Alabama

No plan.

Alabama’s 2010 Criteria for Mechanical Ventilator Triage Following Proclamation of Mass-Casualty Respiratory Emergency included an allocation plan but was removed from the Internet following the resolution of an OCR complaint alleging discriminatory allocation policies.

Not addressed.

Alaska

Patient Care Strategies for Scarce Resource Situations

Alaska plan is copied from Minnesota plan.

April 15, 2020

“This card set is designed to facilitate a structured approach to resource shortfalls at a health care facility. It is a decision support tool and assumes that incident management is implemented and that key personnel are familiar with ethical frameworks and processes that underlie these decisions… Each facility will have to determine the most appropriate steps to take to address specific shortages.”

Pg. 4

The exclusion criteria from the Minnesota plan has been removed.

Not addressed

Not addressed.

Step 1: Calculate patients’ SOFA score.

Step 2: Compare patients based on the tiered framework (see “Patient Prioritization Factors” column).

Step 3: “Re-allocate ventilator/resource only if patient presenting with respiratory failure has significantly better chance of survival/benefit as compared to patient currently receiving ventilation.”

Pg. 15

Highest priority:

• SOFA score ≤7;
• Good prognosis based upon epidemiology of specific disease/ injury;
• No severe underlying disease;
• Short duration – anticipating <3 days on ventilator;
• Improving ventilatory parameters over time.

Intermediate priority:

• SOFA score 8–11;
• Indeterminate/intermediate prognosis based upon epidemiology of specific disease/injury;
• Severe underlying disease with poor long-term prognosis and/or ongoing resource demand and unlikely to survive more than 1–2 years;
• Moderate duration – anticipating 3–7 days on ventilator;
• Stable ventilatory parameters over time.

Resource re-allocated:

• SOFA score ≥12;
• Poor prognosis based upon epidemiology of specific disease/injury;
• Severe underlying disease with poor short-term prognosis (e.g., life expectancy under 6 months, eligible for admission to hospice);
• Long duration – anticipating >7 days on ventilator;
• Worsening ventilatory parameters over time.

Pg. 15

See “Patient Prioritization Factors” column for required anticipated time to improve for each prioritization level.

Arizona

Arizona Crisis Standards of Care Plan

2020

“Legal authorization is generally required to shift the provision of care and resource allocation (e.g., space, staff and supplies) during emergencies. Emergency declarations and ensuing orders are the first step in authorizing such changes and providing liability protections (see ARS §35-192 and ARS §26-303).”

Pg. 85

Not addressed.

Not addressed.

Not addressed.

Step 1: Apply inclusion criteria.

Step 2: Assign patients to color-coded groups based on SOFA score.

Pg. 30-31

• Highest priority: SOFA score ≤7 or single organ failure.
• Intermediate priority: SOFA score 8-11.
• Lowest priority: SOFA score >11.

Pg. 31

Not addressed.

Arkansas

No plan.

California

California SARS-CoV-2

Pandemic Crisis Care

Guidelines

June 2020

“The Patient Care Strategies for Scarce Resource Situations at the end of this document can assist facilities in decision-making; however, it is ultimately up to the facility to determine and implement its own process.”

Pg. 14

“A central feature of this allocation framework is that it does not use categorical exclusion criteria to bar individuals from access to critical care services during a public health emergency.”

Pg. 26

“Age, disability, or any other characteristics from the Key Points do NOT define individuals likely to die in the near-term. Co-morbid medical conditions occur in a spectrum of severity, and should only be used in allocation decisions based on the clinical decision that they will impact near-term survival.”

Pg. 27

“Any pandemic planning framework should be designed to achieve the following… To diminish the impact of social inequalities that negatively impact patients’ long-term life expectancy by keeping in mind historic disparities and inequalities. “

Pg. 16

“To ensure non-discrimination against individuals with disabilities, triage protocols must either not score individuals based on their quality of life after treatment, or assess at most how far treatment will return the patient to their own baseline quality of life.”

Pg. 17

Step 1: “Calculating each patient’s Sequential Organ Failure Assessment (SOFA) or modified SOFA (mSOFA) score.”

Step 2: “Determining each day how many priority groups will receive access to critical care interventions.”

Pg. 25

“In the event that there are ‘ties’ in SOFA or mSOFA priority groups between patients and not enough critical care resources for all patients with the lowest scores, consideration can be given to severe medical co-morbidities and advanced chronic conditions that limit near-term duration of benefit and survival.

Patients who do not have a severely limited near-term prognosis for survival are given priority over those who are likely to die in the near-term, even if they survive the acute critical illness…

The following are examples of severely life-limiting comorbidities which may correlate with a significantly increased risk of short-term mortality from critical illness.

• Minimally conscious or unresponsive wakeful state from prior neurologic injury
• American College of Cardiology/American Heart Association Stage D heart failure World Health Organization Class 4 pulmonary hypertension
• Severe chronic lung disease with FEV120
• Metastatic Cancer with expected survival < 6 months despite treatment
• Refractory hematologic malignancy (resistant or progressive despite conventional initial therapy)

If after consideration of severe comorbidities there are still ties, a lottery (i.e., random allocation) should be used to break the tie.”

Pg. 27-28

“All patients who are allocated critical care services should be allowed a therapeutic trial of a duration to be determined by the clinical characteristics of the disease…

Patients who present for acute care and are already using a ventilator chronically for pre-existing respiratory conditions (e.g., home ventilation or ventilation at a skilled nursing facility) should NOT be separated from their chronic ventilator to reallocate it to other patients. The triage team should conduct periodic reassessments of patients receiving critical care/ventilation. A multidimensional assessment should be used to quantify changes in patients’ conditions, such as recalculation of severity of illness scores, appraisal of new complications, and treating clinicians’ input. Patients showing improvement should continue with critical care/ventilation until the next assessment. If there are patients in the queue for critical care services, then patients who upon reassessment show substantial clinical deterioration, as evidenced by worsening severity of illness scores or overall clinical judgment should have critical care withdrawn, including discontinuation of mechanical ventilation, after this decision is disclosed to the patient and/or family.”

Pg. 28-29

Colorado

Colorado Crisis Standards of Care

Appendix F: Scarce Resource Strategies from Minnesota Healthcare System Preparedness Program is copied from Minnesota plan.

April 5, 2020

“Activation will occur following a declaration of a local disaster, upon request by the local jurisdiction, or in any incident affecting the health and safety of employees or the public. This plan can only be activated following the Governor’s Declaration of a Public Health Emergency and may be accompanied by associated Executive Orders.”

Pg. 2

“Examples of underlying diseases that predict poor short-term survival include (but are not limited to):

• Congestive heart failure with ejection fraction < 25% (or persistent ischemia unresponsive to therapy or non-reversible ischemia with pulmonary edema).
• Severe chronic lung disease including pulmonary fibrosis, cystic fibrosis, obstructive or restrictive diseases requiring continuous home oxygen use prior to onset of acute illness.
• Central nervous system, solid organ, or hematopoietic malignancy with poor prognosis for recovery.
• Cirrhosis with ascites, history of variceal bleeding, fixed coagulopathy or encephalopathy.
• Acute hepatic failure with hyperammonemia.”

