Today the Governor's Expert Emergency Epidemic Response Committee voted to update the crisis standards of care guidelines to take into consideration the challenges presented by COVID-19.

Crisis standards of care are recommendations for how the medical community should allocate scarce resources, such as ventilators and intensive care unit beds, in the extreme case when patient needs exceed available resources. In dire circumstances where resources become limited, the Governor or a designated public health official may declare a Public Health Emergency within which crisis standards of care are authorized, sanctioning the provision of medical care at levels of quality that would otherwise be significantly less than optimal.

“The state has been working hard to avoid having to use these standards,” said Dr. Eric France, chief medical officer at the Colorado Department of Public Health and Environment. “We’re working with the hospitals to increase the number of ICU beds and ventilators to try and meet the anticipated demand. We need everyone’s help to slow the spread of the virus by following public health orders, to reduce the likelihood of putting these standards into practice.” 

Colorado developed crisis standards of care recommendations in 2018, but they are not specific to the challenges presented by COVID-19. A recent American Hospital Association webinar on COVID-19 projected that 5% of COVID-19 patients would be hospitalized, 40% of those would be admitted to the ICU, and 50% of the ICU admissions would require a ventilator. The majority of patients with COVID-19 who experience respiratory failure require mechanical ventilation for more than 12 days. 

“We hope to never get to a point where the Colorado health care system is so stretched that it does not have adequate resources,” said Dr. Stephen Cantrill, Denver Health emergency physician who served in the group of experts who developed the recommendations. “We never want to have to resort to crisis standards of care. But we’ve worked with experts and received community feedback to develop recommendations that we believe are equitable and ethical in case we do have to put them into effect.”

A group of experts have been working to update these standards in the event that they need to be activated in Colorado during the COVID-19 pandemic. Several sub-groups reviewed the content, and community feedback and engagement were used throughout the process to update these recommendations. 

Details about the updated crisis standards of care include:

• A triage team should consist of:

1) an expert on ethics or palliative care

2) an attending physician familiar with critical care (e.g. hospitalist or critical care physician)

3) a representative of nursing staff

4) a representative of the hospital’s leadership. 

• The primary medical team caring for a patient SHOULD NOT be involved in crisis triage decision-making for their own patient. Each institution should create a crisis triage team that is objective and removed from the patient. 
• Triage teams SHOULD NOT base decisions on factors clinically or ethically irrelevant to the triage process, for example:
  • race
  • ethnicity
  • ability to pay
  • disability status
  • national origin
  • primary language
  • immigration status
  • sexual orientation
  • gender identity
  • HIV status
  • religion
  • veteran status
  • “VIP” status
  • criminal history
• When personal protective equipment (PPE) is scarce, health care providers may extend the use of or reuse some PPE, or may use alternate equipment to provide some protection from disease transmission.
• Each hospital should have a crisis triage team that will be activated in a crisis when a hospital approaches its minimal operating capacity for resources like ventilators. The triage team should use a tiered approach for allocation/re-allocation of scarce resources like ventilators. In the event of a tie within a tier, the triage team should move to the next tier of considerations.
  • Tier 1: A scoring system based on a combination of acuity or severity of acute illness (the likelihood of surviving weeks) and morbidity, or measures of chronic illness (the likelihood of surviving months to years).
  • Tier 2: Pediatric patients, health care workers and first responders.
  • Tier 3: Special considerations (pregnancy, life-years saved, sole caregivers).
  • Tier 4: Random allocation.

The state health department recommends that everyone has an advanced directive that is shared with their loved ones. An advanced directive, also called a “living will,” can name a health care power of attorney and outlines what kind of medical interventions a person wants and doesn’t want. It is the best way to take control and ensure your wishes are carried out should you be unable to communicate them to a doctor.  

The workgroup aligned Colorado’s guidelines with the National Academies of Sciences, Engineering, and Medicine’s Rapid Expert Consultation on Crisis Standards of Care for the COVID-19 Pandemic, which was published in March 2020.

A fact sheet about the crisis standards of care for hospitals for the COVID-19 pandemic are linked here. The crisis standards of care documents are available here.

Continue to stay up to date by visiting covid19.colorado.gov.