Pandemic 2020

CDPHE All Hazards Internal Emergency Response and Recovery Plan

For the COVID-19 pandemic, a crisis could exist
when fully functional critical care ventilators (“full ventilators”) become a scarce resource, but less
than optimal alternative forms of ventilation such as anesthesia machines, some non-invasive (NIV)
machines, and disposable resuscitators (“partial ventilators”) are still available and thus could be
provided to a patient.
This triage framework for CSC gives priority for critical care resources to patients with the highest
likelihood of near-term survival (e.g. 1-year survival) were they to receive critical care interventions.3
It also addresses the possibility of re-allocating scarce critical resources like ventilators from patients
with minimal chances of survival to those with higher likelihood of survival. This triage framework has
strong ethical underpinnings. Should there be a declaration of CSC for hospitals in Colorado, the goal

would be to maintain equity between hospitals and reduce institutional variation in implementation
of CSC. A few key principles guided the development of this document:
1. A CSC Triage System needs to be transparent, consistent, equitable, respectful, and fair to
ALL individuals.
2. The clinical care team (e.g., physician, nurse, respiratory therapist) should NOT be involved in
initial triage decisions about their own patients to enhance objectivity, avoid conflicts of
interest and maintain the therapeutic relationship between clinical care teams and their
patients.
3. A structure for triaging patients should be adopted at the highest level to reduce variation
within and between institutions across the state.
4. No categorical exclusionary criteria based on factors clinically and ethically irrelevant to the
triage process (e.g. age, race, ethnicity, ability to pay, disability status, national origin, primary
language, immigration status, sexual orientation, gender identity, HIV status, religion, veteran
status, “VIP” status, housing status, income, or criminal history) will be used to make triage
decisions.
5. The triage framework employs multiple clinically relevant considerations but does not include
any single categorical exclusionary criteria such as age or specific comorbidities. This is a
fundamental change from prior Colorado triage guidance in 2018.
6. Patients who are triaged such that they do not receive a given resource (e.g. do not receive a
ventilator if needed) should receive optimal care within the triage framework, including
expert palliative care if appropriate and available.
7. The triage process will be used for ALL patients who may require critical care resources, not
just those who suffer from COVID-19.
8. The triage process will be iterative in order to account for changes in need for scarce
resources, resource availability and new information learned.
--------------
The CSC Triage Team will:
1. Assign CSC Triage Scores (see Section IV) to patients. Patients with lower CSC Triage Scores
have higher expected survival and should receive higher priority for scarce resources.
2. Determine the “CSC Triage Score Cutoff” based on the available resources for that day. CSC
Triage Scores less than the triage score cutoff would receive critical care interventions such
as a ventilator whereas scores that are equal to or higher may not.
3. At a minimum, meet daily to review cases near the cutoff score and provide updated CSC
Triage Scores for patients at high risk of decompensation/needing a ventilator (see Section
IV).
4. Be on call 24 hours a day, 7 days a weeks for urgent evaluations of patients who are
decompensating but have not yet received a CSC Triage Score (Emergent Triage).
5. Be the lead in any discussion about re-allocating critical care resources such as ventilators or
critical care beds. The final decision for removal of ventilator support will reside with the CSC

Triage Team (unless ventilation or life support is requested to be removed by the patient or
proxy or is removed using institutional non-beneficial care or futility policies).
6. To the greatest degree possible, be blinded to potential biases that are neither clinically nor
ethically relevant to triage decisions including, but not limited to age, race, ethnicity, ability to
pay, disability status, national origin, immigration status, primary language, sexual
orientation, gender identity, HIV status, religion, veteran status, “VIP” status, housing status,
income, or criminal history except as required by the triage process. Institutions should
consider assigning the role of abstracting the necessary data to calculate a CSC Triage Score
to persons not on the CSC Triage Team with sufficient medical knowledge to perform this
task (e.g., medical students, medical librarians, or other medical professionals who cannot
provide direct patient care). Some health systems may have the ability to automate part or all
of the CSC Triage Score calculation based on data from the electronic health record.