Pg. 28

Not addressed.

Not addressed.

Step 1: Calculate patients’ SOFA score.

Step 2: Compare patients based on the tiered framework (see “Patient Prioritization Factors” column).

Step 3: “Re-allocate ventilator/resource only if patient presenting with respiratory failure has significantly better chance of survival/benefit as compared to patient currently receiving ventilation.”

Pg. 47-48

Highest priority:

• SOFA score ≤7;
• Good prognosis based upon epidemiology of specific disease/ injury;
• No severe underlying disease;
• Short duration – anticipating <3 days on ventilator;
• Improving ventilatory parameters over time.

Intermediate priority:

• SOFA score 8-11;
• Indeterminate/intermediate prognosis based upon epidemiology of specific disease/injury;
• Severe underlying disease with poor long-term prognosis and/or ongoing resource demand and unlikely to survive more than 1-2 years;
• Moderate duration – anticipating 3-7 days on ventilator;
• Stable ventilatory parameters over time.

Resource re-allocated:

• SOFA score ≥12;
• Poor prognosis based upon epidemiology of specific disease/injury;
• Severe underlying disease with poor short-term prognosis (e.g., life expectancy under 6 months, eligible for admission to hospice);
• Long duration – anticipating >7 days on ventilator; worsening ventilatory parameters over time.

Pg. 48

See “Patient Prioritization Factors” column for required anticipated time to improve for each prioritization level.

Connecticut

No plan.*

*The October 2010 Standards of Care: Providing Health Care During A Prolonged Public Health Emergency is meant to be guiding ethical principles that hospitals or healthcare providers might use to create their own allocation plans.

District of Columbia

Modified Delivery of Critical Care Services in Scarce Resource Situations*

*Plan is from the DC Emergency Healthcare Coalition but that organization does not have a webpage. Plan cannot be located on the DC.gov website. It can only be found on the Office of the Assistant Secretary for Preparedness and Response website.

June 6, 2013

“The guidance is intended to promote a consistent approach to emergency preparedness and response among DC emergency healthcare organizations when scarce resource situations arise related to critical care patient needs.”

Pg. 6

Not addressed.

Not addressed.

Not addressed.

Not addressed.

Not addressed.

Not addressed.

Delaware

No plan.

Florida

Ethics Guidelines for Crisis Standards of Care in Public Health Emergencies*

*Plan is from the Florida Bioethics Network and is not a state plan. There was a draft state plan from 2011. “The Florida Department of Health in 2010 established a Pandemic Influenza Technical Advisory Committee and commissioned “Pandemic Influenza: Triage and Scarce Resource Allocation Guidelines,” which was completed in 2011. The Committee’s draft was not formally approved or adopted.”

May 1, 2020

Because this is not a state plan it is not mandatory and does not afford legal liability protection.

Not addressed.

“Life-cycle considerations should be used as [a] tiebreaker, with priority going to younger patients, according to these categories/ranges: ages 12-40, 41-60, 61-75 and older than 75”

Pg. 16

“No priority for social status, demographic characteristics or ‘value to society’…”

Pg. 14

Step 1: Calculate patients’ priority score based on the SOFA score.

• 1 point: SOFA <6
• 2 points: SOFA 6-8
• 3 points: SOFA 9-11
• 4 points: SOFA ≥12

Step 2: Calculate patients’ long-term prognosis score:

2 points:

• “Moderate dementia
• Malignancy <5-year survival
• NY Heart Association class III
• Moderate lung disease (COPD/ILD)
• End-stage renal disease
• Severe (inoperable) CAD”

4 points:

• “Severe dementia
• Metastatic/stage IV cancer
• NY Heart Association stage IV
• Severe chronic lung disease (FEV1 < 25%, TLC < 60%, room air PaO2 <55mmHg
• Cirrhosis with MELD > 20
• Traumatic brain injury with GCS best motor response = 1
• Severe burns where predicted survival
• Cardiac arrest categories:
• Unwitnessed arrest
• Recurrent arrest
• Trauma-related arrest
• Severe immunocompromised states.”

Step 3: Calculate patients’ priority score based on the SOFA score and prognosis score.

Step 4: Assign patients to priority groups based on priority score.

Pg. 14-15

• Priority Group 1: Scores 1 – 3
• Priority Group 2: Scores 4 – 5
• Priority Group 3: Scores 6 – 8
• Priority Group NA: No significant organ failure or no requirement for critical care resources

“Ties within Priorities Groups are adjudicated using individualized assessment of, first, co-morbidities associated with short-term survival; second, life cycle; third, healthcare workers and staff.”

Pg. 14-15

“Teams are expected to update SOFA scores and need for ventilation by 8 a.m. daily. At that time, the Triage Evidence Review Team will review all scores. to determine if any intubated patients have achieved scores ≥ 12. If the SOFA score equals or exceeds 12 at any point during the course of a patient’s treatment with mechanical ventilation, the triage team shall make an assessment, including any likelihood of recuperation/recovery and, if appropriate, instruct the treatment team to consult palliative care as well as the patient’s family and primary care physician/surgeon and withdraw mechanical ventilation within 8 hours.”

Pg. 16

Georgia

No plan.

Hawaii

No plan.

Idaho

No plan.

Illinois

Guidelines on Emergency Preparedness for Hospitals During COVID-19

Ethical Guidance for Crisis Standards of Care in Illinois

Undated.

March 2020

The documents appear to be part of an ongoing process of creating a statewide Crisis Standards of Care plan. The language in both alludes to the fact that the documents are only guidance to help individual healthcare entities create their own plans.

“Each hospital must have a medical disaster preparedness and response plan that contains responses related to a catastrophic incident (referred to as disaster response plan). Disaster response plans should anticipate the need for crisis levels of care, which may be required when standard space, staff, or supplies are unavailable and providers must implement alternate methods or interventions in order to provide a sufficient level of care. Hospitals should activate crisis care when resources are exhausted and pre-identified triggers have been reached as described in the ESF-8 CIR Annex.”

Guidelines Pg. 2

“Factors for de-prioritization. The system of rationing resources should allow for de-prioritization of patients who are unlikely to benefit from the scarce resource or treatment based on factors such as (1) risk of mortality or morbidity for a particular patient; (2) likelihood of good or acceptable response to a treatment or resource for a particular patient; and (3) community risk of transmitting infection and ability to reduce that risk by using a particular resource.”

Guidelines Pg. 7

Not addressed.

“It is inappropriate and not permissible to ration based on… judgments that some people will have a greater quality of life than others, as determined by the values of the decision maker.”

Ethical Guidance Pg. 11

Not addressed.

“Essential workers. Hospitals should prioritize essential or key workers within the health care system in order to maintain acceptable staffing levels. This includes prioritizing available personal protective equipment to health care workers so they can continue to provide essential care.”

“Randomized selection. After application of the above criteria, randomized selection processes may still be necessary if two patients are equally likely to benefit from a resource.”

