Journal articles on the topic '111002 Clinical Nursing: Primary (Preventative)'

Background: Expanded applications and increasing volumes of complex endovascular procedures have increased the risk of unintended intraoperative fragmentation and retention of catheters and sheaths. We describe a series of retained or fragmented endovascular devices, a quality improvement program to address this unmet need for improved detection of catheter fragmentation, and the results of this program. Methods: Cases utilizing endovascular devices that resulted in a retained catheter fragment were identified and analyzed during divisional quality improvement review. One consistent area of concern was operating room (OR) staff unfamiliarity with verifying the integrity of an endovascular device. In response, a slide-based training protocol of focused, endovascular nursing education was implemented. Following perceived lack of improvement after this approach, we developed a handheld visual reference display of the tips of common catheters and sheaths. Staff was surveyed before and after intervention to assess the educational value of the display and the impact on staff device familiarity. Results: All 4 described cases resulted in an unplanned return to the OR for retrieval of the fragmented catheter or sheath. No thromboembolic complications were observed, although associated intra-arterial thrombus was noted in 2 cases. Thirty-four OR nurses were polled to trial the visual reference display initiative, with 70% of those reporting primary surgical assignments outside of cardiovascular ORs. Introduction of the new visual reference display improved staff confidence in their ability to identify a broken device (2.4-3.7, P < .001). This improvement was most significant in OR staff with primary assignments in noncardiovascular services. Conclusion: Current OR standard operating procedures fail to address the potential for unintentionally retained catheters and wires during endovascular procedures. Our novel visual reference display of common endovascular items rather than conventional in-service training improved the ability of staff to identify device fragmentation at the time of the index procedure.

Community engagement is a means to help overcome challenges to the delivery of health care and preventative services. On the occasion of the 2021 International Stroke Conference Edgar J. Kenton III Lecture, I review community engagement strategies utilized in the AAASPS trial (African-American Antiplatelet Stroke Prevention Study) and SDBA (Studies of Dementia in the Black Aged) observational studies that I directed. The main community engagement strategies included use of home visits (bringing the study to the community), engagement of churches, community advisors, community physicians, other healthcare providers, major Black community organizations, and utilization of diversity training. Community engagement strategies were a major component of AAASPS and SDBA that helped to ensure successful recruitment and retention of an underrepresented community in clinical trial and observational studies. Lessons learned from these studies largely carried out in the 1980s and 1990s helped to dispel myths that Blacks could not be recruited into large-scale clinical trials, emphasized the importance of studying underrepresented groups with adequate statistical power to test primary study hypotheses, and provided foundational recruitment and retention methods for future consideration.

BACKGROUND AND CONTEXT: The Nurse-Led Healthy Lifestyle Clinics focussed on lifestyle issues for patients with known health inequalities. Much of the nursing was educative and preventative care. This evaluation assessed patient experiences and opinions, as well as clinical outcomes. ASSESSMENT OF PROBLEM: Information came from clinical outcome data for 2850 individuals and 424 patient satisfaction surveys. Results: Patients were aged 0–95 years (45% between 40 and 59 years); 60% Pakeha/European, 31.4% Maori, 4.2% Pacific and 4.4% other ethnicities. Only 19% of claimants (approximately 40% were Maori or Pacific) came from quintile 5 addresses, suggesting the target population was not reached effectively. Ninety-four percent of patients had a better understanding of their diagnosis, medication and treatment plan, and were more motivated to self-manage their health needs. This increase in patient empowerment is a significant outcome of the project. Clinical outcome data showed no significant differences between first and last clinic visits for average weight, blood pressure, smoking, glycosylated haemoglobin levels, waist circumference or cardiovascular risk. Significant improvements were shown in the Dartmouth Primary Care Cooperative Information results for social activity, change in health, and overall health (n=89). STRATEGIES FOR IMPROVEMENT: More effective techniques to access the target population have been implemented, as has an extended period for review of clinical outcomes. LESSONS: More focussed evaluation of clinical outcomes is necessary to provide quantitative data on the clinics. The large percentage of patients who felt more empowered to self-manage their health needs suggests the clinics were effective in this area. KEYWORDS: Nurse-led clinics; life style; program evaluation; patient satisfaction; health status disparities

Background Very few instruments to integrate knowledge, attitude and practice into dementia care as a holistic perspective were available to the Chinese. Method This article documented the development of a 30-item self-administered Chinese instrument of knowledge, attitude and preventive practice on dementia care and reported the results of psychometric testing among 1500 Chinese in Macao Special Administrative Region (SAR), including 234 primary health professionals, 272 staff working at day-care centers and nursing homes, 586 high school students and 408 community-dwelling older people. The Chinese instrument was developed through literature review and committee review. The psychometric methods were used to evaluate the reliability and validity of the Chinese instrument as measures of knowledge, attitude and preventive practice on dementia care for the Chinese. Results The preliminary results indicated that the Content Validity Index of the Chinese instrument was .973 and Cronbach’s alpha coefficient of the Chinese instrument was .842, among which Knowledge subscale, Attitude subscale and Preventive Practice subscale were .749, .633 and .845 respectively. The means and standard deviation were 65.13 ± 24.56 for Knowledge subscale, 74.76 ± 8.37 for Attitude subscale, 73.22 ± 14.05 for Preventative Practice subscale, and 70.99 ± 11.27 for the Chinese instrument. Conclusion The 30-item self-administered Chinese instrument of knowledge, attitude and preventive practice on dementia care had satisfied the psychometric evaluation well enough to warrant further use, and could also have particular implications for other Chinese populations all over the world.

Introduction. Antibiotic stewardship utilizes interprofessional collaborative practices, including professionals from medicine, pharmacy, nursing, social services, and clinical laboratory science, to identify potential problems proactively. A tertiary care integrated health system’s Emergency Department (ED) aimed to identify antimicrobials prescribed to the outpatient community as part of a proactive antimicrobial stewardship project. Methods. A pilot, prospective, snapshot of a tertiary community hospital’s outpatient antimicrobial prescribing habits was conducted. All subjects were identified via a daily report of patients discharged from the ED over 30 days in the summer of 2017 and individually reviewed for prescribed antimicrobial(s). Exclusions were hospital admission, antimicrobial sensitivity, and antimicrobial courses less than five days or more than 14 days. The primary goal was determining the number of antimicrobial oral tablets/capsule prescriptions to adult outpatients within a 5 to 14-day treatment window. Secondary goals were to include the diagnosis, non-capsule/tablet antimicrobial, pediatric patients, and prescriptions outside the treatment window. Results. Total number of antimicrobial prescriptions over the 30-day period was 653 in 5,520 individual visits. Total number of adults prescribed oral antimicrobials was 467 (15.6 daily). Patients were diagnosed with infections including urinary tract, cellulitis, soft tissue injury, abscess, upper respiratory, dental caries, gastrointestinal, sexually transmitted, otitis media/externa, pneumonia, viral, pyelonephritis, tick-borne, fungal, Bell’s Palsy, and sepsis. The number of non-adult, non-oral, and outside window treatment antimicrobial prescriptions were 186 (6.2 daily). With an average 184 patients treated in the ED daily, approximately 11.8% received antimicrobial treatment on discharge. Conclusion. Important aspects of the project were the evaluation of antimicrobial prescribing habits for a midwest ED and identification of potential complications requiring future interventions for follow-up or preventative measures to assist in patient care and community health. Areas of practice improvement were identified inadvertently as a result of this project. Potential future studies included seasonal variability, whether the patient obtained a prescription and complied with treatment, and differences between inpatient and outpatient antimicrobial prescribing practices.