The institutional CSC Triage Team structure, membership, and team leaders should be determined
prior to a declaration of CSC if timing allows. We recommend that the CSC Triage Team practice
assigning CSC Triage Scores and review mock cases to determine how they would make decisions in
the setting of scarce resources.
--------------------

And it goes on, page 93 if anyone cares to read.

As an example,

Healthcare workers and first responders (EMS, firefighters, and law enforcement including
correctional officers) have the potential to save and protect other lives should they recover
(multiplier effect) and they are at increased risk of exposure to a potentially lethal infection by virtue
of being on the front lines of the COVID-19 response. We recommend healthcare workers and first
responders with a role in the COVID-19 response receive a scarce resource over individuals not in
one of these categories if all have the same initial Tier 1 CSC Triage Score.A
Tier Three: Special Considerations as Tiebreakers
Based on expert and community engagement, several other factors should be considered when a
patient has a tie for both Tier 1 and 2 (e.g., a nurse and a firefighter, both with a CSC Triage score of
6). In no particular order these include:
• Essential workers – Essential workers with direct interaction with the public (e.g. grocery
store workers, teachers and school staff, childcare workers, public transportation workers,
etc.) or who work in high density environments with evidence of high transmission rates (e.g.
meat packing workers, agricultural workers, etc.) are at increased risk of exposure due to the
essential function they provide to society.B There is also ample evidence that front-line
essential workers have over representation of members of communities of color which

exacerbates healthcare inequities experienced in the pandemic. Therefore, these front-line
workers should receive some consideration as a Tier 3 tie-breaker from the perspective of
reciprocity and equity. Not all essential workers should receive this consideration. It should
be reserved specifically for those essential workers with increased risk of exposure directly
through their work.
• Pregnancy – priority for a scarce resource may be given to a patient with a confirmed
pregnancy over a non-pregnant patient.
• Life Years Saved - priority for a scarce resource can be given to a patient with more near and
intermediate (1-5 years) life years to be saved. The life-years principle is NOT a categorical
age exclusion criterion as a 35 year old and 70 year old patient could have similar 1-year
survival predictions. The life-years saved principle is the place where more disease-specific
prediction models could be used to provide greater insight on near and intermediate-term
mortality (1-5 years).A For example, even with the same CSC Triage Score (Tier 1), some
consideration may be given to a 35 year old patient with no comorbidities over an 80 year old
with metastatic pancreatic cancer. Similarly, a 70 year old with no comorbidities may receive
consideration over a 40 year old with end stage liver disease with an extremely high Model
for End-Stage Liver Disease (MELD) score.
• Multiplier Effect - priority for a scarce resource may be given to patients who are the sole
caregiver to a dependent child or dependent adult.
------------
Ventilator Allocation (See Figure 2 & 3)
We recommend that at a minimum the CSC Triage Team provide a CSC Triage Score for every patient
receiving critical care (regardless of COVID-19 status) daily based on the most recent labs and vital
signs (Prospective Triage). The reason to repeat CSC Triage Scores on an ongoing basis is to account
for changes in acuity of illness but also shifts in availability of resources (e.g. purchasing of new
ventilators, recoveries or deaths that make ventilators newly available). If possible, the system (e.g.
SOFA + mCCI) should be automated once an assessment of comorbidity status is made. Ventilator
allocation would then be based on comparing a patient’s CSC Triage Score to the CSC Cutoff Score
calculated for that day. If the CSC Triage Score is less than the CSC Cutoff Score, the patient should
receive the ventilator. If it is equal to or higher than the CSC Cutoff Score, the patient should be
triaged to an alternative care plan. If the actual need exceeds the anticipated availability of
ventilators, re-allocation of ventilators should be considered (see below). Should a patient be triaged
not to receive a ventilator but additional resources become available, a reassessment should occur.
In the setting of Emergent Triage, if there is not enough time to notify the CSC Triage Team (e.g.
sudden cardiac arrest outside of the ICU), then the care team should err on the side of caution and
perform all necessary interventions including intubation and manual bag valve mask ventilation with
appropriate PPE protection. As soon as the patient is stabilized, the CSC Triage Team should be
notified. The CSC Triage Team should calculate a triage score for the patient based on the best
available data and compare it to the CSC Triage Score Cutoff. The following outcomes are possible:
1. A ventilator is available and the patient’s CSC Triage Score is sufficiently low such that
mechanical ventilation should continue;
2. A ventilator is not available but the patient’s CSC Triage Score is low enough that
possible re-allocation of a ventilator from a patient that has failed a sufficient therapeutic
trial should be considered; manual ventilation should be continued until a ventilator
becomes available;
3. A ventilator is not available but the patient’s CSC Triage Score is low enough that urgent
transfer to a center with resources should be considered;
4. No ventilator is available and the patient’s CSC Triage Score is greater than the cutoff. In
such a case termination of artificial ventilation is warranted.