Guidelines Pg. 7

“Hospitals should continually assess the availability of resources in order to reallocate resources as needed.”

Guidelines Pg. 7

Indiana

No plan.

Iowa

No plan.

Kansas

No plan.

Kentucky

Crisis Standards of Care: Guidance for the Ethical Allocation of Scarce Resources during a Community-Wide Public Health Emergency*

*Plan has the Kentucky Department for Public Health logo but is not on the Department website and can only be found on the Kentucky Hospital Association website.

March 31, 2020

“[The Kentucky Department for Public Health’s State Health Operations Center] will serve as the base of direction, control and coordination of state level support, in coordination with the state EOC, when activated. Local governments are responsible under all applicable laws, executive orders, proclamations, rules, regulations and ordinances for response within their respective jurisdiction(s).”

Pg. 15

“The plan can be activated prior to a declared or proclaimed emergency.”

Pg. 6

• “Those who are too ill to likely survive the acute illness (as evidenced by the Sequential Organ Failure Assessment (SOFA) score);
• Those whose underlying medical issues make their one-year mortality probability so high that it is not reasonable to allocate critical care resources to them; for example, end-stage ALS, metastatic carcinoma refractory to treatment and end stage organ failure;
• Those who require a larger-than-normal amount of resources, which makes it not feasible to accommodate their hospitalization in a prolonged mass-casualty situation.”

Pg. 35

Not addressed.

Not addressed.

Not addressed.

Not addressed.

Not addressed.

Louisiana

Louisiana Department of Health ESF- 8 Health & Medical Section State Hospital Crisis Standard of Care Guidelines in Disasters*

Plan has the Louisiana Department of Health logo but is not on the department website. It can only be found via the New York Times.

February 2018

“The following information is meant to serve as guidelines to provide direction to healthcare providers when the contingency capacity has been exceeded and crisis standards of care and an Executive Order for a declared state of emergency becomes necessary.”

Pg. 9

• “Severe trauma with a revised trauma score of <2.
• Severe and irreversible neurologic event or condition with persistent (>72 hours) coma and GCS <6.
• Severe burns with a low/ expectant or expectant outcome on the triage for burn victims assessment.
• Cardiac arrest without return of spontaneous circulation.
• Known severe dementia (Limited speech ability, no independent ambulatory ability, cannot sit up without assistance, loss of ability to smile, loss of ability to hold up head independently).
• Advanced untreatable neuromuscular disease (such as ALS, end stage MS or SMA) requiring assistance with activities of daily living or requiring chronic ventilator support.
• Patient is currently admitted / enrolled in hospice.
• Incurable metastatic malignant disease
• End-stage organ failure meeting the following criteria:
• NYHA Class IV heart failure
• COPD with FEV1 < 25% predicted or severe secondary pulmonary hypertension
• Cystic fibrosis with post-bronchodilator FEV1 < 30 % predicted
• Pulmonary Fibrosis with VC or TLC < 60 % predicted, baseline PaO2 < 55 mmHg, or severe secondary pulmonary hypertension
• Primary pulmonary hypertension with Class IV heart failure
• Pugh score of > 9
• Refusal of dialysis or dialysis not indicated
• Completed LaPOST document with Do Not Attempt Resuscitation AND Comfort Measures only.”

Pg. 35

Not addressed.

Not addressed.

Step 1: Apply exclusion criteria.

Step 2: Calculate patients’ mSOFA score.

Pg. 27

• Highest priority: mSOFA score 1-8.
• Intermediate priority: mSOFA score 8-11.
• Lowest priority: mSOFA score >11.

Pg. 34

“Once admitted to the ICU, daily assessment of ICU exclusion criteria should occur.”

Pg. 27

Maine

No plan.

Maryland

No state plan.

Maryland Framework for the Allocation of Scarce Life-sustaining Medical Resources in a Catastrophic Public Health Emergency*

*Plan is from the University of Maryland.

August 24, 2017

Because the plan is from the University of Maryland, it is referred to as “proposed strategy.”

Pg. 15

“In the event of a declared catastrophic public health emergency with an associated Governor’s order to implement this framework, a certain number of conditions would make an individual ineligible for the life-sustaining critical resource in question. Those conditions include:

1. Cardiac arrest: unwitnessed, recurrent, or unresponsive to defibrillation or pacing
2. Advanced and irreversible neurologic event or condition (e.g. massive subdural)
3. Severe burns in patient with both of the following:
1. Age > 60 yr.
2. 50% of total body surface area affected.”

Pg. 14

“…highest priority in this scoring system is given to children, for whom death would come tragically early without intensive care, and to adults through age 49, who would also have foreshortened life spans and whose death is most likely to impose suffering and hardship on other people whose well-being depends directly on their care and support (children, elderly relatives). Adults who have not yet lived a full life (50-69) are given next priority, followed by those who are approaching or have reached the high end of average life expectancy (70-84). Lowest priority is given to patients 85 and over in order to give other patients the same opportunity to live a full life that these patients have already experienced.”

Pg. 13

Not addressed.

Calculate patients’ priority score based on SOFA score and prognosis for long-term survival.

• 1 point: SOFA ≤8
• 2 points: SOFA 9-11
• 3 points: SOFA 12-14
• 4 points: SOFA >14
• 3 points: “Severe comorbid conditions; death likely within 1 year”

• “Priority will be given to those with the lowest scores.”
• Pregnant women: “Pregnant patients will be assigned a priority score based on the same framework used for non-pregnant patients. If a pregnant patient is in the third trimester, obstetrical evaluation of fetal health by heart tones should be performed urgently. Those individuals with a healthy fetus based on this evaluation will be given a one point “credit” (reduction) toward their priority score. The triage team will operate under the general presumption that the pregnant patient’s priority score in this framework should not be modified if the prospects of survival for either the pregnant patient or the fetus are poor.”

Pg. 12

“In the case of ventilators, all patients who are allocated a ventilator will be allowed a minimum therapeutic trial of a duration to be determined by the central triage committee based on epidemiologic pattern of the disease in question.”

Pg. 12

Massachusetts

Crisis Standards of Care Planning Guidance for the COVID-19 Pandemic

April 7, 2020

Not addressed.

“The allocation framework… does not categorically exclude any patients who, in usual circumstances, would be eligible for critical care resources..”

*Same language is used in New Jersey and Pennsylvania

Pg. 9

“In the event there are ties between patients…life-cycle considerations should be used as a tiebreaker, with priority going to younger patients.”

Pg. 20

“Factors that have no bearing on the likelihood or magnitude of benefit, including but not limited…perceived quality of life…are irrelevant and not to be considered by providers making allocation decisions.”

Pg. 4

Step 1: Apply inclusion criteria.

Step 2: Calculate patients’ priority score based on the SOFA score and “prognosis for continued survival (medical assessment of comorbid conditions).”

Step 3: Assign patients to color-coded groups based on priority score.

Step 4: Make a daily determination of how many groups can receive critical care resources based on the color-coded groups.

