As out-of-state health-care workers arrive to help Tucson with the recent surge in coronavirus patients, Scott Speder worries about his son and the measures that could arise if the health crisis continues to worsen.
The Arizona Department of Health Services activated crisis standard of care plans Monday to help hospitals increase bed capacity, share resources like ventilators and address critical staffing shortages in the fight against a virus that’s killed more than 280 people in Pima County since late March.
Most recent data provided by Pima County show that ICU beds were at 91% capacity as of Thursday. Statewide that total reached 91% Friday, a new record. Because of the July 4 holiday, the data for the county will not be updated again until Monday.
If the crisis gets bad enough and resources scarce enough, the state’s plan provides guidelines for what’s called triaging care, which can include determining which patients get critical care based on likelihood of survival.
That’s the part of the plan that Speder, the father of an 8-year-old boy who has Down syndrome, can’t reconcile.
Speder and his wife, Pamela, first heard of triaged care when COVID-19 numbers were running high in New York City and staffing, hospital beds and resources were running low. Speder was sickened to think Matthew, in such a scenario, might not get the same attention as another child.
“To somehow decide who gets care and who doesn’t is appalling,” he said. “All of our scores are different but that’s not a measure of anything other than our diversity.”
“Life and death situations”
Triaging care is an issue that’s being discussed — and often criticized — as the pandemic continues to worsen in some states. Critics say health care should not be a business enterprise, and that triaging care is a result of cutting staff and costs to maximize profit.
“The Crisis Standards of Care (CSCs) activated in Arizona should be revised immediately and brought into compliance with civil rights protections that bar discrimination on the basis of age or disability, among other factors, as Tennessee has recently done,” said Matt Valliere, executive director of the national Patients Rights Action Fund.
“As with other life-and-death situations, like assisted suicide qualifications, faulty prognoses only increase the chances that people with disabilities, the elderly, and other vulnerable groups will not receive equal care if they become sick because their perceived quality and length of life may be less than others.”
In Arizona, 14 people involved with advocacy groups signed an Arizona Center for Disability Law letter to Gov. Doug Ducey this week, asking that the state modify its plan and better protect people with disabilities, the elderly and minority populations particularly vulnerable to the new coronavirus.
The June 23 letter asks that the state prohibit health-care decisions based on disability, perceived quality of life, age, underlying conditions or a person’s need for disability-related accommodations.
“To be clear, no Arizona hospital is triaging care,” said Ducey spokesman Patrick Ptak, when asked about the crisis plan. “We are working diligently with our hospitals and health-care leaders and local and federal partners to ensure we continue to have capacity and adequate staffing across the state.”
Ptak said hospitals are instead utilizing a surge hotline to balance patient loads and manage workloads.
“Arizona has planned and prepared for a surge in cases and will continue to work to ensure everyone has access to care who needs it,” he said. “This was done proactively to help hospitals prepare surge capacity and give hospitals the ability to address space, staff and resource constraints should this capacity be needed.”
People should not equate surge protocols with triage protocols, said Chris Minnick, a Department of Health Services spokesman.
“We want to make sure people understand what’s happening in the hospital system and why this was implemented,” he said. “We don’t ever want it to get to that point (of triaging care), and Arizona is nowhere close to that now.”
Hospital situation called stable, for now
Despite the uptick in cases, Dr. Francisco Garcia, the county’s chief medical officer, labeled the county’s hospital situation as “stable,” with the caveat that things can change quickly.
“We should not be complacent by any extent of the imagination,” he said. “We need to plan for a situation that continues to get worse and celebrate when that doesn’t happen.”
Garcia speaks with local hospital CEOs every day, and said issues with staffing and supplies are the two most critical problems right now.
To help, he said hospitals can share equipment, such as ventilators, and the county recently acquired additional ventilators should they become necessary. They’ve had some issues procuring remdesivir, the drug that has been shown to aid patients with the virus, and are working on building their supply to provide to hospitals, Garcia said.
“This is serious when you’re bringing in personnel from other places to supplement your capacity,” he said. Invoking crisis standards for care “means hospitals are not operating in the normal order.”
While the hospitals are not using triage protocols, Garcia said what’s happening is forcing them to think about the seriousness of the situation.
“It forces us to sort of say that at some point we need to make explicit choices about who gets care and what kind of care they get and that is uncomfortable for us,” Garcia said.
“It certainly is uncomfortable for me to think about that. But I would also not be doing my job if we didn’t at least start to plan for something like that should it become necessary.”
“Running a bare margin for years”
Working under extreme stress and fear of infecting themselves with coronavirus, seven local medical workers, including doctors, nurses and technicians, spoke to Arizona Daily Star but requested to remain anonymous because they said their employers — Banner Health and Carondelet Health Network — prohibit them from speaking to reporters.
At Banner-University Medical Center South, 2800 E. Ajo Way, the last couple of weeks have included ventilator shortage scares, very sick patients crowding the waiting room and sometimes dying in the emergency room. And at both Banner medical centers, including a second one at 1625 N. Campbell Ave., staff members have been upset about only some workers getting “hot-shot bonuses” for their work with COVID-19 patients.