Background: Developing countries, such as Viet Nam, are currently undergoing a health transition from infectious to chronic medical conditions, including vascular diseases. Medications for secondary stroke prevention may be underused. Our objectives were to quantify the frequency of such underuse and to identify patient characteristics associated with it. Methods: Data from consecutive patients admitted with stroke to Da Nang Hospital from March 2010 through February 2011 were collected using the WHO Stroke STEPS approach. Patients with ischemic stroke (IS) discharged alive, and not sent home to die, were included. Hypertension (HTN), diabetes mellitus (DM) and hyperlipidemia (HL) were conditions eligible for preventative medications at discharge. "Underuse" was defined as prescribing less than all appropriate medications, given each patient’s conditions. Patients with intraparenchymal hemorrhage were excluded from analyses. Multivariate associations with underuse were assessed for age, gender, number of conditions, stroke symptoms, employment status, level of education, hospital ward, and discharge modified Rankin scale. Results: Of 754 patients admitted with stroke, 260 patients met our inclusion criteria with a mean age of 67.2 years and with 42% women. Most had HTN (91.5%), and some, DM (9.6%) and HL (11.2%). Patients mostly had ≥ 2 conditions needing treatment at discharge (93.5 %). Underuse occurred in 69.2%, with only half being discharged on antithrombotic agents. Factors independently associated with underuse included older age (RR=1.06 per decade; 95% CI: 1.0-1.1), admission to the ward caring for most stroke patients (RR=2.3; 95% CI: 1.5-3.5), and completing only primary school education (RR=1.3; 95% CI: 1.1-1.7). Conclusions: Stroke patients discharged from Da Nang Hospital in Viet Nam are not consistently prescribed medications for secondary stroke prevention. A specific ward, older age, and lower education were independently associated with underuse of preventative medications. Opportunities exist to increase use of medications for secondary stroke prevention at the time of hospital discharge, but barriers will need to be identified.

Background: Gram-negative bloodstream infection (GNBSI) is a threat to public health in terms of mortality and antibiotic resistance. The hepatopancreatobiliary (HPB) cohort accounts for 15%–20% of GNBSI, yet few strategies have been explored to reduce HPB GNBSI. Aim: To identify clinical factors contributing to HPB GNBSI and strategies for its prevention. Methods: We performed a retrospective analysis of 433 cases of HPB GNBSI presenting to four hospitals between April 2015 and May 2019. We extracted key data from hospital and primary care records including: the underlying source of GNBSI; previous documentation of biliary disease; and any previous surgical or non-surgical management. Findings: Out of 433 cases of HPB GNBSI, 388 had clear evidence of HPB origin. The source of GNBSI was related to gallstone disease in 282 of the 388 cases (73%) and to HPB malignancy in 70 cases (18%). Of the gallstone-related cases, 117 had previously been diagnosed with symptomatic gallstones. Of the 117 with a previous presentation, 93 could have been prevented with a laparoscopic cholecystectomy at the first presentation of gallstones, while 18 could have been prevented if intraoperative biliary tract imaging had been performed during a prior cholecystectomy. Of the 70 malignant cases, five could have been prevented through earlier biliary stenting, use of metal stents instead of plastic stents or earlier pancreaticoduodenectomy. Discussion: The incidence of HPB GNBSI could be reduced by up to 30% by the implementation of alternative management strategies in this cohort.

Abstract Background Urinary tract infections (UTIs) are common in individuals with neurogenic lower urinary tract dysfunction (NLUTD) following spinal cord injury (SCI). They are not only a great burden for affected individuals, but also cause considerable health costs. Furthermore, recurrent antibiotic treatments of UTIs contribute to the growing problem of bacterial resistance to antimicrobial compounds. Even though there is a multitude of different measures to prevent UTIs in individuals with NLUTD, no clear evidence exists for any of these. Oral immunomodulation with UTI-relevant Escherichia coli lysate may be a promising preventative measure with a good safety profile in individuals with NLUTD. However, currently available data are sparse. Methods This is a randomized, quasi-blinded, placebo-controlled, mono-centric pilot trial investigating the feasibility of a main trial regarding the effects of a lyophilized lysate of E. coli strains for oral application (Uro-Vaxom®, OM Pharma SA, Meyrin, Switzerland). There will be two parallel groups of 12 participants each. Individuals with acute SCI (duration SCI ≤ 56 days) from 18 to 70 years of age admitted for primary rehabilitation will be eligible. Blood and urine samples will be taken prior to intervention start, at the end of the intervention, and 3 months after intervention termination. The trial intervention will last 90 days. The participants will not be informed regarding the treatment allocation (quasi-blinded). The nursing staff will prepare the daily dose of the allocated treatment from the original packaging. The trial personnel and the biostatistician will be blinded. Feasibility (e.g., recruitment rate, patient attrition), clinical (e.g., number of symptomatic UTIs), and laboratory parameters (e.g., urinary culture, urinary proteo- and microbiome, blood cell counts) as well as adverse events will be collected. Discussion Effective and efficient measures for the prevention of UTIs in individuals with NLUTD are urgently needed. If the conclusion of this pilot is positive regarding feasibility, the effects of oral immunomodulation with a E. coli lysate will be investigated in a larger, sufficiently powered, multi-center trial. Trial registration ClinicalTrials.govNCT04049994. Registered on 8 August 2019

Background and Purpose: The State of Alaska covers a vast area the size of California, Texas and Montana combined and comprises one-fifth of the total U.S. land mass. The population of approximately 735,132 is spread over 362 communities. The Alaska Native populations comprise 14.7% of the total population of Alaska with most of its members living in remote villages or isolated islands. Two hundred Alaskan communities can be reached only by boat or air. Public health and preventative services are challenging due to inaccessibility during winter months, high winds, volcanic activity, and poor infrastructure. The introduction of telemedicine to critical access facilities has proven effective for not only emergent delivery of stroke interventions but looks to promote access in the primary health setting as well. The purpose of this project was to identify barriers to neurological health and risk factors unique to Alaskans. Methods: Guided by a telehealth model of care for emergency Stroke cases, Providence Alaska Medical Center increased access to 5 spoke hospital sites in the Southeast portion of the State in the past six years. As the hub site for the State, Alaskans are placed in a national data base for outcomes, modifiable risk factor management and disability measurement. Interdisciplinary debriefings occur monthly for evidence-based practice agreements. Results: Patients have access to the only Cerebrovascular Neurologist in the State with a 50% increase in the delivery of tPA for ischemic stroke. Improved door-to-needle times, increased tPA delivery and interventional radiology, along with a decrease in length of stay has lead the way to developing a more extensive telestroke network within the Providence system. Conclusions: Access to primary and emergency neurological care remains a barrier to many Alaskans, especially those living in remote and isolated areas of the State. Using ongoing statistical data compared to other national averages, the telemedicine method of stroke care has proven vital to reducing morbidity and mortality in its large geographical boundaries. Further attention to a telestroke program will only enhance outcomes in the future.

Background: Stroke is the second leading cause of death globally and an increasing concern in low- and middle-income countries (LMIC) where, due to limited capacity to treat stroke, preventative efforts are critically important. Although some research on evidence-based interventions for stroke prevention in LMIC exists, there remains a significant gap in understanding of their implementation across various contexts in LMIC. Objectives: In this scoping review, our objective was to identify and synthesize the implementation outcomes (using Proctor et al.’s taxonomy, 2011) for stroke prevention interventions, as well as to describe the diverse interventions employed. Methods: Eligible studies were empirical, focused on implementation of stroke prevention programs or policies, and occurred in at least one LMIC. Five databases were searched, including PubMed, PsycINFO, CINAHL, EMBASE, and Web of Science. Two reviewers independently assessed studies for selection and charted data; discrepancies were resolved through discussion with a third reviewer until consensus was reached. Narrative synthesis was used to analyze and interpret the findings. Results: Studies were predominantly focused in Asia, targeting primary or secondary prevention, and facility-based. Interventions were conducted at the level of individual (n=11), system (n=12), or both (n=4). Various implementation outcomes were reported, most commonly cost (n=10), acceptability (n=7), fidelity (n=7), and feasibility (n=6), but also adoption (n=4), penetration (n=3), appropriateness (n=1), and sustainability (n=1). Conclusions: Findings highlight the breadth of evidence-based interventions for stroke prevention available to implement in LMIC settings, including culturally acceptable education interventions, cost-effective medications, and community-based interventions implemented by community health workers. Implementation outcomes remain under-reported, and more rigorous research is needed to better plan and evaluate the implementation of these interventions to prevent stroke.

