Severe staffing shortages have emerged as a prominent threat to maintaining usual standards of care during the COVID-2019 pandemic. In dire settings of crisis capacity, healthcare systems assume the ethical duty to maximise aggregate population-level benefit of existing resources. To this end, existing plans for rationing mechanical ventilators and intensive care unit beds in crisis capacity focus on selecting individual patients who are most likely to survive and prioritising these patients to receive scarce resources. However, staffing capacity is conceptually different from availability of these types of discrete resources, and the existing strategy of identifying and prioritising patients with the best prognosis cannot be readily adapted to fit this real-world scenario. We propose that two alternative approaches to staffing resource allocation offer a better conceptual fit: (1) prioritise the worst off: restrict access to acute care services and hospital admission for patients at relatively low clinical risk and (2) prioritise staff interventions with high near-term value: universally restrict selected interventions and treatments that require substantial staff time and/or energy but offer minimal near-term patient benefit. These strategies—while potentially resulting in care that deviates from usual standards–support the goal of maximising the aggregate benefit of scarce resources in crisis capacity settings triggered by staffing shortages. This ethical framework offers a foundation to support institutional leaders in developing operationalisable crisis capacity policies that promote fairness and support healthcare workers.
- resource allocation
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
As the COVID-19 pandemic wears on, shortages of healthcare staff—especially nurses—have emerged as a major challenge.1 Physical and psychological strain has led to burnout, early retirement and insufficient staffing coverage across multiple healthcare settings.2 3 Despite extensive mitigation efforts,4 scarce staff resources threaten the healthcare community’s ability to deliver an acceptable standard of care.
A large body of literature, including National Academy of Medicine (NAM) reports and bioethical analyses, offers guidance for contending with resource limitation in healthcare emergencies.5 6 When a health system or region exhausts all opportunities to mitigate resource shortages and becomes unable to maintain a standard of care that is functionally equivalent to usual practice for all patients, the system must shift to crisis standards of care and adopt a goal to maximise aggregate benefit of a scarce resource across the population.5 Existing triage plans direct allocation of scarce life-supportive resources, such as mechanical ventilators, to maximise the number of lives saved by prioritising individual patients who are most likely to survive.
The NAM approach supports triage for discrete resources (eg, a number of mechanical ventilators), which cannot be effectively subdivided or shared, and for which all patients being considered under such a triage protocol would require this resource to the same degree (eg, patients require mechanical ventilation in order to survive). However, whereas discrete resources such as mechanical ventilators are either available or not (although even this example has exceptions7 and is likely to be more challenging in real-world settings8), staff resources exist along a spectrum. Staff time and energies can be concentrated on a few patients or spread thin to deliver some care for many patients. Staff can also be deployed in different clinical settings and can perform a range of tasks that may provide more or less benefit to patients.9 Efforts to apply the established triage approach—prioritising those patients most likely to survive—to the context of staff shortages prompt puzzling questions. For what group of patients would such a triage algorithm apply and how would we select among patients with diverse conditions and clinical needs? Which types of treatments among the range of interventions offered by staff would be withheld from selected patients? Alternate approaches that better align with the realities of staff resource scarcity are needed to support the primary utilitarian goal of maximising aggregate population benefit (table 1).10
Prioritise the worst-off: estrict access to acute care services and hospital admission for patients at relatively low risk of poor outcomes if this treatment is withheld
Healthcare staff care for groups of patients who are highly heterogeneous in type and intensity of clinical needs and care goals. In settings of ventilator shortages, all patients in need of mechanical ventilation are similar in that they are likely to die if treatment is withheld. In contrast, the broader population of patients in need of staff attention require a range of levels of monitoring including intensive care, acute care, and observation and different types of treatments and interventions. In crisis capacity, when not all patients will receive needed care, a strategy of prioritising those patients who stand to benefit the most from nursing interventions could maximise the aggregate benefit of scarce staff resources.
In contingency capacity settings, a need to conserve resources underlines the importance of timely discharge for patients who no longer need acute care resources. In settings of crisis capacity, this strategy may be extended to include discharging or not admitting certain groups of patients who would typically be admitted for monitoring or minor interventions but are relatively unlikely to experience poor outcomes if not admitted. This approach would not constitute usual standards of care and could confer some excess risk for these patients but would be permissible to support a goal of maximising aggregate population-level benefit. To the extent possible, alternative outpatient treatment and monitoring plans should be used to support patients who are not offered acute care hospitalisation, including instructions to return should their clinical status worsen. For example, patients with low and stable oxygen requirements may be discharged with supplemental oxygen and pulse oximetry as well as regular virtual nursing follow-up to monitor for signals of worsening clinical status.11
Prioritise staff interventions with high near-term value: Systematically restrict selected interventions and treatments that require substantial staff time and/or energy, but offer minimal near-term patient benefit.