Pg. 15-16

• Highest priority: Priority score 1-3.
• Intermediate priority: Priority score 4-5.
• Lowest priority: Priority score 6-8.
• Pregnant women: “If a pregnant patient at or beyond usual standards for fetal viability, the patient will be given a two-point reduction in their priority score.”
• Healthcare workers: “Individuals who are engaged in tasks that are vital to the public health and health care response, including all those whose work directly supports the provision of acute care to others, including those who provide wraparound supports to the provision of acute care to others, should be given heightened priority.”

Pg. 16, 19

“All patients who are allocated critical care services…will be allowed a therapeutic trial of a duration to be determined by the clinical characteristics of the patient’s disease and the expected trajectory of recovery… The Triage Team will conduct periodic reassessments of all patients receiving critical care/ventilation. These assessments will involve re-calculating SOFA scores and consulting with the treating clinical team regarding the patient’s clinical trajectory. Patients showing improvement will continue with critical care/ventilation until the next assessment. If there are patients in the queue for critical care services, then patients who upon reassessment show substantial clinical decline as evidenced by worsening SOFA scores or overall clinical judgment, or demonstrate a failure to progress towards discharge from an intensive care unit, should not receive ongoing critical care/ventilation. Although patients should generally be given the full duration of a trial, if patients experience a precipitous decline (e.g. refractory shock and DIC) or a highly morbid complication (e.g. massive stroke) that portends a very poor prognosis, the Triage Team may make a decision before the completion of the specified trial length that the patient is no longer eligible for critical care treatment.”

Pg. 21

Appeals:

Initial triage decisions: “For initial triage decisions, the only appeals that will be entertained are those based on a claim that an error was made by the Triage Officer in the calculation of the priority score. In the event of such an appeal, the Triage Team will verify the accuracy or the priority score by recalculating it.”

Decisions to withdraw scarce resources:

• “The individuals who are appealing the triage decision should explain the grounds for their disagreement with the triage decision. An appeal may not be brought based on an objection to the overall allocation framework.”
• “Three committee members will be needed for a quorum to render a decision, using a simple majority vote. The process can happen by telephone or in person.”
• “The decision of the Triage Review and Oversight Committee for a given hospital will be final.”
• “The decision of the Triage Review and Oversight Committee will be documented in sufficient detail to demonstrate that the outcome represents a well-considered decision.”

Pg. 22-23

Michigan

Michigan Department of Health and Human Services COVID-19 Practice Management Guide

Appendix H: Patient Care Strategies for Scarce Resource Situations is copied from Minnesota plan.

March 27, 2020

Not addressed.

“Examples of underlying diseases that predict poor short-term survival include (but are not limited to):

• Congestive heart failure with ejection fraction < 25% (or persistent ischemia unresponsive to therapy or non-reversible ischemia with pulmonary edema).
• Severe chronic lung disease including pulmonary fibrosis, cystic fibrosis, obstructive or restrictive diseases requiring continuous home oxygen use prior to onset of acute illness.
• Central nervous system, solid organ, or hematopoietic malignancy with poor prognosis for recovery.
• Cirrhosis with ascites, history of variceal bleeding, fixed coagulopathy or encephalopathy.”

Pg. 71

Not addressed.

Not addressed.

Step 1: Calculate patients’ SOFA score.

Step 2: Compare patients based on the tiered framework (see “Patient Prioritization Factors” column).

Step 3: “Re-allocate ventilator/resource only if patient presenting with respiratory failure has significantly better chance of survival/benefit as compared to patient currently receiving ventilation.”

Pg. 71

Highest priority:

• SOFA score ≤7;
• Good prognosis based upon epidemiology of specific disease/ injury;
• No severe underlying disease;
• Short duration – anticipating <3 days on ventilator;
• Improving ventilatory parameters over time.

Intermediate priority:

• SOFA score 8-11;
• Indeterminate/intermediate prognosis based upon epidemiology of specific disease/injury;
• Severe underlying disease with poor long-term prognosis and/or ongoing resource demand and unlikely to survive more than 1-2 years;
• Moderate duration – anticipating 3-7 days on ventilator;
• Stable ventilatory parameters over time.

Resource re-allocated:

• SOFA score ≥12;
• Poor prognosis based upon epidemiology of specific disease/injury;
• Severe underlying disease with poor short-term prognosis (e.g., life expectancy under 6 months, eligible for admission to hospice);
• Long duration – anticipating >7 days on ventilator;
• Worsening ventilatory parameters over time.

Pg. 71

See “Patient Prioritization Factors” column for required anticipated time to improve for each prioritization level.

Minnesota

Minnesota Crisis Standards of Care Framework: Concept of Operations

Patient Care Strategies for Scarce Resource Situations

Minnesota Crisis Standards of Care Framework: Legal Authority and Environment

May 2020

“Minnesota Statutes Chapter 144 grants the Commissioner of Health broad authority to protect, maintain, and improve the health of the public. In this role, the CSC Framework may be initiated by the Commissioner of Health during a pervasive or catastrophic public health event in the State of Minnesota.”

Concept of Operations, Pg. 3

“In the event the State enacts Crisis Standards of Care to afford protections to medical professionals, MDH will recommend statewide compliance with the MDH Patient Care Strategies for Scarce Resource Situations.”

Concept of Operations, Pg. 17

“Regarding individual volunteers, [the Minnesota Emergency Management Act] states that persons will be considered employees of the State or the local government for purposes of workers’ compensation and tort claim defense and indemnification if those persons:

• Volunteer to assist the State or a local government;
• During an emergency or disaster (not necessarily a declared one);
• Register with the State or local government; and
• Act under the direction and control of the State or a local unit of government.”

Legal Authority, Pg. 14

“Any entity, or an agent acting on its behalf who (1) volunteers without compensation; (2) to assist the State or a local jurisdiction; (3) during an emergency or disaster; who (4) previously registered with the State or local jurisdiction; and (5) acts under direction and control of the State or local jurisdiction; is not liable for civil damages or administrative sanctions as a result of good-faith acts or omissions by that entity or agent in rendering emergency care, advice, or assistance.”

Legal Authority, Pg. 14

“Examples of underlying diseases that predict poor short-term survival include (but are not limited to):

• Congestive heart failure with ejection fraction < 25% (or persistent ischemia unresponsive to therapy or non-reversible ischemia with pulmonary edema).
• Severe chronic lung disease including pulmonary fibrosis, cystic fibrosis, obstructive or restrictive diseases requiring continuous home oxygen use prior to onset of acute illness.
• Central nervous system, solid organ, or hematopoietic malignancy with poor prognosis for recovery.
• Cirrhosis with ascites, history of variceal bleeding, fixed coagulopathy or encephalopathy.
• Acute hepatic failure with hyperammonemia.”

Patient Care Strategies, Pg. 16

Not addressed.

Not addressed.

Step 1: Calculate patients’ SOFA score.

Step 2: Compare patients based on the tiered framework (see “Patient Prioritization Factors” column).

Step 3: “Re-allocate ventilator/resource only if patient presenting with respiratory failure has significantly better chance of survival/benefit as compared to patient currently receiving ventilation.”