Background: Effective interventions to improve stroke preventative care in vulnerable populations have not been reported. Methods: We tested the impact of a chronic care model-based intervention program among 407 subjects with a recent stroke or transient ischemic attack at four Los Angeles County public hospitals. All subjects had a baseline systolic blood pressure (SBP) of at least 120 mm Hg and were randomized after baseline assessment in a 1:1 ratio to usual care or intervention, stratified by hospital and by English/Spanish language. The care management intervention was led by bilingual nurse practitioners or physician assistants, and it consisted of group clinics, self-management support, report cards, decision support, and coordination of ongoing care. Intention-to-treat analyses were conducted using repeated-measures mixed-effects models. The primary outcome was change in SBP. Secondary outcomes were other measures of SBP, low-density lipoprotein (LDL), ACC/AHA 10-year cardiovascular risk, adherence to antihypertensive and to antithrombotic medications, and physical activity. Results: Mean age was 57 years, 60% were male, 18% were African-American race, and 69% were Hispanic ethnicity. 48% had not graduated from high school. Baseline SBP was 150 mm Hg in the usual care arm and 149 mm Hg in the intervention arm. 12 month data were obtained in 333 participants (82%). There were substantial declines in SBP in both the usual care and intervention arms (Table). However, there were no significant differences between the two arms in either improvement of SBP from baseline or other measures of stroke risk factor control. Subgroup analyses did not reveal a differential impact of the intervention by race/ethnicity. Conclusion: Our care management intervention did not improve stroke risk factor control beyond what was attained in usual care. Further analyses are ongoing, and those findings will be used to guide modification of the intervention for future testing.

Issue: The Affordable Care Act, ACA Section III, encourages development of new transitional care models linking hospital reimbursements to improved quality, efficiency, and transparency in care delivery. Unplanned readmissions, a quality indicator, are costly under ACA and on the forefront of the Joint’s Commission effort to advance data utilization and improve care to stroke patients through the Comprehensive Stroke Center (CSC) certification requirements. Follow- up phone calls to patients discharged home from the hospital within seven days are embedded in the above requirements and can be a valuable tool in reducing unplanned readmissions and in improving support to stroke patients with complex psychosocial and medical needs. Purpose: Phone calls initiated by a Nurse Practitioner (NP) to stroke patients after discharge to home in our CSC aimed at increased medication compliance, avoidable readmission rate monitoring, and comparison of outcomes to those reported in the literature. In investigating trends we pursued opportunities to enhance care delivery, establish long-term relationship with patients, and empower them to involve actively in their care. Method: We utilized descriptive statistics in retrospective and prospective hospital data analysis extending our focus on development of quality improvement initiatives. Inclusion criteria consisted of age >18, primary diagnosis, and discharge disposition. Results: Between June 2014 and June 2015, after the calls introduction, we achieved an absolute risk reduction of 4.1% in short-term readmissions within 30 days. Compared to the year before readmission rates decreased by 60% with number needed to treat of 25 and preventative fraction of 40%, similar to reduction rates cited in current literature. Patients expressed satisfaction with care and in discussions with the NP helped identify improvement areas for our program. Limitations of the study include single center observations and specific characteristics of our regional population. Conclusion: When implemented as part of a transitional care model, telephone calls to stroke patients post hospital discharge to home conducted by an NP can be an effective tool in reducing unplanned readmissions and improve patient satisfaction with care.

Background: Depression is a leading cause of disability post-stroke. Nearly a third of stroke victims suffer from depression after event occurrence. Post-stroke depression hinders physical rehabilitation, decreases quality of life, and has a negative effect on long-term survivability. Inflammatory processes post-ischemic stroke are likely associated with the development of depression. The neutrophil-lymphocyte ratio (NLR) is a routinely available marker of systemic inflammation and could serve as a prognostic tool at hospital admission for post-stroke depression. The goal of this project was to determine the relationship between admission NLR and depression 30 and 90 days post-stroke. Methods: 58 ischemic stroke patients were recruited from a regional primary stroke center and followed up to 90 days post stroke. NLR levels were drawn at Emergency Department admission and at 24 hours. The Quick Inventory for Depression Symptomology (QIDS) was used to measure depression symptoms at 24 hours, 30 days and 90 days post stroke. We scaled continuous variables by their standard deviation and used the Box-Cox or exponential transformation if the skew was greater than 0.5. An age-adjusted Pearson's correlation was utilized to assess bivariate relationships. Other methods used include Mann-Whitney-Wilcoxon test and Fisher's Exact test when appropriate to compare ischemic and non-stroke patients. Results: Adjustments for age were included due to weak to strong correlations with various measures of NLR and QIDS. There is a statistically significant correlation between the baseline NLR and baseline QIDS (correlation = -0.54, p-value=0.013) and QIDS at 30 days (correlation=-0.67, p-value=0.028). NLR at 24 hours has a statistically moderate correlation with QID at 30 days (correlation=0.39, p-value=0.055) and QIDS at 90 days (correlation=0.36, p-value=0.134). Conclusions: This preliminary study suggests that NLR at hospital admission could serve as a prognostic marker of post stroke depression at thirty days. Utilization of this marker in clinical practice for stroke care could identify high risk patients and result in earlier treatment of depression. Validation studies and preventative strategies will need to be explored in future studies.