The CSC Triage Cutoff Score is based on the best available data at the time. If more resources
become available on a given day through successful extubations or deaths, the CSC Triage Team can
decide to re-calculate the cutoff score.
Re-Allocation of Ventilators (see Figure 4)
If ventilator scarcity reaches the point of a declaration of hospital CSC, consideration must be given
to patients who have failed a therapeutic trial. There is no uniform definition of treatment failure as it

is specific to each condition. Based on experiences around the world, the majority of patients with
COVID-19 associated respiratory failure require mechanical ventilation for prolonged periods, often
longer than 12 days.13,14 Some patients that require longer periods of mechanical ventilation can
recover, but there is clear evidence that the chances of successfully coming off a ventilator and
surviving decreases the longer someone is on a ventilator.15-18 If re-allocation is required, all
intubated patients should receive a new CSC Triage Score and an assessment of therapeutic failure
(e.g. prolonged duration of ventilation without improvement or progressive multi-system organ
failure). Patients with non-COVID-19 disease should also be considered for re-allocation but the
definition of an appropriate therapeutic trial will vary by disease. The CSC Triage Team must then
decide which patients, if any, should be considered for re-allocation. Re-allocation may mean
removal from the ventilator with a transition to palliative care. However, if all full ventilators have

been utilized but partial ventilators (e.g. NIV ventilator or disposable resuscitators) are available, re-
allocation could mean transitioning the patient whose respiratory failure has stabilized to a partial

ventilator for an additional period of possible recovery. The full ventilator should be used for patients
with lower CSC Triage Scores who have a higher likelihood of survival and receiving benefit from full
critical care resources. If the institution is at or below its MOC, then re-allocation of a ventilator would
mean transitioning a patient who has failed treatment to palliative care.

CSC Triage Scores and the following data should be considered by the CSC Triage Team for re-
allocation decisions:

1. Duration of mechanical ventilation. Average duration of mechanical ventilation varies based
on the cause of respiratory failure. Some conditions like COPD exacerbations tend to require
shorter periods of mechanical ventilation. However, patients with COVID-19 have been shown
to require extended periods of mechanical ventilation prior to improvement. Given the
prolonged needs for ventilation for COVID-19 patients, even among those who recover, we
recommend that re-allocation of ventilators for patients with COVID-19 only be considered
after 14-21 days of mechanical ventilation. For non-COVID conditions, the clinical team must
provide insight as to whether a patient has completed an adequate therapeutic trial for that
disease process. If a patient is progressively worsening despite maximal ventilator support,
consideration for re-allocation can be made earlier based on the CSC Triage Team’s
assessment.
2. Trajectory of illness. Intubated patients who are worsening, such as those with progressive
multi-system organ failure (MSOF) (shock, acute renal failure, etc), and not improving with
appropriate therapy may be considered for re-allocation.
3. Intensity of Resource Utilization. Some patients on a ventilator require significantly higher
levels of care than other patients receiving mechanical ventilation. For example, patients on
continuous renal replacement therapy or extracorporeal membrane oxygenation (ECMO)
often require a single nurse assigned to a single patient. For ECMO, even more personnel are
directly assigned to a single patient. If re-allocation is required, the intensity of resource
utilization combined with trajectory of illness should be considered.
These decisions will require collaboration between the CSC Triage Team and the Clinical Team. Given
the potential for re-allocation of scarce resources during a pandemic, which is very different from
usual critical care, the concept of a time-limited therapeutic trial should be introduced to
patients/surrogates early in the course of mechanical ventilation.

