Arizona Department of Health Services activates plan to ration healthcare for COVID-19 patients
2 July 2020
The state of Arizona, and the American Southwest more generally, have become a new epicenter of the coronavirus pandemic. This region was among the first where state governments ended lockdowns and other restrictions, and record infections and rising deaths are the consequence.
On Wednesday, Arizona, with over 84,000 cases (24,118 cases in one week), surpassed its previous one-day high set on Tuesday with 4,877 new cases and 88 fatalities. The death toll for Arizona stands at 1,720 (257 deaths since last week). With a per capita infection rate of 43 new daily cases per 100,000 residents on a seven-day rolling average, Arizona leads nationally, with Florida second with 34 new cases per 100,000 residents.
By way of comparison, New York state with 2,009 total cases per 100,000 residents experienced a one percent rise since June 24. Arizona, with 1,290 total cases per 100,000, experienced a 40 percent increase. With testing capacity strained, 28 percent of diagnostic tests are returning positive, which indicates both dwindling resources as well as a significantly entrenched community transmission.
Last Friday, Arizona hospitals asked their state’s health department to formally activate the “Crisis Standards of Care” guidelines that would provide hospitals the legal right to determine who and how patients should be treated for the coronavirus. This essentially means hospitals will have to decide who receives life-saving measures and who will not.
Throughout June, the local media, via updates from the health department, had been highlighting Arizona hospitals’ dwindling ICU capacity. The plan ushered in with the words “a compassionate and ethically-based healthcare response for catastrophic disasters within the State of Arizona” went into effect Monday afternoon.
The Arizona Department of Health promulgated a COVID-19 addendum for the allocation of scarce resources in acute care facilities back in April during the initial surge of the pandemic in the United States. Health systems throughout the country were facing severe shortages of PPEs and testing capacity. Based on estimates provided by various health officials, concerns were raised that there would be insufficient capacity to ventilate patients. Equally distressing was the shortage of critical care capacity at health systems overwhelmed by COVID-19 cases. Experiences in Italy had raised the issue of how to allocate limited resources to patients in critical condition infected with COVID-19.
The proposal, written in careful medical-legal jargon, was drafted by the chief medical officers of the University of Arizona College of Medicine, Abrazo Healthcare, Carondelet Healthcare, Common Spirit Arizona Division Dignity Health, Banner Health, and Phoenix Children’s Hospital. They wrote that “it is the intention of Arizona health systems to collaborate such that no system reaches a contingency or crisis level unless all do … if time does not permit and/or other facilities are short on critical resources (hospital beds, ICU beds, ventilators, dialysis machines, etc.), triage protocols as outlined here will go into effect.”
When a “Crisis Standards of Care” is implemented, a facility system Incident Commander will coordinate priorities within the Emergency Operations Center. At the same time, the triage officers review cases according to protocols and guidelines approved by the Department of Health. Infected patients who have arrived for life-saving treatments and critical care at the hospital will have to first undergo an assessment on “the best available relevant and objective medical evidence.”
Patients are given a scorecard that assigns them a “triage priority score” based initially on their Sequential Organ Failure Assessment (SOFA) Score [from 1 to 4], a mortality prediction score that is based on the degree of dysfunction of six organ systems—respiratory, cardiovascular, liver, coagulation, kidney and neurological systems. The higher the score, the higher the predicted mortality rate.
Though the guidance states that age will not be a factor in triaging, the second step involves determining the individual’s 1-year or 5-year mortality. The SOFA score is added to the mortality score—ranging from 1 to 8—after which a triage color grouping is assigned—Red for those expected to survive, while Yellow then Blue are afforded the lowest priority for critical care resources. Treating physicians are recused from decisions regarding the allocation of “scarce resources.”
However, if resources remain exceptionally dire—two patients needing one resource—additional factors may need to be addressed in a manner that seems like a coin toss but includes such considerations as whether those being treated are pediatric patients, frontline workers, single caretakers of minors, pregnant patients, and those deserving the opportunity to experience life stages, which brings age back into the equation.
As the final throwing up of the hands, to quote, “if patients requiring the same scarce resource cannot be effectively prioritized with any of the above, the allocation should proceed randomly.” Though the process allows for appeals, triaging of patients is continuously assessed throughout the admission. Motions could be denied in matters that are time-critical and insufficient to conduct the appeal.
Will Humble, former director of the Arizona Department of Health Services, speaking on MSNBC’s “Rachel Maddow Show” on June 27, said, “Standard of care changes when you get into surge status … when they [governors and elected officials] start talking about hospital capacity as a control measure, as an endpoint for how they are going to manage this epidemic, start worrying. What you really should be doing is putting together policies in place to change people’s behavior, to slow the spread of the virus, so you don’t end up like us in crisis standards of care.”
However, Governor Doug Ducey's response to this catastrophe has been insensitive and irresponsible, even while knowing that the peak in the surge is yet to arrive. Insultingly, he has announced band-aid measures with the closure of bars, nightclubs, and outdoor waterparks for 30 days while pushing back school openings two weeks to August 17. He continues to refuse to mandate face masks in public. During his press brief on Monday, he said, “This is not another executive order to enforce, and it’s not about closing businesses. This is about public education and personal responsibility … do it for your family, for your friends, for your neighbors, for our frontline healthcare workers. You can help reduce the risk for the most vulnerable in our society.”
As part of a damage control effort, Vice President Pence and the Coronavirus Task Force flew in to meet with Ducey on Wednesday to attempt to shore up confidence in the governor’s failed leadership and ensure Arizona holds a steady course as a retreat would reflect poorly on the Trump campaign’s efforts.
After congratulating Ducey for his handling of the pandemic, Pence admitted that the governor had requested 500 medical personnel to assist with the devolving health disaster. He also acknowledged that “something changed in the middle of May” that led to the rapid surge of COVID-19 cases. He added that the United States had to “keep our economy moving forward and get our kids back to school.”
All the warnings by hospitals, health officials, and epidemiologists appear to have had little influence or weight on Ducey and other state and local officials, who were only more than eager to throw the doors wide open in early May for business, commerce, social events, and political rallies all the while remaining utterly indifferent to the developing calamity which amounts to criminal negligence.
There are currently 2,793 patients hospitalized with 683 in the ICUs (89 percent full) and 465 on mechanical ventilators. Some Arizona nurses have commented on social media that high flow oxygen was exceedingly difficult to find for two local hospitals in Maricopa County. They also listed a shortage of Propofol and Precedex, two essential medications for sedating patients before intubating them. Many nurses and physicians have sounded the alarm that Arizona needs to lock down. A petition drafted on June 28 with over 1,000 signatures is being sent to the Governor.