Introduction The current social climate of Western societies understands fatness as the self-inflicted disease ‘obesity’; a chronic illness of epidemic proportions that carries accompanying risks of additional disease and that will eventually lead to death. In recent years, the stigmatisation and general negative societal evaluation of fatness and thus fat identities has increased (Sobal). Primarily, fatness has become a sign of medical deviance in that it is perceived to be a product of unhealthy eating behaviours and physical inactivity (Rothman). As a result, to be fat has become a barrier to entry in terms of employment opportunities, and has restricted the availability of health and insurance services for many (Sobal). Recently there has been a drastic increase in the availability of radical weight-loss solutions that strictly regulate and police fat-bodied deviants, namely in the form of surgery. Bariatric surgery, or weight-loss surgery, physically enforces the achievement of ‘health’ by curing obesity by reducing the size and functionality of the stomachs of the morbidly obese. However, bariatric ‘post-ops’ (short for post-operative) often encounter harmful consequences following their surgery in the form of increased self-surveillance, regulation and control in order to maintain their health through thinness. This article seeks to examine these consequences of surgery as a way to problematise the achievement of health through thinness overall. In order to address this issue, this article first establishes a framework of obesity discourse which enables us to understand how obesity is perceived as a self-inflicted disease in need of medical intervention within modern Western societies. From this position, we can begin to understand the purpose of interventions such as bariatric surgery. While it is acknowledged that surgery provides the morbidly obese with a gateway to health through the achievement of thinness and an escape from a heavily stigmatised identity, it is argued that this is done at the expense of placing increased regulations and surveillance upon individuals. Finally, in drawing on post-op experiences collected for research examining the life impacts of bariatric surgery, this article will examine how post-ops are subjected to intense policing, monitoring and regulating from themselves and others as a result of achieving and maintaining ‘health’ through body size. Obesity Discourse: Establishing a FrameworkScholars Evans, Rich, Davies and Allwood argue that contemporary Western responses to obesity can be conceptualised as operating within an ‘obesity discourse’ which provides a framework of “thought, talk and action concerning the body in which ‘weight’ is privileged not only as a primary determinant but as a manifest index of well-being” (13). Predominantly, this framework draws upon two key assumptions; that obesity is a legitimate and measurable disease that poses significant medical risks to populations, and that both the cause of and solution to obesity are individual lifestyle choices (Rich, Monaghan and Aphramor). More specifically, the obesity discourse is the result of the combined efforts of an extensive process of medicalisation in conjunction with an increasingly neoliberal approach to healthcare. Since the 1950s, fatness has been widely regarded as the disease ‘obesity’. Sobal argues that this occurred through an extensive process of medicalisation, which can be defined as when non-medical issues and behaviour are redefined and understood as medical problems through the use of medical jargon and medical solutions (Conrad). In particular, fat was portrayed as pathological and requiring medical intervention through “frequent, powerful and persuasive claims that [medicine] should exercise social control over fatness” (Sobal 69). In particular this has been exercised through the widespread implementation of the body mass index [BMI] into healthcare settings, as it is seen as an accessible, practical and affordable measure of ‘health’ (Ministry of Health). Unlike other markers of health, body weight is highly visible, and thus using it as an overall indicator of health increases surveillance of the self and others within populations. In this way we can see how the medicalisation of fatness works to produce what Bordo refers to as:one of the most powerful normalizing mechanisms of our century, insuring the production of self-monitoring and self-disciplining ‘docile bodies’ sensitive to any departure from social norms and habituated to self-improvement and self-transformation in the service of these norms. (186)Primarily, this is created through a construction of a ‘normal’ body shape or an ‘ideal’ weight, which can be specified using the BMI, and acts as a health imperative for individuals to achieve and maintain (Rich and Evans). However, these constructions do not factor in individual variations in body composition and thus represent a medically defined ‘thin ideal’, in that they are unobtainable and unrealistic for most people (Metzl 5). Consequently, the idea of a ‘normal weight’ strengthens contemporary body ideals (Burns and Gavey).The recent move in contemporary Western societies towards a neoliberal model of healthcare has significantly impacted societal attitudes towards fatness. The neoliberal healthcare model emphasises an individual’s choice and responsibility with respect to their health, and the privatisation of healthcare systems overall (Fries). While there is a general belief that this change gives patients more autonomy and input within the medical encounter (Lupton), the move towards a ‘democratisation’ of healthcare in reality further entrenches self-surveillance behaviours within populations by asserting that the responsibility for achieving and maintaining ‘health’ lies at the feet of the individual (Fox, Ward and O’Rourke). In particular, there is an assumption that ‘health’ can be ‘unproblematically’ achieved through individual efforts to discipline and regulate body size (Crawford) and thus individuals are obliged to engage in acts of self-discipline as both a personal and public service (Throsby, War). In this way, those who are labelled as ‘obese’ are not only questioned on their ability to appropriately care for themselves, but also their ability to be a good citizen (Throsby, War). Overall, the obesity discourse has intensified the stigmatisation of the obese in that they are portrayed as morally bad and weak-willed (Sobal) and ultimately reinforced the need for external regulatory bodies such as the weight-loss industry to monitor and control the obese. The combined efforts of the medical and weight-loss industry have produced a single message which suggests that if individuals want to maintain ‘health’ and prevent disease, there must be an enduring commitment to a ‘lifestyle change’. A ‘lifestyle change’ implies that in order to achieve successful weight loss and thus ‘health’, there needs to be enduring amendments to diet and exercise that are perceived as a ‘way of life’ rather than the ‘means to an end’ message marketed by other diet regimes (Fullagar). These changes are necessitated through an assumption that excess body weight is a sign of laziness and poor personal habits (Evans and Colls). Similar to the causes of obesity, there is a definitive notion that individual choices predicate the outcomes of weight loss endeavours. Thus, weight-loss successes and failures directly reflect how well individuals adhered to their ‘lifestyle change’ rather than the reliability and validity of the weight-loss regimes themselves (Saguy and Riley).Addressing Bariatric Surgery: The Solution to Morbid ObesityOver the past decade there has been a drastic increase in the availability of radical weight-loss solutions that strictly regulate and police fat-bodied deviants, namely in the form of surgery. While there appears to be support from the medical community for the effectiveness of a ‘lifestyle change’ as the primary solution to obesity, it should be highlighted that a ‘lifestyle change’ is only seen as a realistic option for certain obesity cohorts. In particular, surgery is reserved for the very highest of obesity cohorts – the morbidly obese – and is presented as their only viable option. ‘Morbid obesity’ is defined as having a BMI of 40 or higher and is associated with the most risk