A technician at one of the Banner medical centers said that while “ICU nurses deserve a bigger bonus” than anyone else, “everyone working directly with COVID-19 patients should be considered a hot-shot worker.”
“We have been suffering under horrible work conditions,” the technician said. “And now, to be working and not getting recognized at all ... .”
A Banner doctor also criticized the singling out of only certain staff members.
“If they don’t feel valued, you’re undermining your greatest resource,” the doctor said, adding that’s the problem with for-profit medicine. “If it’s revenue-driven, why invest in the things that bring you the least amount of money?”
Banner has eligibility criteria for the hot-shot bonus, said Rebecca Ruiz Hudman, a spokeswoman.
“We recognize that it may be disappointing not to meet the eligibility criteria,” she said, without providing specifics.
“We value all of the team members who have been contributing so much during this pandemic.”
One doctor employed by Carondelet, which includes St. Mary’s Hospital, 1601 W. St. Mary’s Road and St. Joseph’s Hospital, 350 N. Wilmot Road, said problems with staffing and “frightening health protocols” are common at all hospitals and are “the effect of the corporatization of medicine, where metrics and productivity goals and finances trump adequate staffing to provide quality medical care.”
“I can tell you that one of the big issues is that unlike the flu, where admissions are typically in for only a few to several days and rarely require prolonged hospitalization, COVID is very different,” the doctor said.
“Many more patients require ICU care and are hospitalized for weeks on end, taking up vital resources and staff, which then creates a backlog to the whole system that has been running a bare margin for years.”
COVID-19 patients are staff-intensive
At Tucson Medical Center, a team of 42 nurses, physicians, nurse practitioners, pharmacists, paramedics, physician assistants and respiratory therapists came from out of state to increase staffing capacity after state and county officials requested federal assistance last week.
They started work at the hospital last week and will stay in Pima County until July 11.
“The infusion of staff will assist us in opening more ICU beds. We regularly use temporary ‘travel’ support — this is just from a different source and is more coordinated. We believe we will learn a lot from the experiences of this team in other markets and it will make us better prepared for the months to come,” said TMC spokeswoman Angela Pittenger.
Banner Health, which operates two Tucson facilities, has plans to bring in additional staff workers for support. That included 22 at Banner University last week, and is a combination of contracting with agencies to bring in out-of-state nurses, but also hiring new staff workers, rehiring retired workers, transferring medical professionals from other Banner hospitals out-of-state, or teaching nurses new skills.
“COVID-19 patients require an extensive amount of care — more than what you would expect of a typical ICU patient. That means that our ICUs currently require more staff to care for these patients,” Ruiz Hudman, the Banner spokeswoman, said.
At Carondelet, officials are “working aggressively to secure additional staff and protect our current staff to continue to manage the increase in COVID-19 patients,” according to spokeswoman Angela Martinez.
That, and pressure from health-care professionals across the state, prompted Dr. Cara Christ to activate the crisis care plan that usually guides the allocation of treatment based on factors like likelihood for survival.
Local hospitals said they are taking part in surge plans and are prepared to make modifications, but all reported that they are not following triage protocols laid out in the state’s health guidelines, like divvying up treatment and creating scores for each patient based on survival probability.
“At this time, we have not activated crisis care standards and have no immediate plans to do so,” Northwest Medical Center spokeswoman Veronica Apodaca said in a prepared statement. “While we continue to see an increase in COVID-19 patients, we remain ready to care for the community.”
Others, like the Southern Arizona VA Health Care System, recently reached agreements to take other patients from taxed hospitals. They’ll be able to care for up to five nonveteran patients starting July 6 for a period of 30 days.
“The SAVAHCS has assembled a work group to oversee a plan for admission, discharges and coordination of care for these patients,” VA spokesman Stan Holmes said.
“Upholding my oath to do no harm”
Matt Heinz, a doctor at Tucson Medical Center, said treating patients with coronavirus is extremely stressful because they have severe symptoms and require targeted medical care. He said many of his most recent patients have been under the age of 35.
He said patients might require multiple infusions of medicine, might be in medically induced comas, have other chronic diseases or might be on ventilators, where the longer they are on the machines the less likely they are to survive.
Staff shortages have been prevalent in his 17 years in Tucson, Heinz said, and now that it’s being compounded by the virus, he welcomes outside help. Some nurses are being asked to work one or two extra shifts a week, he said.
Bed shortages aren’t an issue, Heinz said, because you can create hospital beds in places like stadiums or dormitories but still need the health workers and ventilators to treat patients.
Heinz, who is a candidate for the county’s Board of Supervisors, said he would like to see the state impose a statewide mask requirement to eliminate confusion over local protocols.
What he said hasn’t been helpful are the triage protocols, which he believes would not be followed by nurses and doctors if they ever actually go into effect.
“That’s the complete opposite of everything that I have spent the last however many decades of my life doing — upholding my oath to do no harm. That will not go over well with the people that I work with. I can’t think of anybody who would say, ‘Oh, that’s a great idea. Sign me up.’”