As COVID-19 worsens, AZ is the first state to enact ‘crisis care’ standards

Arizona’s failure to contain COVID-19 means the state has the dubious distinction of being the first in the nation’s history to activate crisis standards of care for hospitals, according to a top administrator at the state’s largest hospital system.

In an email to Banner Health employees on Friday, chief clinical officer Dr. Marjorie Bessel explained that, at the request of Banner and other health care systems, the Arizona Department of Health Services activated crisis standards on June 29 “for the first time in the state’s history and the first time any state has done this in the country.”

Crisis standards of care give hospitals more flexibility to allocate resources based on which patients are most in need. 

“This means there is now a state-wide coordinated plan in place to provide guidance for how we should react to the challenges of the pandemic and manage resources in this health care emergency,” Bessel said in the email.

Most importantly, the standards provide hospitals a framework for deciding who to treat and who not to treat if they are not able to care for every patient.

Dr. Cara Christ, the ADHS director, announced the decision on Monday. 

ADHS’s decision comes as the COVID-19 outbreak increasingly taxes the state’s hospital system. According to data provided on the agency’s website, a record high 91% of Arizona’s intensive care unit beds are now in use, with 741 of the 1,540 filled beds currently occupied by COVID-19 patients. There are only 156 ICU beds unused in the entire state, DHS reported Friday, though that number doesn’t include additional beds that are available through the hospitals’ surge capacity plans, which both Banner and Dignity Health have tapped into.

And 85% of all in-patient beds are full, including a record high 3,013 of 6,538 filled beds occupied by coronavirus patients; only 1,135 beds statewide are open. Additionally, 47% of the state’s ventilators are in use, also a new high, including 489 by COVID-19 patients. There are still 917 ventilators available in the state, according to ADHS.

“It is important to understand that we are truly at a crisis level as we continue to see an increase in hospitalizations, ICU and ventilator usage, and nearing capacity levels at our hospitals,” Bessel wrote.

Most individual hospitals and hospital systems don’t release their capacity data, and ADHS won’t release that information either, making only the cumulative statewide information available to the public.

Bessel explained in the email that, as a result of Banner implementing its crisis standards of care plan, employees “may see changes in staffing models at your hospitals, alternate areas/sites for patient care, and providers in different roles than usual.” Activation of the plan also gives Banner’s employees additional liability and malpractice protections.

Banner hasn’t fully tapped into the plan, however. Bessel said it’s important to note that Banner hasn’t implemented its “COVID-19 triage addendum” yet. 

“However, we have a plan in place should that need arise,” she said.

Banner spokeswoman Becky Armendariz said the triage plan will help health care providers make decisions on who to treat if resources become scarce. Banner can’t say with certainty whether it will ultimately have to enact its triage plan, Armendariz said, which will depend on whether COVID-19 cases continue to rise. 

Armendariz said Banner is hopeful that recent actions by Ducey and various mayors over the past few weeks will help slow the spread of the virus. In mid-June, Ducey allowed cities and counties to require mask usage in public, a move he’d previously blocked, despite requests from several mayors. About 75% of the state is now under mask requirements, he said. On June 29, Ducey announced that bars, gyms and several other types of businesses would have to close for at least 30 days.

“At this time, we have adequate resources and beds for COVID-19 and non-COVID-19 patients in our Arizona hospitals,” Armendariz told Arizona Mirror.

Patrick Ptak, a spokesman for the governor, also emphasized that no Arizona hospitals have had to implement triage care plans. Arizona has planned and prepared for a surge in cases, he said.

Ptak also noted that Arizona hasn’t had to use the types of emergency responses seen earlier in the crisis in New York and other states, and that Arizona still has hospital capacity.

“While I cannot confirm what actions other states have taken, I’d point out Arizona’s situation and (positivity) rate is not comparable to places like New York during its peak, not even close. For context, New York’s COVID-19 positivity rate surpassed 50% in April. Arizona’s rate is less than half of that,” Ptak told the Mirror, referring to the percentage of COVID tests that come back positive.

The crisis standards of care come as Arizona grapples with perhaps the worst COVID outbreak in the country. Cases have risen dramatically over the past month, since Gov. Doug Ducey lifted his stay-at-home order and state and local governments simply ignored violations of the restrictions that were still in effect. 

ADHS reported 4,433 new cases on Friday, which will be a record number if it holds up, though some of those cases will almost certainly be reassigned to previous days due to lags in reporting.