Dallas Hospitals Did Not Agree to Triage Based on Vaccination Status

Yesterday afternoon, the Dallas Morning News published an article with the online headline: “When North Texas Run Out of Intensive Care Beds, Doctors Can Take into account a patient’s vaccination status.”

This is a big, bold, and false headline to get internet and TV station attention and that is exactly what happened. The story, written by Dave “The Watchdog” Lieber, left out some crucial details that would have helped the public understand what doctors are investigating. According to the doctors involved, this was never a policy, but a discussion of the ethics of such a policy when the situation got serious enough. The headline was hysterical bombast, and the story weaves between what is set in stone and what is not.

Let’s talk about something called the Mass Critical Care Guidelines. The state has no set “standards of care” when demand in a region’s hospitals exceeds supply of beds or equipment. This leaves it up to the individual regions to come together and devise a triage plan for their coverage area that does not discriminate based on race, gender, economic status, disability, or other factors if hospitals run out of ICU beds or ventilators.

The guidelines require clinicians to perform a series of assessments to determine how patients are triaged. These include the internationally recognized SOFA score, which is an acronym for sequential organ failure assessment, and about half a dozen other assessment tools for decision-making. Doctors say they considered adding vaccination status to these metrics. But they didn’t set it up as a formal guideline.

Here’s what should happen when the critical care guidelines go into effect:

The overall goal is to save as many lives as possible. If, for some reason, a patient is so ill that they are unlikely to survive until hospital discharge, there is no point in allocating scarce life support to that patient. Such patients are admitted to supportive palliative care or hospice care, with scarce life support being assigned to patients who are believed to be more likely to survive until discharged.

These processes are triggered when hospitals reach a certain shortage of staff, beds or equipment. As Lieber rightly points out, these guidelines are unenforceable but are generally followed by our hospitals. Because of this, there is widespread involvement of local hospital systems and community stakeholders in the organizing group that discusses these issues.

The body responsible for developing this plan is the North Texas Mass Critical Care Guideline Task Force. It is made up of about three dozen doctors, hospital staff, civil servants, religious leaders, and advocates of disability. Developing this plan requires a great deal of research and discussion, and the process is intended to respond to any specific public health emergency or disaster that is fueling a rush for hospital beds and equipment. Local medical societies began developing such a plan after the SARS outbreak in 2003 and 2004. They wanted to be prepared for the rare event that demand exceeded supply. We are getting very close to this moment. The first plan was approved in 2010; it has since been updated under the guidance of the federal government. You can read the current guidelines here.

In January of this year, the US Department of Health’s Civil Rights Bureau announced that it was working with the North Texas Task Force and similar agencies in southwest Texas, North Carolina, to revise crisis standards for care, and the Indian health service. The OCR ensured that these plans did not violate federal anti-discrimination laws, such as Title VI of the Civil Rights Act of 1964. If North Texas changes its strategy, it could jeopardize this “seal of approval” if the new policy leads to someone being discriminated against.

“These plans will help ensure that older people and people with disabilities are not excluded from health care based on judgments that their lives are somehow less worth saving,” said OCR Director Roger Severino in a statement at the time of approval. “Everyone should be treated with equal dignity and respect, and these plans reflect those fundamental principles.”

The task force’s efforts have been praised by groups such as Disability Rights Texas, who stated that “Without the Guidelines, people with disabilities and older adults in Texas could potentially continue to face discriminatory rations and put their lives at risk.” (Disability Rights Texas helped create the guidelines.)

COVID-19 has changed since it arrived in March 2020. It would be surprising if our local task force didn’t debate whether to consider vaccination status – there are currently 22 occupied ICU beds available in Dallas County and 20 in Tarrant. The patient flow could happen quickly. But it doesn’t seem that the idea of ​​incorporating vaccination status was more than a point of discussion, and so this group creates the intensive care plan. Yet the news story presented it as impending politics. It is worth noting that the task force discussed vaccination status, but there is no evidence that it was ready for implementation.

“The memo referred to in recent media reports was created for internal discussion only and does not represent decisions that have been made to change the guidelines in any way,” said a prepared statement by Dr. Mark Casanova, the chair of the task force. Casanova declined to chat with D Magazine, instead referring to on-camera interviews held on Thursday night after the running of the story, in which he clarified the matter as a discussion point before saying it was not implemented will. (The news reported that Casanova “revised his story” calling it a “reversal.”)

This is how we got here: Rather, an email was leaked and then he interviewed “doctors who were involved in the decision for two hours,” including Casanova.

This email contained three bullet points that read like a series of resentments: Since the COVID-19 vaccine significantly reduces hospital stays and deaths, vaccination status should therefore be “part of the medical assessment of each individual’s likelihood of survival”. It includes carve-outs for patients who did not have suitable accommodation to receive the vaccination, which means they did not deliberately refuse to be vaccinated. Finally, triage decisions should prioritize those people who are most likely to survive their complaints.

Dear reported that Dr. Task Force co-chair Robert Fine asked participants to forward these recommendations to their respective organizations for consideration. Of course they would; The guidelines are the result of a joint discussion in our hospitals.

In Lieber’s defense, and in the context of the story’s perspective, Fine and Casanova speak like men trying to defend a decision. But in the context of the task force’s work, it can also be read as if experts are trying to determine the implications of including vaccination status as an element of triage. Lieber’s story never dictates how firm that decision was, and the headline emphatically declares politics to be a reality.

The news didn’t allow any comment. The newspaper has already written about this task force. In April 2020, Fine and Casanova and a few others informed the editorial team about the intensive care plan. The board has fulfilled its purpose:

But there is also the possibility that the virus will spread faster than any of our emergency preparednesses, and that those who administer our health system will be faced with the toughest choice imaginable: deciding which patients will be more limited in administration, when Even critical forms should be prioritized for care when the number of patients overwhelms our hospitals. For example, the need for ventilators – a critical device in the management of breathing difficulties – could exceed the number of devices available.

This whole ordeal here in Dallas, with a hysterical headline in the newspaper, feels like our version of what happened when the Washington Post leaked a CDC PowerPoint file that contained a slide claiming the new one Delta variant of the corona virus is as contagious as chickenpox. They reported it and it went everywhere. Then it later turned out that the report was wrong; the CDC used the slide as a discussion point.

It also recalls the news outlets that used the Provincetown, Massachusetts study of an outbreak among vaccinated people to update their coverage of “breakthrough” infections after the shot. Most failed to realize that Provincetown was a total runaway, a big party that filled bars, restaurants, and homes with thousands and thousands of men for over a week – behavior that is more of a weekend than a lifestyle.

Fine even wrote an editorial in the News last year detailing this intensive care plan: “The medical societies and hospitals in the North Texas county are all committed to following these regional guidelines. We hope and pray that we do not have to activate the full guidelines, but we are concerned that the time will come and therefore we want our entire North Texas church to understand the guidelines beforehand. “

From Lieber’s story it was clear that Fine and Casanova were unwilling to bring this matter up to the public. But the news rushed on, leaving aside the nuances that would help the community understand what is happening among the people charged with prioritizing our treatment.

Lieber’s claim that he spent two hours interviewing task force doctors is a nifty interim solution, but it also shows that it required more time and thought before it became public. The word got around all over the place, with a sensational headline that has since changed and doesn’t reflect reality. It takes less than a day for misinformation to infect countless numbers of people. Getting more people vaccinated should be of paramount importance, and a story like this carries a weight that deserves a lot of time and attention. By now, I can’t see this going down well with the medical community, which is tense and burned out again as it cares for the very people this news story claims will soon be left aside.

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