Patient Care Strategies, Pg. 16

Highest priority:

• SOFA score ≤7;
• Good prognosis based upon epidemiology of specific disease/ injury;
• No severe underlying disease;
• Short duration – anticipating <3 days on ventilator;
• Improving ventilatory parameters over time.

Intermediate priority:

• SOFA score 8-11;
• Indeterminate/intermediate prognosis based upon epidemiology of specific disease/injury;
• Severe underlying disease with poor long-term prognosis and/or ongoing resource demand and unlikely to survive more than 1-2 years;
• Moderate duration – anticipating 3-7 days on ventilator;
• Stable ventilatory parameters over time.

Resource re-allocated:

• SOFA score ≥12;
• Poor prognosis based upon epidemiology of specific disease/injury;
• Severe underlying disease with poor short-term prognosis (e.g., life expectancy under 6 months, eligible for admission to hospice);
• Long duration – anticipating >7 days on ventilator;
• Worsening ventilatory parameters over time.

Patient Care Strategies, Pg. 16

See “Patient Prioritization Factors” column for required anticipated time to improve for each prioritization level.

Mississippi

Mississippi Crisis Standards of Care

Plan is “classified” as noted on page 2 of this introductory document.

February 21, 2017

“The [Mississippi State Department of Health] CSC planning documents are not intended to reflect the MSDH official policy but to provide healthcare providers and healthcare facilities with options to consider when planning their response to an event in which the decision to allocate scarce resources in a manner that is different from usual circumstances but appropriate to the situation.”

Pg. 4

Classified.

Classified.

Classified.

Classified.

Classified.

Classified.

Missouri

No plan.

Montana

No plan.

Nebraska

No plan.

Nevada

Nevada Crisis Standards of Care (CSC) Plan*

*Plan on file with author. Received plan document via email from Malinda Southard, Public Health Preparedness Program Manager, on 05/22/2020 and confirmed that the plan is not posted online.

March 2020

“[State Disaster Medical Advisory Team (SDMAT)] recommendations are meant as guidance and the provider has the ultimate responsibility of doing what is best for the patient. No current laws would hold medical providers accountable in this situation unless the licensed health care provider is practicing outside their scope AND outside the SDMAT recommendations AND outside licensing board recommendations. Medical providers adhering to SDMAT recommendations during CSC activation will strengthen defenses available and will lead to a better response for recovery.”

Pg. 59

Not addressed.

Not addressed.

Not addressed.

Step 1: Apply inclusion criteria.

Step 2: Calculate patients’ SOFA score.

Step 3: Assign patients to color coded priority groups based on SOFA score.

Pg. 28

• Highest priority: SOFA score ≤7 or single organ failure.
• Intermediate priority: SOFA score 8-11.
• Lowest priority: SOFA score >11.

Pg. 28

Not addressed.

New Hampshire

No plan.

New Jersey

Executive Directive

Allocation of Critical Care Resources During a Public Health Emergency

April 11, 2020

“All health care facilities in New Jersey that possess mechanical ventilators for the care of all patients requiring use of such ventilators must determine whether to adopt a written policy to govern the allocation of mechanical ventilators during the public health emergency arising from COVID-19. Such a policy may, in addition, govern the allocation of other scarce medical resources.”

Executive Directive, Pg. 3

“A health care facility that adopts the Department of Health's model policy Allocation of Critical Care Resources During a Public Health Emergency, as well as the health care facility's agents, officers, employees, servants, representatives and volunteers, shall not be civilly liable for any damages arising from an injury to a patient caused by any act or omission pursuant to, and consistent with, such policy. Such immunity supplements any other immunities and defenses that may apply.”

Executive Directive, Pg. 3

“The allocation framework… does not categorically exclude any patients who, in usual circumstances, would be eligible for critical care resources..”

*Same language is used in Massachusetts and Pennsylvania

Allocation, Pg. 3

“We suggest that life-cycle considerations should be used as a tiebreaker if there are not enough resources to provide to all patients within a priority group, with priority going to younger patients.”

Allocation, Pg. 9

Not addressed.

Step 1: Calculate patients’ priority score using the multi-principle allocation framework using the SOFA scale.

Step 2: Make daily determinations (at least twice per day) of how many priority groups can receive scarce critical care resources based on various grouping approaches:

• “According to their raw score on the 1-8 multi-principle allocation score;” or 
• “By creating 3 priority categories based on patients’ raw priority scores (e.g., high priority, intermediate priority, and low priority);” or
• “Color-sided priority groups.”

Allocation, Pg. 8-10

• “Priority will be given to those with lower [SOFA] scores.”
• Healthcare workers: “Individuals who perform tasks that are vital to the response, including those whose work directly supports the provision of acute care to others, should be given heightened priority… Options include subtracting points from the priority score for these individuals or using it as a tiebreaker criterion.”

Allocation, Pg. 9

According to Step 2, patients are reassessed at least twice per day.

Allocation, Pg. 10

New Mexico

New Mexico Crisis Standards of Care Plan

Pandemic Influenza Plan

Coronavirus Pandemic Plan

2018

July 17, 2019

February 7, 2020

“NMDOH leadership [sic] notifies [the Healthcare Coalition] to activate and support CSC at facility level.”

Pg. 27

Not addressed.

Not addressed.

Not addressed.

Step 1: Apply inclusion criteria.

Step 2: Calculate patients’ SOFA score.

Step 3: Assign patients to color coded priority groups based on SOFA score.

Pg. 34-35

• Highest priority: SOFA score <7 or single organ failure.
• Intermediate priority: SOFA score 8-11.
• Lowest priority: SOFA score >11.

Pg. 35

Not addressed.

New York

Ventilator Allocation Guidelines

November 2015

“The Department of Health is empowered to issue voluntary, non-binding guidelines for health care workers and facilities; such guidelines are readily implemented and provide hospitals with an ethical and clinical framework for decision-making.”

Pg. 8

“There is no guarantee that a court will accept adherence to the Guidelines as a defense against liability should lawsuits arise, and at this time there is no statutory protection for individuals and institutions for actions taken during a public health emergency.”

Pg. 8-9

• Cardiac arrest.
• Irreversible age-specific hypotension unresponsive to fluid resuscitation and vasopressor therapy.
• Traumatic brain injury with no motor response to painful stimulus.
• Severe burns: where predicted survival ≤ 10% even with unlimited aggressive therapy.
• Any other conditions resulting in immediate or near-immediate mortality even with aggressive therapy.

Pg. 57

“…because of a strong societal preference for saving children, the Task Force recommended that young age may be considered as a tie-breaking criterion in limited circumstances. When the pool of patients eligible for ventilator therapy includes both adults and children, the Task Force determined that when all available clinical factors have been examined and the likelihood of survival among the pool of eligible patients has been found equivalent, only then may young age be utilized as a tie-breaker to select a patient for ventilator therapy.”

Pg. 84

“Triage decision-makers should not be influenced by subjective determinations of long-term survival, which may include biased personal values or quality of life opinions.”

Pg. 101

Exclusion criteria “should never rely on subjective judgments on quality of life.”