Death Panels for tRUmptards LOL.

captainmorgan said:

Death Panels for tRUmptards LOL.

Click to expand...

My Home Depot has no motherdamn clue. I’m certain they stock Death Panels, and by all that is unholy, I want some.

Roger A. Shrubber said:

it just sounds like triage to me...you have to have some guide lines of who to treat out of a pool of people who need treatment. when there isn't enough resources to go around, you have to be careful what you use the resources you do have for. i don't know what the criteria they use are, but they do need some, age, general health, VACCINATION STATUS....should all be considered...why waste resources on someone who's likely to die anyway? why waste resources on someone who refuses to take any kind of steps to avoid being infected in the first place?

Click to expand...

That's not what the article said. It said that people who, in better times could expect to stay at the local hospital, can be shipped off to another facility if local resources are too thin to support everybody in that hospital's care. It does allow for triage in an emergency but not denial of care to anybody.

Regarding denying care based upon vaccination status. I understand the urge to dehumanize antivaxxers. I've said as much on this forum too. I'm not really in to just allowing a people to suffer and die due to lack of care.

The fake story that Sky repeated was that a person was deprived of care BECAUSE they had not been vaxxed. The urban legend goes on to say he was left to linger for three weeks until he got better on his own. Under the standards of care orders, that person would be shipped off to a place that can take them as soon as a place can be found and the patient is able to go. That sounds reasonable to me. Just letting a person die for not being vaxxed when a place could be found that could take them is a bullshit story. It relies on this image of hospitals being uncaring corporate entities. The people working there, most of them, are deeply committed to saving lives. No way what sky said is true.

You tend to get worked up. Angry people are a pain in the ass. Maybe we should deny care people who get angry all the time. Would that be OK with you?

Expert says it will take about two weeks to determine if the new variant evades vaccine protection and whether it's really 5x as infectious. They also think it's already spread world wide.

Fogdog said:

That's not what the article said. It said that people who, in better times could expect to stay at the local hospital, can be shipped off to another facility if local resources are too thin to support everybody in that hospital's care. It does allow for triage in an emergency but not denial of care to anybody.

Regarding denying care based upon vaccination status. I understand the urge to dehumanize antivaxxers. I've said as much on this forum too. I'm not really in to just allowing a people to suffer and die due to lack of care.

The fake story that Sky repeated was that a person was deprived of care BECAUSE they had not been vaxxed. The urban legend goes on to say he was left to linger for three weeks until he got better on his own. Under the standards of care orders, that person would be shipped off to a place that can take them as soon as a place can be found and the patient is able to go. That sounds reasonable to me. Just letting a person die for not being vaxxed when a place could be found that could take them is a bullshit story. It relies on this image of hospitals being uncaring corporate entities. The people working there, most of them, are deeply committed to saving lives. No way what sky said is true.

You tend to get worked up. Angry people are a pain in the ass. Maybe we should deny care people who get angry all the time. Would that be OK with you?

Click to expand...

Not to mention the thousands $ loss for E transport.

captainmorgan said:

Expert says it will take about two weeks to determine if the new variant evades vaccine protection and whether it's really 5x as infectious. They also think it's already spread world wide.

Click to expand...

(pours an extra teaspoon of bleach into the masks bucket)

Roger A. Shrubber said:

if they aren't denying ventilators to the unvaxxed, that's their mistake. i'm thoroughly sick and tired of the whining wretches crying about not wanting to get vaccinated, then crying when they they get infected. let them stay at home and cry to their dog, who may or may not give a shit either. maybe the dogs will eat them when they die, and we won't have to bury their covid riddled corpses, thereby putting the funeral workers at risk.

Click to expand...

