Apr 27, 2020

Please see the NCMS COVID-19 Update re: the North Carolina Protocol for Allocating Scarce Inpatient Critical Care Resources in a Pandemic (2020 protocol), a set of recommendations from the North Carolina Institute of Medicine (NCIOM), North Carolina Medical Society (NCMS) and North Carolina Healthcare Association (NCHA). An educational webinar for clinicians on the protocol will be held on Tuesday, April 28 at 7 p.m. Learn more and register here.

In light of the COVID-19 pandemic, the North Carolina Department of Health and Human Services requested that the NCIOM, NCMS and NCHA develop a recommended protocol for the allocation of scarce critical care resources, to be effective only during a Governor’s declared state of emergency due to a pandemic, and when demand for critical care resources exceeds supply. The NCIOM, NCMS and NCHA have produced the 2020 protocol and submitted it to the NC DHHS for review, approval, and inclusion in the state’s emergency preparedness plan. To date, the protocols have not been officially adopted by the state. We write to provide some context about the need for, and process of developing, these recommendations.

In addition, we invite you to an educational webinar about the protocol, including its goals and implementation, on Tuesday, April 28 at 7 p.m. This webinar is aimed at health care providers, administrators, and other health care professionals whose patients may be affected by the protocol.
The primary purpose of the 2020 protocol is to provide recommendations for the triage of all inpatients in the event that a pandemic creates overwhelming demand for critical care resources, such as ventilators, that outstrips the supply. Key recommendations to achieve the critical purposes of the 2020 protocol include:

  1. the creation and utilization of triage teams and review committees to promote objectivity;
  2. use of accepted criteria, methodologies, and processes for initial allocation of critical care resources;
  3. periodic reassessment to determine whether ongoing provision of critical care treatment is likely to result in improvement for individual inpatients; and
  4. effective communication with patients and their representatives regarding goals of care and treatment preferences, as well as allocation decision-making processes and results.

The protocol is not only grounded in ethical obligations (including the duty to care, the duty to steward resources to optimize public health, distributive and procedural justice, inclusivity, equity, and transparency), but it also specifically promotes objectivity in decision-making and endeavors to avoid conflicts of commitments and minimize moral distress. Additionally, the protocol is intended to establish guidance for health care personnel on a standard of care for managing scarce critical resources.

On Thursday, March 26, 2020, the NCIOM, NCMS, and NCHA convened a Scarce Critical Care Resource Allocation Advisory Group (advisory group) to raise awareness about and obtain community input on a draft revised protocol for allocating scarce inpatient critical care resources during the crisis stage of a pandemic. This advisory group reviewed revisions to a 2010 draft protocol and on March 31, 2020, convened an additional group (health care stakeholder group), comprised of representatives from most major health systems in the state, for additional discussion and review.

The 2020 advisory group included representatives from community and advocacy groups representing racial and ethnic minorities, immigrant populations, vulnerable populations, people with disabilities, older adults, and faith communities, as well as representatives from several clinical specialties (including intensive care, pediatrics, palliative care, emergency medicine, family medicine, psychiatry, infectious disease, nephrology, and anesthesiology), nursing, spiritual care, ethics, law, and public health.

Through several drafts, the protocol’s authors considered key feedback from advisory group and stakeholder sessions as well as a recently released model protocol published by the University of Pittsburgh School of Medicine (UPSM). A health care stakeholder group reached consensus that the UPSM model provided a responsive starting point for a North Carolina protocol, with some revisions. These revisions included removing heightened priority for health care personnel due to definitional and equity concerns, and removing children ages 12-17 from the protocol in lieu of a new 2020 protocol appendix, now under development, addressing pediatric populations. Additional modifications may also be recommended from time to time to reflect advances in pandemic emergency medical care generally.

To learn more about the protocol and what it means for your work and community, please join us for the webinar on April 28 at 7 p.m. Further information about the protocol can also be found at this webpage.