Pg. 106

Step 1: Apply inclusion and exclusion criteria.

Step 2: Calculate the patient’s SOFA score.

Step 3: Assign the patient to a color-coded priority level based on the SOFA score.

Pg. 54-67

• Highest priority: SOFA score <7 or single organ failure.
• Intermediate priority: SOFA score 8-11.
• No ventilator provided: SOFA score >11 or exclusion criteria.

Pg. 59

 “Periodic clinical assessments at 48 and 120 hours using SOFA are conducted on a patient who has begun ventilator therapy to evaluate whether s/he continues with the treatment. The decision whether a patient remains on a ventilator is based on his/her SOFA score and the magnitude of change in the SOFA score compared to the results from the previous official clinical assessment.”

48-hour assessment:

• Highest priority: SOFA score <7 and decrease in score compared to the initial assessment or SOFA score <11 and decrease in score compared to the initial assessment.
• Intermediate priority: SOFA score <7 and no change in score compared to the initial assessment.
• No ventilator provided: Exclusion criterion or SOFA score >11 or SOFA score 8-11 and no change in score compared to the initial assessment.

120-hour assessment:

• Highest priority: SOFA score <7 and progressive decrease in score compared to the previous assessment.
• Intermediate priority: SOFA score <7 and minimal decrease in score (<3 point decrease in previous 72 hours) compared to the previous assessment.
• No ventilator provided: Exclusion criterion or SOFA score >11 or SOFA score <7 and no change in score compared to the previous assessment.

Pg. 61

North Carolina

No plan.

North Dakota

No plan.

Ohio

No plan.

Oklahoma

Hospital Crisis Standards of Care*

*Draft plan only

April 7, 2020

Draft plan only.

Not addressed.

In resolving ties within priority scores, younger patients may be prioritized.

Pg. 15

“Decision on resource allocation should not consider… perceptions of quality of life…”

Pg. 15

Step 1: Calculate patients’ SOFA score.

• 1 point: SOFA <6
• 2 points: SOFA 6-8
• 3 points: SOFA 9-11
• 4 points: SOFA ≥12

Step 2: Assess patients’ prognosis of long-term survival based on the below list of comorbidities:

2 points:

• Moderate Alzheimer’s disease or related dementia
• Malignancy with a <10 year expected survival
• New York Heart Association Class II heart failure
• Moderately severe chronic lung disease (e.g. COPD, IPF)
• End-stage renal disease in patients <75
• Severe multi-vessel CAD
• Cirrhosis with history of decompensation

4 points:

• Severe Alzheimer’s disease or related dementia
• Cancer being treated with only palliative interventions
• New York Heart Association Class IV heart failure and evidence of frailty
• Severe chronic lung disease plus evidence of frailty
• End-stage renal disease in patients ≥75
• Severe multi-vessel CAD
• Cirrhosis with MELD score ≥20, ineligible for transplant

Step 3: Calculate patients’ total score based on SOFA and long-term prognosis scores.

Step 4: Assign patients to color-coded groups based on priority score.

Pg. 13-15

• Highest priority: Priority score 1-3.
• Intermediate priority: Priority score 4-5.
• Lowest priority: Priority score 6-8.
• Healthcare workers: In resolving ties within priority scores, healthcare workers may be prioritized.

Pg. 14-15

“There should be periodic reassessment of the ongoing utility of the assigned resource after this therapeutic trial, which should consider recalculation of severity of illness scores, inclusion of new complications, and treating clinician’s input.

Patients showing improvement on reassessment after a therapeutic trial should continue with mechanical ventilation until the next assessment.

If at reassessment after a therapeutic trial, there are other patients who need mechanical ventilator support but have not been allocated this resource, patients who have experienced clinical deterioration during their therapeutic trail should have mechanical ventilation withdrawn (and reallocated to other patients).”

Pg. 15

Oregon

Oregon Crisis Care Guidance

June 2018

O.R.S. 401.025 permits the Governor to “declare an emergency or a public health emergency under certain circumstances.”

Pg. C-1

“Following a declaration of emergency, the Governor may take necessary actions to respond to the emergency, including suspending a state order or rule if compliance with the order or rule would ‘prevent, hinder or delay mitigation of the effects of the emergency.’” O.R.S. 401.168, 401.175.

Pg. C-2

“Based on the goal to maximize the number of lives saved in a sustained public health crisis, people with confirmed advanced disease or severe injury for which the average life expectancy is less than six to twelve months will be referred to less aggressive care rather than aggressive, critical care. These conditions include advanced illnesses such as cancer with spread to distant parts of the body, heart failure, liver disease, neurologic disease, or other conditions with an average life expectancy of less than six to 12 months.”

Pg. E-2

Life expectancy less than 6-12 months is an exclusion criterion.

Pg. E-2

“Care decisions should not be based on non-clinical factors such as…clinician-perceived quality of life…”

Pg. 7.

Step 1: Apply inclusion criteria.

Step 2: “Triage decisions should be based on integrating assessments in two principal areas:

1) The likelihood of death, based on the best information available, if the presenting patient does not receive critical care services, and

2) The likelihood of survival and recovery from the current illness or injury if critical care services are provided.

Additional relevant, but not over-riding considerations include:

3) The expected scope and amount of medical resources that would be needed to provide critical care for this patient and the scarcity of those resources, and

4) Underlying medical conditions (other than those listed as critical care exclusion criteria) and their expected impact on the patient’s long-term prognosis. In regard to the first two areas, critical care triage decisions should be made using best clinical judgment and, as noted above, should be based on objective clinical measurements. The authors recognize that different tools have been developed to guide critical care decision-making.”

Pg. E-3 – E-4

Not addressed.

“Any patient occupying an intensive care unit bed at the onset of a public health crisis of a severity and pervasiveness requiring implementation of this triage model should be reassessed periodically in accordance with the critical care triage principles outlined above. Patients who do not meet criteria for critical care should be transferred out of the intensive care unit for less aggressive medical treatment or palliative care.”

Pg. E-5

Pennsylvania

Interim Pennsylvania Crisis Standards of Care for Pandemic Guidelines

April 10, 2020

Not addressed.

“The allocation framework … does not categorically exclude any patients who, in usual circumstances, would be eligible for critical care resources.”

*Same language is used in Massachusetts and New Jersey

Pg. 29

“In the event that there are ‘ties’ in priority scores between patients and not enough critical care resources for all patients within the prioritized group, life-cycle considerations should be used as the first tiebreaker, with priority going to younger patients.”

Pg. 33

Not addressed.

Step 1: Apply inclusion criteria.

Step 2: Calculate patients’ priority score based on the SOFA score and “prognosis for continued survival (medical assessment of underlying conditions that severely limit life expectancy).”

• 1 point: SOFA <6
• 2 points: SOFA 6-8
• 3 points: SOFA 9-11
• 4 points: SOFA ≥12
• 2 points: “Major underlying conditions that limit near-term prognosis; death likely within 5 years”
• “4 points: Severely life limiting conditions; death likely within 1 year”

Step 3: Assign patients to color-coded groups based on priority score.