of comorbid diseases such as type II diabetes, cardiovascular disease and hypertension (Foo et al.). According to the Ministry of Health, for individuals classified as morbidly obese, clinicians in New Zealand should strongly recommend bariatric surgery. Bariatric surgery describes a group of surgical procedures that physically restrict and redesign the stomachs of morbidly obese patients to achieve weight-loss as most procedures are permanent, and are associated with the greatest long-term weight loss in patients (Ministry of Health). Bariatric surgical procedures became popular due to their long-term effectiveness in weight-loss, and cost-effectiveness particularly for countries with public healthcare, through the drastic reduction in public health expenditure for co-morbid diseases such as diabetes and cardiovascular disease (Sampalis et al.). These procedures are considered the only effective treatment option for morbid obesity or a ‘last resort’ (Cranwell and Seymour-Smith; Ogden, Clementi and Aylwin), and consequently the amount of surgeries performed annually within Australasia has increased at an exponential rate (Buchwald and Williams).What makes bariatric surgery so important as a weight-loss method is that it offers the ‘morbidly obese’, who are seen as persistently deviating from idealised body norms and unable or unwilling to conform to standardised forms of self-regulation, a reprieve from their stigmatising identity. Indeed, many morbidly obese individuals who are seeking weight loss state that bariatric surgery is their only ‘hope’ or choice, or the ‘right’ choice for them (Morgan; Ogden, Clementi and Aylwin). In particular, the fear of, or the onset of, illnesses associated with obesity can be a major factor in their decision to undergo surgery (Ogden, Clementi and Aylwin). In this way, motivations to have surgery are heavily reflective of obesity discourse in that the presence of body fat is a marker of ‘impending doom’ (Rich, Monaghan and Aphramor). Indeed as Wann highlights:I really do understand why someone would consider this extreme option. The stigma attached to even the slightest amount of body fat can be daunting, and the surgeon’s sales pitch can be very slick. (41)However, as Morgan argues, more must be done to critique bariatric surgery as it largely exemplifies the social forces that control and regulate modern societies. Bariatric surgery physically enforces weight-loss and adherence to acceptable eating practices, and makes dissent both punishable and difficult (203). The removal of a large portion of the stomach means that, bariatric surgery imposes “corporeal order and discipline” (Morgan 203) upon individuals. The stomach not only enforces strict self-surveillance protocols but also an unyielding control over the individual through the “forceful prohibition or ejection” (Morgan 202) of substances. Thus, if individuals fail to regulate and govern their intake, the surgical intervention does it for them. The side-effects of vomiting and dumping syndrome act as a regulation failsafe and a form of punishment – an ‘internal policeman’ (Morgan) – that rejects deviant behaviour and punishes the individual through unpleasant and often painful experience. In this way, bariatric surgery can be viewed as the ‘ultimate weapon’ in the war against obesity as it is a means through which deviant individuals and bodies can be controlled and normalised (Glenn, McGannon and Spence).Bariatric Surgery: For Better or for Worse?In order to interrogate the dominant notion perpetuated through obesity discourse that fatness is a disease and body weight more generally is a legitimate way of measuring ‘health’ overall, this article will now draw on key findings generated from recent research examining the life impacts of bariatric surgery conducted with a support group for bariatric surgery in Auckland, New Zealand. While bariatric surgery is portrayed as a gateway to health, Throsby (Re-Birthday) argues that ultimately it is constructed as a ‘tool’ for weight-loss, rather than a cure-all ‘magic pill’ (130). This means that users are required to engage in normative dieting practices in the midst of developing new techniques of discipline that are specific to the post-surgery experience. In this way bariatric surgery creates new levels of self-surveillance that are unique to post-surgery life (Throsby, Re-Birthday 120). Self-surveillance and policing are methods in which bariatric post-ops are subjected to critique, monitoring and maintenance by both themselves and others. A key aspect of this involves the moral construction of ‘good’ and ‘bad’ foods, which often influenced eating behaviours and narratives whereby bariatric post-ops adhere to normalised understandings of diet, nutrition and health (Simpson 84). This dichotomy of good and bad foods reflects dominant understandings of the causal relationship between food, health and body size. Researchers have noted that there is a significant change in the relationship individuals have with food following surgery, and that often this comes with a serious fear of weight regain, and thus an intense policing of food (Cranwell & Seymour-Smith; Ogden, Clementi and Aylwin). Often, further restrictions are placed on an already restricted diet in order to achieve thinness, which emphasises the importance of achieving and maintaining thinness through the micromanagement of food intake (Simpson). In part, this reflects the way that the rhetoric that equates obesity with individual responsibility can equally ascribe blame to patients for any subsequent weight gain following surgery (Throsby, Re-Birthday 130) and indeed previous research has highlighted extensive fear of weight regain, particularly when users encounter fluctuations in their weight (Cranwell and Seymour-Smith). This is arguably what makes discussions around the concept of ‘maintenance’ so important. Maintenance refers to the monitoring process post-ops enter into after losing a significant portion of their weight and reaching a ‘plateau’, or a point where they stop losing weight; in essence it involves discussions around how to maintain and manage a ‘healthy’ weight (Simpson 79). Largely this draws on the assumption that despite being treated for obesity through a surgical intervention, one can never be recovered or truly ‘cured’ of obesity and thus individuals must engage in consistent monitoring as a preventative measure through ‘maintenance’ (Throsby, Re-Birthday). Maintenance is a complex process for bariatric post-ops; it is inextricably linked to weight management and is therefore a visible and moral indicator as to how ‘well’ post-ops are doing in their weight loss endeavours (Simpson). In this way maintenance is heavily couched in obesity discourse as individuals are expected to integrate self-surveillance and regulation practices into a ‘lifestyle change’ in order to prevent future weight gain (Cranwell and Seymour-Smith). For most, maintenance is difficult, and is understood to require a consistent consciousness of food related behaviours in order to be successful. In the observed support group, participants discussed the observations that they had made about their difficulties with resisting ‘crave’ or ‘bad’ foods (primarily those associated with high calories) that they enjoy, as well as revealing the ways in which they had altered their behaviour to address maintenance concerns (Simpson 79). One participant revealed that recent weight gain was making maintenance ‘very hard’, and it was clear that they attributed this weight gain to personal failings despite admitting that there had been no change to their ‘healthy’ eating behaviour (80). In order to address this issue, the participant admitted that they had resorted to traditional dieting rhetoric and removed dairy from their diet (83). Other support group members encouraged the participant to also remove carbohydrates from their diet (83), which further reinforced the notion that weight is a product of personal choice and individual responsibility (Crawford; Donaghue and Clemitshaw). As a result of the rapid weight loss achieved through bariatric surgery, many post-ops struggle to adjust to their ‘new’ bodies. This makes maintenance increasingly difficult as many individuals continue to see themselves as ‘fat’ despite having achieved a ‘normal’ weight (Simpson). Arguably