Radio host Howard Stern said people who refuse to get vaccinated against COVID-19 are "idiots" and called for vaccinations to be mandatory.

"When are we gonna stop putting up with the idiots in this country and just say it's mandatory to get vaccinated? F--- 'em. F--- their freedom. I want my freedom to live," Stern said on his SiriusXM program on Tuesday. "I want to get out of the house already. I want to go next door and play chess. I want to go take some pictures. This is bull----."

"The other thing I hate is that all these people with COVID who won't get vaccinated are in the hospitals clogging it up," he said. "So like, if you have a heart attack or any kind of problem, you can't even get into the ER. And I'm really of mind to say, 'Look, if you didn't get vaccinated [and] you got COVID, you don't get into a hospital.'"

"Go f--- yourself," Stern added. "You had the cure and you wouldn't take it."

Fogdog said:

That's not what the article said. It said that people who, in better times could expect to stay at the local hospital, can be shipped off to another facility if local resources are too thin to support everybody in that hospital's care. It does allow for triage in an emergency but not denial of care to anybody.

Regarding denying care based upon vaccination status. I understand the urge to dehumanize antivaxxers. I've said as much on this forum too. I'm not really in to just allowing a people to suffer and die due to lack of care.

The fake story that Sky repeated was that a person was deprived of care BECAUSE they had not been vaxxed. The urban legend goes on to say he was left to linger for three weeks until he got better on his own. Under the standards of care orders, that person would be shipped off to a place that can take them as soon as a place can be found and the patient is able to go. That sounds reasonable to me. Just letting a person die for not being vaxxed when a place could be found that could take them is a bullshit story. It relies on this image of hospitals being uncaring corporate entities. The people working there, most of them, are deeply committed to saving lives. No way what sky said is true.

You tend to get worked up. Angry people are a pain in the ass. Maybe we should deny care people who get angry all the time. Would that be OK with you?

Click to expand...

i wasn't refering to the article schuylar posted,
i was refering to this

What if four patients in respiratory distress need a ventilator to keep them alive, but a hospital has just one available? Who makes that call? And how?

Public health and community leaders are contemplating excruciating dilemmas just like that before demand for medical help in the coronavirus crisis peaks in coming weeks.

They’re updating protocols, called “crisis standards of care,” for the most urgent medical decision-making possible, guidelines to determine, as resources get scarce, who gets care and at what level and who does not.

that doesn't sound to me like they're just talking about moving people from facility to facility...of course at the moment this is all just preparation, but if things do get bad enough, where are they going to send people when there are NO beds left in their state? or the neighboring state?...they WILL be making those decisions if things get bad enough...so what criteria would you use?

and yeah, me getting upset totally equates to someone refusing to get a shot that would have prevented them from taking up valuable resources to begin with...when they're likely responsible for breeding the variants that are requiring others to need to resources to begin with


"It does allow for triage in an emergency but not denial of care to anybody. "
what do you think triage means in a real emergency? it absolutely can come down to denying care to some in a real emergency, when there are not enough resources to go around. lets just hope it doesn't come down to that...

Israel closes border to all foreigners due to new coronavirus variant

Don't Bogart said:

I have a guy boarding at my house. He ended up in the hospital Wens. Heart attack. Maybe one of those affected by the vaccine?

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Yeah, all heart attacks are vaccine related.

Roger A. Shrubber said:

i wasn't refering to the article schuylar posted,
i was refering to this

Suspected phishing site | Cloudflare

What if four patients in respiratory distress need a ventilator to keep them alive, but a hospital has just one available? Who makes that call? And how?

Public health and community leaders are contemplating excruciating dilemmas just like that before demand for medical help in the coronavirus crisis peaks in coming weeks.