Step 4: Make a daily determination of how many groups can receive critical care resources based on the color-coded groups.

Pg. 29-32

• Highest priority: Priority score 1-3.
• Intermediate priority: Priority score 4-5.
• Lowest priority: Priority score 6-8.
• Pregnant women: “If a pregnant patient at or beyond usual standards for fetal viability, the patient will be given a two-point reduction in their priority score.”
• Healthcare workers: “Individuals who are engaged in tasks that are vital to the public health and health care response, including all those whose work directly supports the provision of acute care to others, including those who provide wraparound supports to the provision of acute care to others, should be given heightened priority.”

Pg. 32-34

“All patients who are allocated critical care services will be allowed a therapeutic trial of a duration to be determined by the clinical characteristics of the disease… Evaluation of patients undergoing critical care/ventilation for other medical conditions may also need to be reassessed at appropriate durations. However, patients who are utilizing personal (supplied by the patient, not supplied by the hospital where they present for care) ventilators for pre-existing respiratory conditions, should NOT be separated from their personally provided equipment for reallocation to other patients.”

Pg. 34

Rhode Island

Crisis Standards of Care Guidelines

April 27, 2020

“RIDOH is empowered to issue voluntary, non-binding guidelines for healthcare workers and facilities; such guidelines are readily implemented and provide hospitals with an ethical and clinical framework for decision-making.”

Pg. 9

“A patient who is screened for a medical condition associated with a short life expectancy, regardless of their current acute illness, will be classified as not eligible for a triaging assessment for potential use of a scarce critical resource.”

Pg. 18

“Healthcare may have, as part of their [Crisis Standards of Care] Program, an exclusion step prior to triage.”

Examples of Exclusion Criteria:

• Cardiac arrest.
• Traumatic brain injury with no motor response to painful stimulus.
• Severe burns.
• End-stage organ failure.
• Terminal conditions (“to a reasonable degree of medical certainty, death will occur within six months”).

Pg. 23

Treated as an exclusion criterion whereby patients with a short life expectancy “will be classified as not eligible for a triaging assessment for potential use of a scarce critical resource.”

Pg. 18

“Prioritization for access to critically scarce lifesaving resources should not depend on necessarily subjective assessments of quality-of-life.”

Pg. 19

“The most common triage tool of survivability for adults is [SOFA] tool.”

Pg. 18

• Highest priority: SOFA score ≤ 7.
• Intermediate priority: SOFA score 8-11.
• Defer/discharge: No SOFA score.
• Lowest access/palliate/discharge: SOFA score >11.

Pg. 19

“All patients who are allocated critical-care services will be allowed a therapeutic trial period… These assessments involve recalculating the triage score. Clinical improvement or decline while receiving treatment via a critical resource is taken into consideration at each re-assessment. If there are patients waiting for critical-care services, then patients who, upon reassessment, show substantial clinical decline may be considered for withdrawal of the critical resource.”

Pg. 19

South Carolina

South Carolina Prepares for Pandemic Influenza: An Ethical Perspective

September 2009

The plan only recommends that the Department of Health and Environmental Control “should determine the use of its authorities under its basic public health authorities and the Emergency Health Powers Act, Sections 44‐4‐100 to ‐570, to trigger a statewide implementation of the [pandemic flu guidelines] for triage and treatment during a [Pandemic Influenza Public Health Event].”

Pg. 35

• People with very poor prognosis/chance of survival even when treated with aggressive critical care:
• Severe burns or inhalation injury.
• Unwitnessed or recurrent cardiac arrest patients or no response to prompt electrical interventions.
• Patients with a SOFA score > 11 whose mortality rate exceeds 90% even with full critical care during normal circumstances.
• People needing level of resources that cannot be met during pandemic ‐ trauma or medical conditions requiring high volume blood transfusions, due to high mortality and limited supply of uninfected blood products.
• People with advanced medical illnesses with high short‐term mortality even without concurrent critical illness:
• Advanced cancer or immunosuppression.
• End‐stage organ failure.

Pg. 65-66

In choosing between patients of equal SOFA scores, “maximizing the number of ‘life‐years’ saved and prioritizing younger patients to offer opportunities to live through life’s stages” may apply.

Pg. 30

Not addressed.

“Triage officers will determine who may received [sic] critical care, specifically ventilator support, based upon [SOFA] as a decision rule.”

Pg. 30

• Highest priority: SOFA score ≤ 7 or single organ failure.
• Intermediate priority: SOFA score 8-11.
• Medical management or palliative care: SOFA score >11 or excluded patients.

Pg. 67

Patients’ SOFA score should be reassessed at 48 hours and every 24 hours thereafter.

48-hour assessment:

• Highest priority: SOFA score <11 and decreasing.
• Intermediate priority: SOFA score <8 and no change.
• Palliative care: SOFA score >11, 8-11 and no change, or excluded patients.

96-hour assessment:

• Highest priority: SOFA score <11 and decreasing progressively.
• Intermediate priority: SOFA score <8 and minimal decrease (“<3 point decrease in the past 48 hours”).
• Palliative care: SOFA score >11, 8-11 and no change, or excluded patients.

Pg. 68-69

South Dakota

No plan.

Tennessee

Guidance for the Ethical Allocation of Scarce Resources during a Community-Wide Public Health Emergency as Declared by the Governor of Tennessee

2020

“T.C.A. Section 58-2-107 § (e)(1) states that the Governor may: Suspend any law, order, rule or regulation prescribing the procedures for conduct of state business or the orders or rules or regulations of any state agency, if strict compliance with any such law, order, rule, or regulation would in any way prevent, hinder, or delay necessary action in coping with the emergency;

§(l)(2): If additional medical resources are required, the governor, by executive order, may provide limited liability protection to health care providers, including hospitals and community mental health care centers and those licensed, certified or authorized under titles 33, 63 or 68, and who render services within the limits of their license, certification or authorization to victims or evacuees of such emergencies; provided, however, that this protection may not include any act or omission caused by gross negligence or willful misconduct.”

Pg. 11

“Those whose underlying medical issues make their imminence of mortality probability so high that it is not reasonable to allocate critical care resources to them in a crisis situation, based on survivability probability and an individualized assessment rather than a categorical exclusion.”

Pg. 8

Not addressed.

“…persons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative “worth” based on the presence or absence of disabilities or age.”

Pg. 12

“Use hospital and ICU/ventilator admission triage algorithm and tools…to determine which patients to send home for palliative care or medical management and which patients to admit or keep in hospital or ICU.”

Pg. 19

• Highest priority: SOFA score 1-7.
• Intermediate priority: SOFA score 8-11.
• Lower priority: SOFA score >11.

Pg. 20

“Reassess need for ICU/ventilator treatment daily after 48-72 hours of ICU care.”

Daily reassessment:

• Highest priority: SOFA score <8 to <11 and decreasing.
• Intermediate priority: SOFA score increasing or 8-11.
• Lower priority: SOFA score >11.

Pg. 19

Texas

No plan.

