It’s staff, not stuff: Applying crisis standards of care to allocating health care workers

As the Omicron variant of Covid-19 rages across the country, health care workers who are already physically, mentally, and morally exhausted are facing a hidden crisis: having to make decisions at patients’ bedsides about rationing health care. Political leaders and health care system administrators have left them to make life-or-death decisions about how to allocate increasingly scarce resources — not least of all their own time and expertise.

Leaders have long known that a prolonged pandemic was likely to produce severe shortages in supplies and staff. In anticipation of such a moment, guidance known as crisis standards of care (CSC) have been developed. These are defined by the Institute of Medicine as a strategy to optimize the allocation of scare medical resources and shift the moral burden of making these decisions away from bedside clinicians to triage officers or others not directly involved in a patient’s care. Although implicit in CSC standards, staff allocation is generally viewed as an operational issue.

Many individual hospitals are already employing some crisis standard of care strategies, such as transferring patients to less overwhelmed hospitals, curtailing elective procedures, and developing algorithms to allocate medical equipment. The CSC standards are a framework that moves the continuum of care across three phases: conventional to contingency to crisis.

The goal is to avoid moving into the crisis phase. But it’s too late for that.

As hospitals face yet another staff shortage due to the latest pandemic-related surge of patients, it is beyond time for governors and legislators across the country to put these strategies to use on a statewide level. Their failure to enact crisis standards of care has effectively abandoned clinicians at the point of care, forcing them to make decisions one patient at a time. Enacting crisis standards of care requires elected leaders to make the unwelcome declaration that the threshold of scarcity exists and that rationing of care is necessary. A statewide, coordinated effort to enact a consistent, equitable, and coordinated framework reduces the burden on individual hospitals and health care workers, creates legal protections, and proactively addresses inequities on a larger scale.

The reality is that, because of the burgeoning health care worker staffing crisis, rationing care has already begun. But it is simply hidden from public view. Most hospital staffing levels are calculated on razor thin margins that make it difficult to absorb large influxes of patients. When a system is unprepared, the shift from focusing on the needs of individual patients to maximizing the benefits to the entire population requires bedside caregivers to assume the decision-making burden.

Through no fault of their own, frontline clinicians are forced to limit the usual care and treatments they can provide to some patients for a greater benefit of others who are sicker. This reallocation occurs through delayed tests and procedures, missed medications, and deprioritized care practices that can lead to worse patient outcomes.

Put simply, the most important resource for patient outcomes is trained and healthy staff not “stuff,” and they are being allocated without the rigor that has been applied to scarce equipment, supplies, and treatments.

The refrain “there are no more beds” has become a common one these days. It’s a misnomer, really. The health care system has plenty of beds. It’s just running out of staff, nurses most of all. It’s theoretically possible to make almost every patient room in a hospital into a mini-intensive care space — it’s just a room with a bed, wall suction, and lots of electrical outlets. But what the public doesn’t know, and what hospitals and health care systems fail to acknowledge, is that with the onslaught of patients the pandemic can bring, it’s not the physical space that poses barriers to patient care. The problem is that hospitals don’t have adequate numbers of trained nurses and other health care workers available to take care of sick patients. Bedside staff are a finite resource that cannot be expected to continue to compensate for systemic failures that predated the pandemic.

Already exhausted clinicians are strained further. The volume of patients requires them either to turn sick people away from the emergency room and clinics — which they are loathe to do, knowing that some of the lives lost could have been saved — or to take on more patients than they can safely handle. While a public health emergency requires adopting a population-focused ethical framework, it can leave clinicians feeling as if their professional value of “first do no harm” is violated. Moral injury, an assault to one’s moral core, results either way. In a recent study, 38% of nurses and 32% of clinicians overall reported clinically significant symptoms of moral injury.

These compromises cut deep into the psyche of clinicians, and are likely to result in more deaths, injuries, and illness. The path of least resistance for hospitals is to stretch their staff without adjusting for the consequences of asking staff to do more with less, even as these clinicians face the additional burden of deciding not only how to provide care, but also to whom. To add to the burden, they are also left with the responsibility of explaining these decisions to patients or their families. Many nurses and other clinicians being put in these situations feel betrayed by the leaders they trusted to create a safe practice environment and to provide guidance and leadership in crisis situations.

The same investment of time and attention that was devoted to designing ethically grounded guidelines for allocation of ventilators, medicines, vaccines, and other treatments must now be turned toward the allocation and protection of human resources, specifically nurses as the largest segment of the health care workforce. And these new crisis standards of care must be implemented and evaluated to understand their impact.

Implementing an ethical framework for human resource allocation is not merely an operations issue. It is an issue of fundamental respect for the humanity of patients, their families, and those who are delivering care. Allocation of human resources is not just a pandemic problem; it is fundamentally built into our health care “system.” The hidden crisis of bedside rationing was happening well before the pandemic, and clinicians were burning out before the pandemic for the same reasons they are today. Denying the reality of bedside rationing is not a sustainable coping strategy, nor is transferring the burden of adequate staffing to clinicians who have already sacrificed so much.

We, as a society, must fundamentally re-think assumptions about what efficient and effective health care looks like. This reconceptualization would start with reducing the moral burden on health care workers during this pandemic. But it must continue afterward by peeling back blinders to the cost of a profit-based model for health care and addressing the value placed on rescue care versus preventive care. Maintaining the status quo increases the moral burden placed on clinicians and results in a less healthy population, and more expensive care. We should aspire to a real health care system designed with the humanity of everyone in the forefront.

Health care systems are unsustainable without a healthy workforce. The nation depends upon realizing the need for fair, equitable allocation of all types of resources in pandemic and non-pandemic times. How many health care workers have to leave their jobs or the profession before we take implementing crisis standards of care seriously?

Cynda Hylton Rushton is a professor of clinical ethics and nursing at the Johns Hopkins Berman Institute of Bioethics and the School of Nursing, and member of the ethics advisory board of the American Nurses Association Center for Ethics and Human Rights. Ian Wolfe is a clinical ethicist at Children’s Minnesota and a member of the ethics advisory board for the American Nurses Association Center for Ethics and Human Rights. Tener Goodwin Veenema is a contributing scholar at the Johns Hopkins Bloomberg School of Public Health’s Center for Health Security and Professor of Nursing.