a key factor in their misinterpretation of their body size and composition is the abundance of excess skin that is left over after rapid weight-loss. Excess skin, which has to be surgically removed and cannot be lost through diet or exercise, is a sore issue for bariatric post-ops, as it is a reminder of their former ‘fat’ selves, and thus a source of continuous dissatisfaction and lowered self-esteem (Groven, Råheim and Engelsrud). This is a common problem for many bariatric post-ops, with many citing that their low-hanging stomach or ‘apron’ is a primary source of anguish. Indeed, one post-op admitted that it was “even harder now because … it doesn’t seem to be going anywhere” (Simpson 63), and another revealed that while they consciously understood that their ‘apron’ was excess skin and not fat, they still used it as a sign that they must continue to lose weight. In this way, the reduction of the ‘apron’ has become a dangerous fixation for this post-op and the way in which they measure their success (Simpson 63). Further, post-ops were monitored by family and friends, primarily through concerns over their small portion sizes, which led them to develop techniques to escape the scrutiny of others (Simpson 78). One technique that was particularly popular was the use of a smaller side plate during dinner time (Simpson 78). A smaller plate was both an easy way for post-ops to monitor and regulate their portions, and a method of avoiding criticism and monitoring from others as it effectively masked their reduced portions from the gaze of others. Indeed many post-ops lamented over the consistent external pressures from friends and family to increase their intake and discussed further masking techniques such as moving food around the plate to convince others that they were eating (Simpson 78). These behaviours are troubling as they mimic many primarily observed within the eating disorder community (Prestwood) and indeed Rich and Evans highlight that the level of stigmatisation surrounding fat and body size may push obese individuals into disordered relationships with food, exercise and the body (354). This would suggest that the discourses surrounding the bariatric and the eating disorder communities have lines of similarity in that weight and in particular, thinness is privileged as the primary method in which health and overall personal success is measured (Burns and Gavey; Rich and Evans). Concluding RemarksThe existence of behaviours such as maintenance, food policing and body fixation forces us to question the extent to which bariatric surgery is a gateway at all to ‘health’. While bariatric surgery enables morbidly obese individuals to escape stigmatisation by achieving the appearance of health, often this comes at the expense of increased surveillance, regulation and control of the individual. In this way it would seem that solutions to obesity only serve to extend and intensify behaviours of regulation and control promoted through obesity discourse. Ultimately the reality of the post-op existence problematises the very foundational assumptions that the pursuit of thinness is a legitimate pursuit of health.ReferencesBordo, Susan. Unbearable Weight: Feminism, Western Culture and the Body. Los Angeles: University of California Press, 1993. Burns, Maree, and Nicola Gavey. “‘Healthy Weight’ at What Cost? ‘Bulimia’ and a Discourse of Weight Control.” Journal of Health Psychology 9.4 (2004): 549-65.Buchwald, Henry, and Stanley E. Williams. “Bariatric Surgery Worldwide 2003.” Obesity Surgery 14.9 (2004): 1157-64.Conrad, Peter. “Medicalisation and Social Control.” Annual Review of Sociology 18 (1992): 209-32.Cranwell, Jo, and Sarah Seymour-Smith. “Monitoring and Normalising a Lack of Appetite and Weight Loss.” Appetite 58 (2012): 873-81.Crawford, Robert. “Healthism and the Medicalisation of Everyday Life.” International Journal of Health Services 10.3 (1980): 365-88.Donaghue, Ngaire, and Anne Clemitshaw. “‘I’m Totally Smart and a Feminist … and Yet I Want to Be a Waif’: Exploring Ambivalence towards the Thin Ideal within the Fat Acceptance Movement.” Women’s Studies International Forum 35 (2012): 415-25.Evans, Bethan, and Rachel Colls. “Doing More Good than Harm? The Absent Presence of Children’s Bodies in (Anti-)Obesity Policy.” Debating Obesity: Critical Perspectives, eds. Emma Rich, Lee F. Monaghan, and Lucy Aphramor. Houndmills: Palgrave Macmillan, 2011. 115-38.Evans, John, Emma Rich, Brian Davies, and Rachel Allwood. Education, Disordered Eating and Obesity Discourse: Fat Fabrications. London: Routledge, 2008.Foo, Jonathan, et al. “Bariatric Surgery: A Dilemma for the Health System?” New Zealand Medical Journal 123.1311 (2010): 12-4.Fox, Nick J., Katie J. Ward, and Alan J. O’Rourke. “The ‘Expert Patient’: Empowerment or Medical Dominance? The Case of Weight Loss, Pharmaceutical Drugs and the Internet.” Social Science and Medicine 60 (2005): 1299-309.Fries, Christopher J. “Governing the Health of the Hybrid Self: Integrative Medicine, Neoliberalism, and the Shifting Biopolitics of Subjectivity.” Health Sociology Review 17.4 (2008): 353-67.Fullagar, Simone. “Governing Healthy Family Lifestyles through Discourses of Risk and Responsibility.” Biopolitics and the ‘Obesity Epidemic’: Governing Bodies, eds. Jan Wright and Valerie Harwood. New York: Routledge, 2009. 108-26.Glenn, Nicole M., Kerry R. McGannon, and John C. Spence. “Exploring Media Representations of Weight-Loss Surgery.” Qualitative Health Research 23.5 (2012): 631-44.Groven, Karen S., Målfrid Råheim, and Gunn Engelsrud. “Dis-appearance and Dys-appearance Anew: Living with Excess Skin and Intestinal Changes Following Weight Loss Surgery.” Medicine, Health Care and Philosophy 16.3 (2013): 507-23.Lupton, Deborah. “Consumerism, Reflexivity and the Medical Encounter.” Social Science and Medicine 45.3 (1997): 373-81.Metzl, Johnathan M. “Introduction: Why 'Against Health'?” Against Health: How Health Became the New Morality. Ed. Jonathan M. Metzl and Anna Kirkland. New York: New York University Press, 2010. 1-14. Ministry of Health, Clinical Trials Research Unit. Clinical Guidelines for Weight Management in New Zealand Adults. Wellington: Ministry of Health, 2009. Morgan, Kathryn P. “Foucault, Ugly Ducklings, and Technoswans: Analyzing Fat Hatred, Weight-Loss Surgery, and Compulsory Biomedicalised Aesthetics in America.” The International Journal of Feminist Approaches to Bioethics 4.1 (2011): 188-220.Ogden, Jane, Cecilia Clementi, and Simon Aylwin. “The Impact of Obesity Surgery and the Paradox of Control: A Qualitative Study.” Psychology and Health 21.2 (2006): 273-93.Prestwood, Chris. “The Person with an Eating Disorder.” The Art and Science of Mental Health Nursing: A Textbook of Principles and Practice. 2nd ed. Eds. Ian Norman and Iain Ryrie. Maidenhead: Open University Press, 2009. 469-89.Rich, Emma, and John Evans. “‘Fat Ethics’ – The Obesity Discourse and Body Politics.” Social Theory and Health 3 (2005): 341-58.Rich, Emma, Lee F. Monaghan, and Lucy Aphramor. “Introduction: Contesting Obesity Discourse.” Debating Obesity: Critical Perspectives, eds. Emma Rich, Lee F. Monaghan, and Lucy Aphramor. Houndmills: Palgrave Macmillan, 2011. 1-35.Rothman, Kenneth J. “BMI-Related Errors in the Measurement of Obesity.” International Journal of Obesity 32 (2008): S56-9.Saguy, Abigail C., and Kevin W. Riley. “Weighing Both Sides: Morality, Mortality, and Framing Contests over Obesity.” Journal of Health Politics, Policy and Law 30.5 (2005): 869-921.Sampalis, John S., et al. “The Impact of Weight Reduction Surgery on Health-Care Costs in Morbidly Obese Patients.” Obesity Surgery 14.7 (2004): 939-47.Simpson, Aimee B. Governing Obese Bodies: Examining Bariatric Surgery ‘Post-Op’ Narratives. MA thesis. University of Auckland, 2015.Sobal, Jeffery. “The Medicalization and Demedicalization of Obesity.” Eating Agendas: Food and Nutrition as Social Problems, eds. Jeffery Sobal and Donna Maurer. New York: Aldine de Gruyter, 1995. 67-90.Throsby, Karen. “Happy Re-Birthday: Weight Loss Surgery and the New Me.” Body and Society 14.1 (2008): 117-33.———. “The War on Obesity as a Moral Project.” Weight Loss Drugs, Obesity Surgery and Negotiating Failure.” Science as Culture 18.2 (2009): 201-16.Wann, Marilyn. Fat!So? Because You Don’t Have to Apologise for Your Size. Berkeley: Ten Speed Press, 1998.