An additional strategy for maximising aggregate benefit of staff resources involves directing staff time and energy towards treatments and tasks that offer high near-term value. Classes of interventions that require substantial work and/or provide minimal or rare near-term benefit to patients could be withheld for all patients (or for a defined population of patients for whom the intervention is least effective).
This strategy is analogous to cost-effectiveness analyses, which have helped to guide approaches to allocating limited healthcare funds in low-resourced countries.12 Staff time and energy are not as fungible as fiscal resources because personnel have different skill sets and it is difficult to quantify the amount of time and energy that each staff member represents. Further, even if we adopt the narrow definition of value as the impact of an intervention on likelihood of survival, it is unlikely that a heterogenous set of staff interventions could be practically or meaningfully ranked along a spectrum of value, or that all stakeholders would agree on how to prioritise treatments of intermediate value and cost. However, policy makers could draw on this conceptual approach to understand the ethical foundation and develop explicit justification for policies that restrict extreme examples of resource-intensive interventions that confer relatively little near-term benefit in settings of staffing crisis.
In contingency capacity, this conceptual approach underlies the practice of excluding treatments and tasks when the near-term benefit to patients is negligible. For example, medical record documentation can dominate a substantial portion of nursing shifts,13 but much of this charting is intended primarily to support billing and medico-legal records. In staffing contingency capacity, charting has been limited to that which supports meaningful communication about patient care (online supplemental table 1). The strategy of restricting tasks that have relatively low immediate value also offers support for the practice of restricting non-emergent surgical procedures when these are not expected to impact patients’ near-term health in order to preserve intensive care resources.
In staffing crisis capacity, institutional or regional leadership may enact policy that mandates withholding interventions that are staff resource-intensive and provide only minimal or rare medical benefit in terms of improving survival. For example, provision of extracorporeal life support (ECLS) for one patient can require the exclusive attention of two nurses for weeks. The effectiveness of this treatment varies by underlying health condition, but notably, the benefit for adults who are critically ill with COVID-19 appears to be unfortunately low.14 Other interventions, such as cardiopulmonary resuscitation (CPR) for adults with multiorgan failure, similarly require substantial staff time and energy, but offer modest survival outcomes. In crisis capacity, when staffing ratios are already strained, temporary redeployment of staff to perform a CPR procedure could result in an unacceptable standard of care for other hospitalised patients. It is not likely to be practical to stratify the entire population of patients by their likelihood of benefiting from this procedure. However, restricting this procedure for a cohort of patients who are exceedingly unlikely to benefit, such as people with multiorgan failure, may meaningfully conserve staff resources compared with usual practice.
Supporting staff and adapting to dynamic types and degree of resource limitation
Staff are unique among healthcare resources in that their capacity is impacted not only by the number of hours worked but also by moral distress and burnout. Early reports from front-line clinicians signalled substantial distress directly related to lack of guidance around how to manage limited resources, leaving clinicians to grapple with these ethical dilemmas at the bedside.15 Instituting standardised, transparent, and operationalisable policies and plans are important to supporting staff and maintaining limited staff resources.2 15 Broader efforts to promote staff well-being at the individual, team, institutional and regional levels are also increasingly recognised to be critical in maintaining an effective healthcare workforce during the pandemic and in the future.16
The implementation of any resource allocation strategy needs to be proportionate to the degree of scarcity and tailored to local context. Institutional leaders can use a standardised process to ensure that policies are proportionate, equitable and transparent.17 Restrictions on intensive treatments for which patients may be transferred between hospitals, such as ECLS, may benefit from standardised policy across healthcare systems. A declaration of crisis capacity from a regional authority would support local leaders in coordinating efforts across institutions and legitimise these difficult but necessary steps to institute explicit policy changes in dire settings of staff scarcity.
As healthcare institutions face severe staff shortages, we must adopt policies that align with the complex realities of this unique type of resource scarcity. If all mitigation strategies are exhausted, crisis capacity strategies may include restricting hospital admission for groups of patients at relatively low medical risk and limiting specific interventions that involve substantial expenditure of staff time and energy relative to their potential benefit. These strategies support the foundational goal of maximising population-level benefit of a scarce healthcare resource and lay a foundation to support institutional leadership in developing ethically justified, standardised and transparent policies to fairly allocate scarce staff resources during the COVID-19 pandemic.
Patient consent for publication
Contributors CRB wrote the primary draft. CRB, LBW and DSD contributed to the conception and critically revised and approved the final draft.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.