For the healthcare industry and our healthcare system, the COVID-19 pandemic
has been a crisis without precedent. For the first time in living memory,
we have been forced to grapple with the concept that we may reach a point
when we are no longer able to provide every patient with the resources
they need because critical resources, such as ventilators, are not available
in sufficient quantities for every patient.
Ever since Governor Newsom and Alameda County declared a public health
crisis due to COVID-19 in March 2020, we have been working with two goals
in mind: (1) we need to be prepared for the worst, and (2) we need do
everything possible to avoid the worst. Since then, we have taken an “all
hands on deck” approach preparing for a crisis situation. We started
a daily COVID call (6 days per week) in which representatives from all
Washington inpatient and outpatient departments, clinics, and medical
staff worked together to ensure that Washington was prepared for the worst.
Critically, we focused on securing ventilators and other essential equipment,
obtaining as many “days of supply” of personal protective
equipment as reasonably possible and working to secure Washington’s
ability to obtain additional equipment if needed, expanding Washington’s
ability to test for COVID-19, and converting rooms to “negative
pressure” so that we could treat additional COVID-positive patients
while also protecting our nurses, physicians and support staff.
The response from everyone has been outstanding, and words cannot express
what our staff and physicians were able to accomplish in those early days.
Needless to say, while there were struggles to keep certain supplies in
stock, at no point were we forced to turn away any patients because we
did not have the rooms, supplies, and protective equipment to treat them
safely and effectively.
To that end, in March, the Medical Staff leadership and I called together
a multidisciplinary team to create a policy to address what would happen
should we not have space or supplies to treat every patient who needed
care. Should this happen, we are required to utilize a “Crisis Standard
of Care.” This standard differs from both (i) the “Conventional
Standard of Care,” which is the standard for delivery of care under
normal circumstances: all patients receive the resources that they require,
and (ii) the “Contingency Standard of Care,” where efforts
are made to conserve and extend existing resources (such as moving to
double-occupancy rooms) but every patient still receives all the resources
that they require. Under a Crisis Standard of Care, the focus of care
shifts from delivering individual patient care to delivering the best
care for the patient population.
The multidisciplinary team consisted of members of the medical staff leadership,
including medical staff members trained in critical care, a bioethicist,
members of the Bioethics Committee (which counts among its members lay
members of the community), representatives from nursing, Washington administrative
staff, and Legal Counsel. They met (virtually) on a weekly basis to develop
the initial draft of the document. The Medical Executive Committee approved
the initial draft in April 2020. At that time, due in large part to the
efforts of the Washington community described above, it became clear that
we would not need to seek your approval of the policy but could defer
bringing this forward until it became necessary.
On June 8, 2020, the California Department of Public Health (CDPH) released
its own Crisis Standard of Care guidance, including a model policy. The
multidisciplinary team continued to meet during the summer, fall, and
winter to discuss the CDPH guidance. In addition, they continued to examine
policies from other organizations, including Stanford and the University
of California, to ensure that Washington’s draft policy remained
consistent with its peers.
On December 28, 2020, CDPH released All Facilities Letter 20-91. This letter
instructed each hospital in California to submit its Crisis Standard of
Care policy to CDPH for review and to post a copy of the policy on the
Hospital’s public website no later than January 6, 2021. When CDPH
issued this letter, members of our multidisciplinary team met over the
holidays and updated the policy based on the guidance from CDPH and the
best available information from other hospitals in California.
The Medical Executive Committee approved the draft at a special meeting
on Monday, January 4, 2021. The policy was approved by the Washington
Township Health Care District at a special meeting on Tuesday, January
5, 2021. The policy is substantially consistent with the policies of the
other major healthcare systems in the Bay Area and is in line with CDPH
guidelines. Under the policy, and consistent with federal and state law
and widely acknowledged ethical principles, healthcare decisions, including
the allocation of scarce resources, will not be based on race, disability
(including weight-related disabilities and chronic medical conditions),
gender, sexual orientation, gender identity, ethnicity (including national
origin and language spoken), ability to pay, weight/size, socioeconomic
status, insurance status, perceived self-worth, perceived quality of life,
immigration status, incarceration status, homelessness, or past or future
use of resources.
The Hospital will continue to do everything in its power to avoid activating
Washington Hospital Crisis Standard of Care