Validation of a Crisis Standards of Care Model for Prioritization of Limited Resources During the Coronavirus Disease 2019 Crisis in an Urban, Safety-Net, Academic Medical Center.

OBJECTIVES: The coronavirus disease 2019 pandemic has overwhelmed healthcare resources even in wealthy nations, necessitating rationing of limited resources without previously established crisis standards of care protocols. In Massachusetts, triage guidelines were designed based on acute illness and chronic life-limiting conditions. In this study, we sought to retrospectively validate this protocol to cohorts of critically ill patients from our hospital. DESIGN: We applied our hospital-adopted guidelines, which defined severe and major chronic conditions as those associated with a greater than 50% likelihood of 1- and 5-year mortality, respectively, to a critically ill patient population. We investigated mortality for the same intervals. SETTING: An urban safety-net hospital ICU. PATIENTS: All adults hospitalized during April of 2015 and April 2019 identified through a clinical database search. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 365 admitted patients, 15.89% had one or more defined chronic life-limiting conditions. These patients had higher 1-year (46.55% vs 13.68%; p < 0.01) and 5-year (50.00% vs 17.22%; p < 0.01) mortality rates than those without underlying conditions. Irrespective of classification of disease severity, patients with metastatic cancer, congestive heart failure, end-stage renal disease, and neurodegenerative disease had greater than 50% 1-year mortality, whereas patients with chronic lung disease and cirrhosis had less than 50% 1-year mortality. Observed 1- and 5-year mortality for cirrhosis, heart failure, and metastatic cancer were more variable when subdivided into severe and major categories. CONCLUSIONS: Patients with major and severe chronic medical conditions overall had 46.55% and 50.00% mortality at 1 and 5 years, respectively. However, mortality varied between conditions. Our findings appear to support a crisis standards protocol which focuses on acute illness severity and only considers underlying conditions carrying a greater than 50% predicted likelihood of 1-year mortality. Modifications to the chronic lung disease, congestive heart failure, and cirrhosis criteria should be refined if they are to be included in future models.

Crisis Intervention Psychotherapy in the Age of COVID-19.

Crisis intervention psychotherapy (CIP) is an underutilized form of therapy that can be offered as a treatment during psychiatric disasters and emergencies, and it may be especially useful during the age of Coronavirus Disease 2019 (COVID-19). CIP is a problem-solving, solution-focused, trauma-informed treatment, utilizing an individual or systemic/family-centered approach. CIP is a brief form of psychotherapy delivered as a companion or follow-up to psychological first aid. Crisis psychotherapy is designed to resolve a crisis and restore daily functioning. CIP can be adapted as a single session for a COVID-19 mental health emergency or for a hotline or as 2 to 20 sessions of treatment with COVID-19 patients and families offered virtually on a psychiatric inpatient unit, through a consultation-liaison service, or in outpatient settings. This article reviews the history of critical incident stress management and the use of its replacement, psychological first aid. The history and core principles of crisis psychotherapy and 8 core elements of treatment are described. The use of digital and virtual technology has enabled the delivery of crisis psychotherapy during the COVID-19 pandemic. A case study of a family impacted by COVID-19 is reported as an illustration. The use of a 6-week timeline, an ecological map, and a problem-solving wheel-and-spoke treatment plan are demonstrated.