For now, Alabama hospitals have enough life-saving ventilators to meet demand, but if the coronavirus outbreak gets worse, they could dust off a decade-old state document that offers guidance for worse-case scenarios.

The Alabama Department of Public Health drafted the document in 2010. AL.com first reported its existence. The emergency operations plan contemplates a “mass casualty event” that overwhelms the hospital system.

“It would be characterized by frequent, widespread cases of respiratory failure occurring in sufficient volume to quickly exhaust available mechanical ventilator resources,” the document states. “One example might include, not exclusively, a virulently aggressive form of pandemic influenza.”

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The document describes the triage options as “measures of last resort” and counsels hospitals to first exhaust all possibilities to expand supply.

The recommendations are not binding on hospitals and doctors, who would make the ultimate decisions if shortages arise.

“Decision for care remain those of the medical professional, as the treating provider, in discussion with the patient and the patient’s family,” state medical officer Dr. Karen Landers said in a statement to FOX10 News. “Sometimes clinicians at the bedside will be faced with very difficult decisions, and in a true catastrophe, clinicians will be tasked with making the best possible decisions.”

Rendi Murphree, an epidemiologist at the Mobile County Health Department, said at a press briefing on Tuesday that worst-case-scenario decisions about how to triage care are complicated. She said health scholars, politicians, scientists and community leaders provide input when drawing up such recommendations.  

“So just remember when, someone asks me what is the biggest thing you’re worried about, it’s keeping our hospitals open and keeping our critical health care infrastructure open, keeping our long-term health care facilities open, so that we can care for and treat the volume of older adults, or people in severely immune-compromising conditions or other medical frailties,” she said.

Mechanical ventilators, which help patients breathe when their lungs fail, have been crucial in treating a disease that has no cure.

Shortages in hard-hit Italy have prompted agonizing decisions by doctors on which patients should get the machines and which ones should not.

How the triage works

The state triage document lays out a series of factors to consider when determining which patients should get ventilators. For instance, the document recommends not giving ventilators to certain patients with end-stage organ failure. Examples might include some patients with kidney and heart failure; stroke victims; some cancers; and AIDS.

Triage grid

This appendix, which appears in an Alabama Department of Public Health document, offers hospitals guidance on deciding which patients should have access to ventilators and which should not in the event of a shortage. 

If those measures prove insufficient, the plan recommends withdrawing ventilators from some patients who do not respond to treatment. A final set of restrictions could exclude patients who do not meet thresholds for survivability based on age and other factors.

State health leaders have been reluctant to discuss how they would react under similar circumstances, but they have acknowledged that the potential exists.

The state has a relatively small number of COVID-19 cases – 242, according to the most recent figures from the state health agency. Health Officer Dr. Scott Harris told reporters on a conference call Tuesday that roughly 8 percent to 9 percent of those people have been hospitalized, a lower rate than many other states.

Still, Harris said, there is little excess capacity in hospitals. Statewide, hospitals are typically about 75 percent filled. And he said that in Alabama’s coronavirus epicenter, Jefferson County, occupancy usually runs about 90 percent.

“It would not take large numbers of people for them to overwhelm their capacity there,” he said.

He noted that the state shifted resources and patients when overcrowding because an issue during the H1N1 outbreak in 2009.

“We don’t have a concrete plan to move any patients from one hospital to another,” he said. “But that general concept is something that we’ve been working on for a few weeks.”

Harris said his agency is working on a plan with the Alabama Emergency Management Agency to increase bed space, if needed.

“Hope that it’s not necessary for us,” he said. “But we’ll be prepared if and when the time comes. … We’ve been planning for some time for the possibility of a hospital surge.”

Scrambling for more supplies

State officials and hospitals, alike, have scrambled to build up critical supplies.

Mike Burke, a spokesman for the company that owns Providence Hospital in Mobile, declined to address how a ventilator shortage would be addressed. But he told FOX10 News via email that the hospital is making every effort to protect employees and patients.

“We are taking proactive steps with our distributor and suppliers to ensure access to supplies,” he wrote. “We are arranging expedited shipments directly from manufacturers, assessing alternative products and taking advantage of our abilities as a regional and national system to make intra-hospital inventory transfers when appropriate. We have also implemented conservation measures, in anticipation of further supply chain disruption over the coming months due to COVID-19. At this time, we are not experiencing any issues with our supply inventories.”

Don Williamson, the president of the Alabama Hospital Association, said at a news conference last week that the state’s hospitals have, 1,344 ventilators and that about 550 are in use on a typical day.

Harris said the state on Tuesday received its second shipment of medical supplies from the federal Strategic National Stockpile. He said all Alabama hospitals are linked electronically to provide real-time reports on supplies.

“We have been shifted some resources internally,” he said.

Harris said the state also is trying to buy more ventilators and other equipment, but he added that every state is trying to do the same thing.

Alabama Gov. Kay Ivey told reporters Tuesday that several companies have expressed an interest in converting their plants to manufacture ventilators. But she cautioned that it is not a short-term solution.

“To completely change a model of business cannot happen overnight for big products like ventilators,” she said.

All content © 2020, WALA; Mobile, AL. (A Meredith Corporation Station). All Rights Reserved.

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