They’re updating protocols, called “crisis standards of care,” for the most urgent medical decision-making possible, guidelines to determine, as resources get scarce, who gets care and at what level and who does not.

that doesn't sound to me like they're just talking about moving people from facility to facility...of course at the moment this is all just preparation, but if things do get bad enough, where are they going to send people when there are NO beds left in their state? or the neighboring state?...they WILL be making those decisions if things get bad enough...so what criteria would you use?

and yeah, me getting upset totally equates to someone refusing to get a shot that would have prevented them from taking up valuable resources to begin with...when they're likely responsible for breeding the variants that are requiring others to need to resources to begin with


"It does allow for triage in an emergency but not denial of care to anybody. "
what do you think triage means in a real emergency? it absolutely can come down to denying care to some in a real emergency, when there are not enough resources to go around. lets just hope it doesn't come down to that...

Click to expand...

When a patient arrives at the hospital with head injuries and needs immediate intubation to keep him alive that's when the decision has to be made. Going through Colorado's standards of care document, one of the values listed in the standard is to maintain the ability to care for that emergency accident victim. Colorado isn't at a point where there is NO capacity. Not like it was in NY or NOLA in the early days of the pandemic. The standard is meant to keep hospitals safely staffed. So your concern is premature and hopefully the standards of care won't need to be moved again to encompass life and death decisions.

Not Covid. Covid is a slow-moving train wreck and there is time to find a way to accommodate them.

Seems like a lot of people want revenge.

Roger A. Shrubber said:

i wasn't refering to the article schuylar posted,
i was refering to this

Suspected phishing site | Cloudflare

What if four patients in respiratory distress need a ventilator to keep them alive, but a hospital has just one available? Who makes that call? And how?

Public health and community leaders are contemplating excruciating dilemmas just like that before demand for medical help in the coronavirus crisis peaks in coming weeks.

They’re updating protocols, called “crisis standards of care,” for the most urgent medical decision-making possible, guidelines to determine, as resources get scarce, who gets care and at what level and who does not.

that doesn't sound to me like they're just talking about moving people from facility to facility...of course at the moment this is all just preparation, but if things do get bad enough, where are they going to send people when there are NO beds left in their state? or the neighboring state?...they WILL be making those decisions if things get bad enough...so what criteria would you use?

and yeah, me getting upset totally equates to someone refusing to get a shot that would have prevented them from taking up valuable resources to begin with...when they're likely responsible for breeding the variants that are requiring others to need to resources to begin with


"It does allow for triage in an emergency but not denial of care to anybody. "
what do you think triage means in a real emergency? it absolutely can come down to denying care to some in a real emergency, when there are not enough resources to go around. lets just hope it doesn't come down to that...

Click to expand...

People who get upset disturb the force and gives the dark side a chance to make novel viruses. It's all your fault.

Fogdog said:

People who get upset disturb the force and gives the dark side a chance to make novel viruses. It's all your fault.

Click to expand...

sorry, i'll try to meditate more

Roger A. Shrubber said:

sorry, i'll try to meditate more

Click to expand...

too late.

You are on a "no treat list". Take care.

Fogdog said:

People who get upset disturb the force and gives the dark side a chance to make novel viruses. It's all your fault.

Click to expand...

Midi-Cloroxians, dammit

Fogdog said:

When a patient arrives at the hospital with head injuries and needs immediate intubation to keep him alive that's when the decision has to be made. Going through Colorado's standards of care document, one of the values listed in the standard is to maintain the ability to care for that emergency accident victim. Colorado isn't at a point where there is NO capacity. Not like it was in NY or NOLA in the early days of the pandemic. The standard is meant to keep hospitals safely staffed. So your concern is premature and hopefully the standards of care won't need to be moved again to encompass life and death decisions.

Not Covid. Covid is a slow-moving train wreck and there is time to find a way to accommodate them.

Seems like a lot of people want revenge.

Click to expand...

yeah, i understand we aren't there yet, they still have beds and equipment now, i was talking if things went south quickly, which is entirely possible. i also know they won't deny the unvaccinated treatment...until it does go south, then i feel that that is a valid criteria for triage...they did have ample opportunity to protect themselves, how can it be unfair to give those who made the effort preferential treatment in that area?

There are a lot of experts and governments freaking out over the new variant that didn't have that same reaction about Delta, makes me a little uneasy.