and hope, that might help you persist and manage in the face of the difficulties we all inevitably face.

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How to be hopeful when things feel hopeless

Here are a few tips from our experts:

If it’s really hard to feel hopeful right now, start by just acknowledging that.

Some people are just naturally optimistic, even in a situation like this. But, generally, resilience is something that’s learned—first through our experiences in childhood, potentially, and then later as we go through the inevitable challenges of life, Dr. Tedeschi says. So for those of us who maybe feel a little silly trying to look for a silver lining in, you know, these Unprecedented Times, trying to be hopeful just doesn’t feel genuine. And if it’s not authentic, it isn’t very helpful.

If you’re someone who finds it difficult or even feels silly trying to be optimistic right now, know that hope doesn’t necessarily mean thinking that everything will always be amazing. Being hopeful doesn’t have to be about looking for the bright side or deluding ourselves into thinking everything will be just fine, Dr. Comas-Diaz says. Hope is really just a (realistic) expectation that something good will happen—and that you have some control over it.

For some people, it might be difficult to be hopeful because they don’t have a source of hope they can immediately point to, Dr. Comas-Diaz says. In those cases, she will ask her patients to do an inventory, asking what sources of hope their friends, family, or larger culture draw upon and if the patient can “borrow” from that source as well. Think about, say, your mom or a close friend—what brings them hope? Can you share that with them or get some hope vicariously through them? Or is there a particular cause you’re really passionate about that you can draw some sense of optimism from?

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Gelato recalled in Ontario after testing find norovirus contamination of raspberries

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Gelato recalled in Ontario after testing find norovirus contamination of raspberries

Angelo’s Italian Market Inc. is recalling Gelato Artigianale al gusto di Raspberry Gelatois from the marketplace because of possible norovirus contamination of the raspberries used in this product.

This recall was triggered by Canadian Food Inspection Agency test results.

The recalled product has been sold at Angelo’s Italian Market Inc. in London, Ontario.

Recalled product:

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Brand Product Size UPC Codes
None Gelato Artigianale al gusto di Raspberry Gelato 1 L 0 000000 067430 None – Sold at Angelo’s Italian Market Inc., 755 Wonderland Road North, London, ON up to and including June 14, 2022

As of the posting of this recall, there have been no reported illnesses associated with the consumption of this product.

Recalled products should be thrown out or returned to the location where they were purchased

About norovirus infections

People with norovirus illness usually develop symptoms of gastroenteritis within 24 to 48 hours, but symptoms can start as early as 12 hours after exposure. The virus can live on surfaces for long periods of time and survives freezing temperatures. It is highly contagious.

The illness often begins suddenly. Even after having the illness, you can still become reinfected by norovirus. The main symptoms of norovirus illness are diarrhea, vomiting (children usually experience more vomiting than adults), nausea, and stomach cramps.

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Other symptoms may include low-grade fever, headache, chills, muscle aches, and fatigue (a general sense of tiredness). Most people feel better within one or two days, with symptoms resolving on their own, and experience no long-term health effects.

As with any illness-causing diarrhea or vomiting, people who are ill should drink plenty of liquids to replace lost body fluids and prevent dehydration. In severe cases, patients may need to be hospitalized and given fluids intravenously.

(To sign up for a free subscription to Food Safety News, click here.)

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10 Luxe Mattresses You Can Get Right on Amazon

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10 Luxe Mattresses You Can Get Right on Amazon

It should come as no surprise that Amazon, retail behemoth that it is, has a fantastic range of bedding available—in fact, some of the best mattresses on Amazon come from high-quality brands like Casper, Nectar, and Tuft & Needle. In other words, while you’re perusing early Amazon Prime Day deals on vacuums, furniture, outdoor gear, and wellness products, you can pick up a new mattress for yourself too—how’s that for one-stop shopping? Before you get to scrolling, here’s a quick rundown on what mattress type might suit your sleeping style and give you the best sleep you can get.

Mattresses for Side Sleepers

You should look for a medium-firm mattress that will prevent pressure points from building around your shoulders, hips, and knees (which can lead to back pain). All-foam or hybrid innerspring mattresses will work for you, as long as they provide contouring and support.

Mattresses for Stomach and Back Sleepers

These might be opposite sleep positions, but stomach sleepers can benefit from the same type of mattress as back sleepers: A firm bed that won’t let your lower back arch out of alignment. Again, a memory foam mattress can fit the bill as well as a hybrid mattress, but bear in mind that foam mattresses tend to be on the softer side (making uncomfortable sinkage a risk).

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Overall you want to find a mattress that provides pressure relief and, most of all, nightlong comfort. And Amazon has plenty of options to choose from. From beloved bed-in-a-box mattress brands to best-selling beds at affordable price points, we’ve highlighted our top Amazon mattress picks here. 

All products featured on SELF are independently selected by our editors. However, when you buy something through our retail links, we may earn an affiliate commission.

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