Abstract
Little is known about how US clinicians have responded to resource limitation during the coronavirus disease 2019 (COVID-19) pandemic. To describe the perspectives and experiences of clinicians involved in institutional planning for resource limitation and/or patient care during the pandemic. This qualitative study used inductive thematic analysis of semistructured interviews conducted in April and May 2020 with a national group of clinicians (eg, intensivists, nephrologists, nurses) involved in institutional planning and/or clinical care during the COVID-19 pandemic across the United States. Emergent themes describing clinicians' experience providing care in settings of resource limitation. The 61 participants (mean [SD] age, 46 [11] years; 38 [63%] women) included in this study were practicing in 15 US states and were more heavily sampled from areas with the highest rates of COVID-19 infection at the time of interviews (ie, Seattle, New York City, New Orleans). Most participants were White individuals (39 [65%]), were attending physicians (45 [75%]), and were practicing in large academic centers (≥300 beds, 51 [85%]; academic centers, 46 [77%]). Three overlapping and interrelated themes emerged from qualitative analysis, as follows: (1) planning for crisis capacity, (2) adapting to resource limitation, and (3) multiple unprecedented barriers to care delivery. Clinician leaders worked within their institutions to plan a systematic approach for fair allocation of limited resources in crisis settings so that frontline clinicians would not have to make rationing decisions at the bedside. However, even before a declaration of crisis capacity, clinicians encountered varied and sometimes unanticipated forms of resource limitation that could compromise care, require that they make difficult allocation decisions, and contribute to moral distress. Furthermore, unprecedented challenges to caring for patients during the pandemic, including the need to limit in-person interactions, the rapid pace of change, and the dearth of scientific evidence, added to the challenges of caring for patients and communicating with families. The findings of this qualitative study highlighted the complexity of providing high-quality care for patients during the COVID-19 pandemic. Expanding the scope of institutional planning to address resource limitation challenges that can arise long before declarations of crisis capacity may help to support frontline clinicians, promote equity, and optimize care as the pandemic evolves.
Highlights
Since the first US case of coronavirus disease 2019 (COVID-19) was diagnosed in mid-January 2020,1 the pandemic has completely transformed health care delivery in this country
The 61 participants included in this study were practicing in 15 US states and were more heavily sampled from areas with the highest rates of COVID-19 infection at the time of interviews
Unprecedented challenges to caring for patients during the pandemic, including the need to limit in-person interactions, the rapid pace of change, and the dearth of scientific evidence, added to the challenges of caring for patients and communicating with families. The findings of this qualitative study highlighted the complexity of providing high-quality care for patients during the COVID-19 pandemic
Summary
Since the first US case of coronavirus disease 2019 (COVID-19) was diagnosed in mid-January 2020,1 the pandemic has completely transformed health care delivery in this country. Reports from frontline clinicians in global epicenters describing extreme shortages and bedside rationing of ventilators and intensive care unit (ICU) beds[2] prompted a national conversation about how to respond to similar challenges in the United States.[3] Hospitals and health care systems drew on frameworks developed by the Institute of Medicine (IOM) and other national organizations to guide care in resource-limited emergency settings.[4,5,6,7]. If resources become so limited that a functionally equivalent standard of care can no longer be sustained, institutions shift to crisis capacity, and care is redirected to provide the greatest aggregate benefit to the population.[8] Under crisis standards of care, a specialized triage team becomes responsible for rationing scarce resources and making decisions about which patients will and will not receive potentially life-saving treatments. Experience in current role, mean (SD), y 17.9 (10.5) US region
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