Utah

Utah Pandemic Influenza Hospital and ICU Triage Guidelines

August 11, 2009

“Guidelines should be activated in the event of pandemic influenza or other public health emergency declared by the governor of the state of Utah.”

“These triage guidelines apply to all healthcare professionals, clinics, and facilities in the state of Utah.”

Pg. 1

• Known DNR status.
• Severe and irreversible chronic neurologic condition with persistent coma or vegetative state.
• Acute severe neurologic event with minimal chance of functional neurologic recovery (physician judgment). Includes traumatic brain injury, severe hemorrhagic stroke, hypoxic ischemic brain injury, and intracranial hemorrhage.
• Severe acute trauma with a revised trauma score <2.
• Severe burns with <50% anticipated survival.
• Cardiac arrest not responsive to ACLS interventions within 20-30 minutes.
• Known severe dementia medically treated and requiring assistance with activities of daily living.
• Advanced untreatable neuromuscular disease (such as ALS, end-stage MS, or SMA) requiring assistance with activities of daily living or requiring chronic ventilatory support.
• Known chromosomal or untreatable disorders that are uniformly fatal in the first 2 years of life.
• Incurable metastatic malignant disease.
• End-stage organ failure meeting various criteria.
• Age:
• Triage Level 1: >95 years.
• Triage Level 2: >90 years.
• Triage Level 3: >85 years.

Pg. 5

Treated as an exclusion criterion whereby older patients are excluded based on triage level:

• Triage Level 1: >95 years.
• Triage Level 2: >90 years.
• Triage Level 3: >85 years.

Pg. 5

Not addressed.

Step 1: Apply inclusion and exclusion criteria.

Step 2: “Interpret mSOFA score along with physician judgment about patient condition” to determine priority level.

Pg. 4

• Highest priority: mSOFA score <8 or <11 and decreasing.
• Intermediate priority: mSOFA score increasing or 8-11 unchanged.
• Lower priority: mSOFA score >11.

Pg. 4

“Reassess daily after 48-72 hrs ICU care to determine continued priority for ICU/ventilator.”

Pg. 4

Vermont

Vermont Crisis Standards Care Plan

May 18, 2020

(Crisis Standards of Care Mechanical Ventilator Allocation Assistance Guide specific to COVID-19 expires on July 31, 2020 and requires revision and reapproval at that time.)

Requires a declaration of emergency by the Governor as authorized by 20 V.S.A. § 9.

20 V.S.A. § 20(a) provides that the “state, any of its agencies, state employees as defined in 3 V.S.A. § 1101, political subdivisions, local emergency planning committees, or individual, partnership, association, or corporation involved in emergency management activities shall not be liable for the death of or any injury to persons or loss or damage to property resulting from an emergency management service or response activity, including the development of local emergency plans and the response to those plans.”

20 V.S.A. § 20(b) provides that “[a]ny individual, partnership, association, corporation or facility that provides personnel, training or equipment through an agreement with the local emergency planning committee, the state emergency response commission or local emergency response officials is immune from civil liability to the same extent as provided in subsection (a) of this section for any act performed within the scope of the agreement.”

Pg. 19-22

• Severe trauma with poor expected outcome.
• Severe burns with any two of the following: >60 yrs. of age; >40% of body surface area affected; or co-existent inhalational injury.
• Unwitnessed, recurrent or unresponsive cardiac arrest.
• Metastatic malignant disease with poor expected response to therapy.
• Co-existent end-stage failure of a major organ (e.g. heart, lung, liver, or brain) with poor prior prognosis.

Pg. 45

Not addressed.

Not addressed.

Step 1: Apply inclusion and exclusion criteria.

Step 2: Among patients who were not excluded by the criteria above, patient illness severity is judged by the mSOFA score.

Step 3: Determine patient triage code based on patient mSOFA score is used to determine.

Step 4: Engage Appeals Team, as necessary (see “Miscellaneous” column).

Step 5: Use randomization system to differentiate patients if providers are still unable to identify patients most likely to benefit from mechanical ventilator.

Pg. 40-43

• Highest priority: mSOFA score 4-7.
• Intermediate priority: mSOFA score 8-11.
• Lower priority: mSOFA score 0-3 and >11.

Pg. 47

Not addressed.

Appeals: University of Vermont Health Network Fair Resource Allocation Appeals Team may be contacted if uncertainty arises or disputes exist among the patient’s clinical care team. The Appeals Team may review and re-prioritize patients based on medical factors permitted in Steps 1-3 but may not consider social factors, including “any disability or degree of disability including physical disability, developmental/cognitive disability, functional status, mental health diagnosis, chronic disease diagnosis, infectious diseases such as HIV, HCV, etc.”

Pg. 41-42

Virginia

No plan.

The 2009 Critical Resource Shortages Planning Guide advises healthcare delivery organizations on steps they should take to create their own plan.

Washington

Scarce Resource Management & Crisis Standards of Care*

*Plan has the Washington State Department of Health logo but is not on the Department website and can only be found on the Northwest Healthcare Response Network website.

Undated.

Not addressed.

Step 1 of the allocation determination process states: “If resources are inadequate, consider transferring the following patients to out-patient or palliative care with appropriate resources and support as can be provided”:

• Pre-existing or Persistent coma or vegetative estate
• Severe acute trauma (e.g. non-survivable head injury)
• Severe burns with Low Survival burn scores based on the Triage Decision for Burn Victims table
• Significant underlying disease process that predict poor short-term survival, including but not limited to:
• Severe congestive heart failure
• Severe chronic lung disease
• Central nervous system, solid organ or hematopoietic malignancy with poor prognosis for recovery
• Severe cirrhotic liver disease with multi-organ dysfunction
• Baseline functional status (consider loss of reserves in energy, physical ability, cognition and general health)

Pg. 34

Not addressed.

Not addressed.

Step 1: “Screen adult patients for ICU care during scarce resources” (See “Exclusionary Criteria” column to the left.)

Step 2A: Apply inclusion criteria.

Step 2B: “To determine critical care resource allocation the following should be considered:

• Expected duration of need of critical care resource
• Prognosis with consideration to both current epidemiology and underlying illness
• Response to current treatment
• Degree of Organ Dysfunction as measured by the MSOFA
• Baseline functional status (consider loss of reserves in energy, physical ability, cognition and general health).”

Step 3: Assess for re-allocation (see “Time to Improve or Reassessment” column to the right).

Pg. 34-35

See Step 2B.

“To determine critical care resource allocation the following should be considered:

• Expected duration of need of critical care resource
• Prognosis with consideration to both current epidemiology and underlying illness
• Response to current treatment
• Degree of Organ Dysfunction as measured by the MSOFA
• Baseline functional status (consider loss of reserves in energy, physical ability, cognition and general health).”

“It is recommended that every 24 hours of a patient’s ICU stay, their clinical condition will be reviewed and they will be determined to be “Improving”, “Unchanged” or “Worsening”. This determination must not only take into account data points as outlined in Step 6 but must also include updated epidemiology, critical care resource availability and census demands.”

Pg. 35-36

West Virginia

No plan.

Wisconsin

No plan.

Wyoming

No plan.