Operational Recommendations for Scarce Resource Allocation in a Public Health Crisis

Michael R Ehmann; Elizabeth K Zink; Amanda B Levin; Jose I Suarez; Harolyn M E Belcher; Elizabeth L Daugherty Biddison; Danielle J Doberman; Karen D'Souza; Derek M Fine; Brian T Garibaldi; Eric A Gehrie; Sherita H Golden; Ayse P Gurses; Peter M Hill; Mark T Hughes; Jeffrey P Kahn; Colleen G Koch; Jason J Marx; Barry R Meisenberg; Jeffrey Natterman; Cynda H Rushton; Adam Sapirstein; Stephen R Selinger; R Scott Stephens; Eric S Toner; Yoram Unguru; Maureen van Stone; Allen Kachalia

doi:10.1016/j.chest.2020.09.246

Operational Recommendations for Scarce Resource Allocation in a Public Health Crisis

Chest. 2021 Mar;159(3):1076-1083. doi: 10.1016/j.chest.2020.09.246. Epub 2020 Sep 28.

Authors

Michael R Ehmann¹, Elizabeth K Zink², Amanda B Levin³, Jose I Suarez⁴, Harolyn M E Belcher⁵, Elizabeth L Daugherty Biddison⁶, Danielle J Doberman⁶, Karen D'Souza⁷, Derek M Fine⁶, Brian T Garibaldi⁸, Eric A Gehrie⁹, Sherita H Golden¹⁰, Ayse P Gurses¹¹, Peter M Hill¹, Mark T Hughes¹², Jeffrey P Kahn¹³, Colleen G Koch³, Jason J Marx¹⁴, Barry R Meisenberg¹⁵, Jeffrey Natterman¹⁶, Cynda H Rushton¹⁷, Adam Sapirstein³, Stephen R Selinger¹⁸, R Scott Stephens⁶, Eric S Toner¹⁹, Yoram Unguru²⁰, Maureen van Stone²¹, Allen Kachalia²²

Affiliations

¹ Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD.
² Department of Neurology, Johns Hopkins University, Baltimore, MD; Department of Neuroscience Nursing, The Johns Hopkins Hospital, Baltimore, MD.
³ Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
⁴ Department of Neurology, Johns Hopkins University, Baltimore, MD; Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD; Department of Neurosurgery, Johns Hopkins University, Baltimore, MD.
⁵ Department of Pediatrics, Johns Hopkins University, Baltimore, MD; Center for Diversity in Public Health Leadership Training, Kennedy Krieger Institute, Baltimore, MD.
⁶ Department of Medicine, Johns Hopkins University, Baltimore, MD.
⁷ Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD.
⁸ Department of Medicine, Johns Hopkins University, Baltimore, MD; Department of Physiology, Johns Hopkins University, Baltimore, MD.
⁹ Department of Pathology, Johns Hopkins University, Baltimore, MD; Department of Surgery, Johns Hopkins University, Baltimore, MD.
¹⁰ Department of Medicine, Johns Hopkins University, Baltimore, MD; Department of Epidemiology, Johns Hopkins University, Baltimore, MD; Office of Diversity, Inclusion, and Health Equity, Johns Hopkins Medicine, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD.
¹¹ Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD.
¹² Department of Medicine, Johns Hopkins University, Baltimore, MD; Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD.
¹³ Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD.
¹⁴ Department of Medicine, University of Maryland St Joseph Medical Center, University of Maryland Medical System, Towson, MD.
¹⁵ Department of Medicine, Anne Arundel Medical Center, Annapolis, MD.
¹⁶ Department of Risk Management, The Johns Hopkins Hospital, Baltimore, MD.
¹⁷ Berman Institute of Bioethics, Johns Hopkins University, Baltimore, MD; School of Nursing, Johns Hopkins University, Baltimore, MD.
¹⁸ Department of Medicine, MedStar Franklin Square Medical Center, MedStar Harbor Hospital, Baltimore, MD.
¹⁹ Johns Hopkins Center for Health Security, Johns Hopkins University, Baltimore, MD.
²⁰ Division of Pediatric Hematology/Oncology, Sinai Hospital, Baltimore, MD.
²¹ Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD; Maryland Center for Developmental Disabilities, Kennedy Krieger Institute, Baltimore, MD.
²² Department of Medicine, Johns Hopkins University, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD. Electronic address: kachalia@jhu.edu.

Abstract

The coronavirus disease 2019 pandemic may require rationing of various medical resources if demand exceeds supply. Theoretical frameworks for resource allocation have provided much needed ethical guidance, but hospitals still need to address objective practicalities and legal vetting to operationalize scarce resource allocation schemata. To develop operational scarce resource allocation processes for public health catastrophes, including the coronavirus disease 2019 pandemic, five health systems in Maryland formed a consortium-with diverse expertise and representation-representing more than half of all hospitals in the state. Our efforts built on a prior statewide community engagement process that determined the values and moral reference points of citizens and health-care professionals regarding the allocation of ventilators during a public health catastrophe. Through a partnership of health systems, we developed a scarce resource allocation framework informed by citizens' values and by general expert consensus. Allocation schema for mechanical ventilators, ICU resources, blood components, novel therapeutics, extracorporeal membrane oxygenation, and renal replacement therapies were developed. Creating operational algorithms for each resource posed unique challenges; each resource's varying nature and underlying data on benefit prevented any single algorithm from being universally applicable. The development of scarce resource allocation processes must be iterative, legally vetted, and tested. We offer our processes to assist other regions that may be faced with the challenge of rationing health-care resources during public health catastrophes.

Keywords: COVID-19; disaster planning; healthcare rationing; medical ethics; triage.

MeSH terms

COVID-19* / epidemiology
COVID-19* / prevention & control
COVID-19* / therapy
Change Management
Civil Defense / organization & administration*
Disaster Planning
Health Care Rationing* / methods
Health Care Rationing* / standards
Health Workforce*
Humans
Intersectoral Collaboration
Maryland / epidemiology
Public Health / trends*
Resource Allocation* / ethics
Resource Allocation* / organization & administration
SARS-CoV-2
Triage / ethics
Triage / organization & administration