Photo by Adhy Savala on Unsplash ABSTRACT During a crisis, when healthcare capacity becomes overwhelmed and cannot meet regular standards of patient care, crisis standards of care are invoked to distribute scarce hospital space, staff, and supplies. When transitioning between conventional standards of care and crisis standards, hospitals may have to manage resources under scarcity constraints in an intermediate phase defined as the contingency phase. While much attention has been paid to the ethics of crisis standard of care protocols, contingency measures were more widely implemented, though little exists within the literature on the ethics of contingency measures or a clearly explicated contingency standard of care. This paper addresses three ethical issues with the current contingency response to COVID-19: the lack of formalization, the risks of using short-term solutions for prolonged contingency shortages, and the danger of exacerbating health disparities through hospital-level resource allocation. To mitigate these ethical issues, I offer recommendations for reimagining resource allocation during contingency standards of care. INTRODUCTION When transitioning between conventional standards of care and crisis standards, or in situations where shortages do not immediately threaten care delivery, hospitals may have to manage scarce resources in an intermediate phase, known as the “contingency” phase.[1] While much attention has been paid to the ethics of crisis standards, less literature covers the ethics of contingency measures or a clearly explicated contingency standard of care. Many states and hospital systems do not have contingency standards of care to dictate allocation absent an event triggering crisis standards. Crisis standards of care, used when healthcare capacity becomes overwhelmed and cannot meet regular standards of patient care, reflect ethical priorities relevant in times of shortage or other emergencies. These priorities include saving the most lives, the stewardship of scarce resources, and justice relating to equitable resource distribution.[2] Crisis standards of care delineate specialized allocation protocols and triage decision-making bodies at the institutional or state levels. Crisis standards of care require formal activation at the state level, and in the absence of clear triggers or governmental willingness to use them, hospitals may adopt informal strategies to manage allocation in the form of contingency measures. The contingency phase is defined by two simultaneous goals: prevent or stall crisis-level scarcity by managing limited resources and providing patient care that is functionally equivalent to usual care.[3] In other words, allocate scarce resources with no significant health consequences to patients. However, this is an unrealistic expectation: meeting a patient’s medical needs and allocating resources on the basis of scarcity instead of medical indications can be at odds, creating ethical tension. This paper addresses three ethical issues with the current contingency response stemming from this tension: the lack of formalization, the risk of using short-term solutions for prolonged contingency shortages, and the danger of exacerbating health disparities through hospital-level resource allocation. To mitigate these ethical issues, I offer recommendations for reimagining resource allocation during contingency standards of care. l. Lack of Formalization One shortcoming of current contingency measures is that they fail to meet the same level of procedural detail and clarity as crisis standards. The early COVID-19 surges in Italy and France demonstrated the pitfalls of bedside allocation in the absence of procedural guidance. The acute scarcity of critical care resources forced doctors in these countries to make allocation decisions at the bedside, which often resulted in de facto age-based allocation as well as experiences of moral distress and shame among providers.[4] In France, medical allocation guidelines and statistics were never released to the public, raising concerns over the role of transparency in implementing crisis standards and triage guidelines and causing the public to question the trustworthiness of provider triage.[5] Though many states in the US have crisis standards of care that can be implemented in the case of a large-scale triage event, these measures vary widely. A 2020 review of 31 crisis standards of care in the US found that only 18 contained strong “ethical grounding,” 28 used “evidence-based clinical processes and operations,” 21 included “ongoing community and provider engagement, education, and communication,” and 16 had “clear indicators, triggers, and lines of responsibility.”[6] The need for standardization, public transparency, and guidelines for crisis standards of care to prevent bedside allocation has been widely recognized. However, these issues remain unresolved by public policy or legislative efforts during the contingency period before (or after) crisis standards apply. A recent public health study that observed triage team members in a high-fidelity triage simulation highlighted the challenges of making equitable frontline allocation decisions.[7] In the simulation, participants nudged patient priority status up or down depending on what they subjectively identified as morally relevant factors. Through the simulation, participants reported difficulty separating implicit biases about patient characteristics from their clinical judgment. In the absence of formal institutional or regional guidelines for allocation during contingency-level shortages, there are few to no procedural safeguards against biased, ad hoc, and non-transparent rationing. Without formalized or standardized contingency allocation guidance, providers are left to make bedside allocation decisions that are susceptible to individual biases and patterns of unintended discrimination. An example of this susceptibility is seen when hospitals allow patients who no longer benefit from ICU resources to continue occupying ICU beds. This is based on a first-come-first-served (FCFS) approach to bed allocation. FCFS is often a default for patient intake, which led to disparities in care access during the early COVID-19 pandemic. Media reports of hospitals with “plenty of space” being unwilling to accept patients from overwhelmed, lower-income hospitals illustrate that the FCFS default advantages those who could show up first to a particular hospital: often privileged, well-funded healthcare systems that were inaccessible to low-income communities.[8] FCFS is blind to several morally relevant factors, including the likelihood of survival to discharge, reciprocity (i.e. prioritizing healthcare workers), and varying degrees of access to healthcare. Therefore, it inappropriately privileges those in proximity to healthcare systems or with social connections enabling greater initial access to care.[9] During crisis standards of care, excessive mortality that would result from FCFS is mitigated through formalized system-wide triage protocols based on current patient health status and potential benefit from resources. Crisis and contingency standards may provide liability coverage for providers who reallocate critical care beds away from those who no longer benefit during periods of scarcity. This liability coverage shifts bed allocation away from an FCFS model, but only if the policy is well-defined, clearly established, and known to providers. Without a formal system to guide the process or transition from the usual method of allocation to the contingency period, contingency decisions about who gets a scarce resource may continue to operate on an implicit FCFS basis, even when approaching crisis levels of scarcity. Additionally, these decisions will fall unsustainably on individual providers or transfer center workers, leading to moral distress on the frontlines when hospitals are already strained. Lessons from the crisis and contingency responses during COVID-19 can improve future contingency responses. There are multiple ways of achieving equity during contingency allocation, ranging from hospital-level to state-level policy changes. State-wide policies and interventions to facilitate resource-sharing can relieve some of the scarcity burdens that hospitals may face during the contingency period. For example, moving ICU patients to lower levels of care once they have sufficiently recovered is a challenge for doctors, who often call other hospitals to find open beds. In these situations, providers who do not move patients who no longer benefit from ICU beds unknowingly reinforce the FCFS system in which those who arrive first keep the scarce beds, while those who arrive later or wait for one are disadvantaged by having limited access to them. State-wide patient transfer centers, often facilitated by state public health departments, present an alternative by balancing patient needs and bed distribution more equitably and efficiently than individual physicians do, as demonstrated following COVID-19 surges in hospitalization.[10] These centers aid not only in allocating open tertiary care beds, but also in identifying open beds at lower levels of care and assisting physicians with transferring out patients who can be safely downgraded and no longer benefit from tertiary care resources. However, the simplest solution is to encourage the creation of ethics guidance or protocols for contingency allocation at the hospital level. In hospitals, institutional ethics guidance can help providers navigate difficult decisions and conversations with patients. When providers face time-sensitive allocation decisions, like the allocation of open ICU beds, the guidance would be a useful tool for making transparent, principled, and ethically justified allocation decisions in real-time to mitigate the risk of ad hoc or implicit rationing. ll. Unsuited for Prolonged Resource Shortages Secondly, neither contingency nor crisis standards are currently designed to respond to prolonged strains on the healthcare system. Since the start of the pandemic, a prolonged period of staffing shortages began and is projected to persist.[11] However, both crisis and contingency standards assume that the system will eventually return to conventional standards of care. For example, as a contingency or crisis standard, many hospitals deferred elective surgeries to preserve limited resources for emergency and life-saving procedures. Massachusetts, for instance, issued a public health emergency order that required hospitals to defer 50 percent of all non-essential and non-urgent (elective) surgeries. This order demonstrates the use of this contingency measure in response to prolonged staffing and bed shortages.[12] However, the deferral of elective procedures can result in adverse long-term community health consequences. Medical conditions typically addressed through elective surgery, such as joint replacement surgeries for osteoarthritis patients, may worsen if delayed. This can result in greater numbers of acute emergencies, the need for more complex surgical procedures later, increased reliance on pain medications, and longer recovery times.[13] Without a greater understanding of long-term complications in community health, existing contingency strategies, such as the deferral of elective surgeries, may be unsuitable for prolonged shortages. This becomes a greater threat to patient safety when contingency measures inappropriately take the place of crisis standards, risking the long-term implementation of emergency measures designed for temporary use. Although some state emergency planning documents identify indicators and triggers for activating contingency and crisis operations,[14] this transition is not always clear in action. For example, New York did not implement crisis standards of care during the early COVID-19 pandemic despite being one of the hardest-hit cities in the US.[15] Other states, including California, Texas, and Florida, did not activate crisis standards of care, leaving hospitals to implement informal contingency measures that ultimately required allocation strategies very similar or identical to many crisis standards of care protocols.[16] Due to the hesitance to activate crisis standards, ad hoc contingency measures and bedside decision-making prevailed over formal triage protocols. If contingency measures are not set forth in objective documents and are inappropriately used in the place of crisis standards, these short-term measures may result in an unfair or non-transparent distribution of scarce resources. When shortages in space, staff, or supplies jeopardize the ability to provide necessary care for critically ill patients under a conventional standard of care, failures to activate crisis standards risk the inappropriate use of ad hoc contingency measures in their place. With clear contingency standards of care, the duration of an ad hoc approach could be limited. Crisis standards are defined and activated at the regional or state-wide level, but outside of hospital-specific resource limitations, there are generally no standardized indications or triggers for transitioning into and out of contingency measures. Leaving contingency needs to individual hospitals may seem beneficial but defining the contingency period at the hospital level and the crisis period at the state or regional level blurs the line about when it is appropriate for decision makers to activate crisis standards, risking delayed activation or failure to activate them at all. Therefore, it is important that state policies implement automatic triggers for activation that clearly delineate between contingency and crisis responses.[17] Automatic triggers based on validated metrics like remaining available resources can inform the appropriate decision makers about when they must activate crisis standards. These triggers should be transparent to the public, validated, and updated over time with evolving data. These automatic triggers would prevent confusion, inconsistent guidelines, and inequitable contingency allocation at the hands of distressed providers when crisis standards are needed. Defining when to begin crisis standards could help limit the length of the contingency period. This would protect against the inappropriate application of contingency measures to crisis-level scarcity and prolonged shortages that they could not sustainably ameliorate. lll. Potential to Exacerbate Health Disparities Inconsistencies in contingency allocation open the door to disparities in care and unequal distribution of scarcity burdens among different communities based on their location or health needs. This is a concern because it is unclear whether contingency measures can meet their goal of achieving functionally equivalent patient outcomes when resource allocation must be balanced with patient-centered care.[18] The care under contingency standards is meant to be functionally equivalent to regular care. The definition assumes (or may wrongly suggest) that any contingency strategy in place to avoid critical scarcity has no significant impact on patient outcomes. While functional equivalence is attainable, there is currently little research into which contingency measures achieve functionally equivalent outcomes and which patient groups may be disproportionately affected by harmful resource allocation strategies. Although the transition from contingency standards to crisis standards is defined by the inability to provide functionally equivalent care, the difference in practice may merely be a distinction between visible, immediate sacrifices to patient well-being during crises and less-obvious, long-term decrements in community health due to protracted contingency care alterations. Two common contingency measures are cause for concern over disparate patient outcomes and the attainability of functional equivalence. First, restricting emergency room visits by the patient’s degree of need has worrying consequences. In late 2021 and early 2022, hospitals in Massachusetts faced widespread staffing shortages, leading to an emergency order that restricted emergency visits to emergency needs.[19] While this order is a reasonable method of allocating limited staff in the emergency department during severe shortages, it is doubtful that the outcomes of this restriction were equivalent to usual care. Health issues that are soon-to-be emergencies are filtered out until they worsen, resulting in patients overflowing to urgent care clinics or presenting to ERs with more severe forms of sicknesses later on. Given the empirical evidence demonstrating ER treatment and admission disparities that disadvantage Black and Hispanic patients, such a measure would only exacerbate these disparities by further limiting access to needed care.[20] Second, altered staffing ratios, which stretch a limited number of providers to meet patient needs during a staffing shortage, are another concerning yet common contingency measure. Staffing allocation is often viewed similarly to the allocation of space and medical equipment, such that contingency alterations to staffing operations may not seem like they significantly jeopardize patient care quality and outwardly appear functionally equivalent.[21] However, lower ratios of qualified nurses are associated with poor outcomes such as higher inpatient mortality[22] and lower survival rates of in-hospital cardiac arrest for Black patients.[23] These examples highlight the strong potential for contingency measures to amplify social health disparities, particularly when adopted over a prolonged time frame. Lowered standards of care in crisis allocation disproportionately impact racial and ethnic minorities.[24] For example, crisis standards of care used clinical scoring systems that were not developed or validated for crisis triage to prioritize access to life-saving treatments during the COVID-19 pandemic. This practice actively gives rise to racial health disparities and discrimination against disabled patients.[25] Not only were the standards inequitable in practice, but they varied widely from state to state and sometimes even from hospital to hospital, creating disparities across and within geographic regions.[26] If contingency measures are similarly implemented across hospitals or hospital departments without standardization or advance planning to ensure equitable outcomes, it is likely that the burden of a lower standard of care will fall primarily on disadvantaged patient groups and racial minorities. However, standardization alone may be insufficient. Other factors like varying levels of details on patients’ charts between hospitals could produce unfair outcomes if used to determine patient admission or transfer priority, even if the criteria for admissions and transfers are consistent. Thus, ongoing monitoring for unintended patterns of disparity must accompany standardization to ensure that blind spots in the allocation process are identified and corrected. Bioethics has long been preoccupied with the micro-allocation of limited resources within hospitals instead of confronting the structural inequities that underlie broader scarcity and patient needs. The traditional dilemma of allocating limited hospital resources among a certain number of patients overlooks questions about how other resources have already been allocated, which patients were present at the hospital in the first place, where hospitals have (and have not) been built, and whether previous allocation strategies created bias in the broader distribution of resources. Therefore, to achieve fairness, bioethicists must pay attention to aspects of the broader distribution of resources, such as social determinants of health and the allocation of preventative resources at the public health level. One strategy for measuring and addressing these disparities is the Area Deprivation Index (ADI). The ADI quantifies the effects of race, class, and socioeconomic background by geographic region for use in public health research and the prioritization of resources.[27] It has shown promise in identifying geographic regions in need of targeted community health efforts for diabetes management based on electronic patient health records.[28] The ADI and similar tools would be useful in proactively deciding how to allocate public health resources when hospitals are strained. Moreover, through using population health and resource data, public health organizations may forecast contingency shortages allowing for the adoption of early measures to mitigate health disparities that might otherwise be amplified from hospital-level contingency allocation decisions. CONCLUSION Meeting community health needs during periods of contingency scarcity, both before and after crisis standards of care apply, will require contingency standards of care rather than a bedside ad hoc distribution of scarce resources. While it is not inherently ethically unjustifiable for hospitals to adopt measures that may lower the standard of care during contingency standards, the necessity of these measures requires that bioethicists consider how equity, transparency, and the overall aim of functional equivalence can best be achieved under conditions of scarcity. The long-term health consequences of existing contingency measures, the potential for ad hoc and inconsistent allocation of scarce resources, and the need for consensus about when it becomes appropriate to make the formal transition to crisis standards of care demand further consideration. Because contingency measures will likely amplify existing disparities as crisis standards have, hospital-level management of scarcity is inadequate. Public health measures should be adopted in parallel to anticipate and manage health needs at the community or state level when resources are strained. - [1] Altevogt, B. M., Stroud, C., Hanson, S. L., Hanfling, D., & Gostin, L. O. (2009). Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. The National Academies Press. https://doi.org/10.17226/12749 [2] Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M., Glickman, A., Zhang, C., Boyle, C., Smith, M., & Phillips, J. P. (2020). Fair Allocation of Scarce Medical Resources in the Time of Covid-19. New England Journal of Medicine, 382(21), 2049–2055. https://doi.org/10.1056/NEJMsb2005114 [3] Alfandre, D., Sharpe, V. A., Geppert, C., Foglia, M. B., Berkowitz, K., Chanko, B., & Schonfeld, T. (2021). Between Usual and Crisis Phases of a Public Health Emergency: The Mediating Role of Contingency Measures. The American Journal of Bioethics, 21(8), 4–16. https://doi.org/10.1080/15265161.2021.1925778 [4] Rosenbaum, L. (2020). Facing Covid-19 in Italy—Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line. New England Journal of Medicine, 382(20), 1873–1875. https://doi.org/10.1056/NEJMp2005492 [5] Orfali, K. (2020). What Triage Issues Reveal: Ethics in the COVID-19 Pandemic in Italy and France. Journal of Bioethical Inquiry, 17(4), 675–679. https://doi.org/10.1007/s11673-020-10059-y [6] Romney, D., Fox, H., Carlson, S., Bachmann, D., O’Mathuna, D., & Kman, N. (2020). Allocation of Scarce Resources in a Pandemic: A Systematic Review of US State Crisis Standards of Care Documents. Disaster Medicine and Public Health Preparedness, 14(5), 677–683. https://doi.org/10.1017/dmp.2020.101 [7] Butler, C. R., Webster, L. B., Diekema, D. S., Gray, M. M., Sakata, V. L., Tonelli, M. R., & Vranas, K. C. (2022). Perspectives of Triage Team Members Participating in Statewide Triage Simulations for Scarce Resource Allocation During the COVID-19 Pandemic in Washington State. JAMA Network Open, 5(4), e227639. https://doi.org/10.1001/jamanetworkopen.2022.7639 [8] Dwyer, J. (2020, May 14). One Hospital Was Besieged by the Virus. Nearby Was ‘Plenty of Space.’—The New York Times. The New York Times. https://www.nytimes.com/2020/05/14/nyregion/coronavirus-ny-hospitals.html [9] Persad, G., Wertheimer, A., & Emanuel, E. J. (2009). Principles for allocation of scarce medical interventions. Lancet (London, England), 373(9661), 423–431. https://doi.org/10.1016/S0140-6736(09)60137-9 [10] Mitchell, S. H., Rigler, J., & Baum, K. (2022). Regional Transfer Coordination and Hospital Load Balancing During COVID-19 Surges. JAMA Health Forum, 3(2), e215048. https://doi.org/10.1001/jamahealthforum.2021.5048 [11] ASPE. (2022, May 3). Impact of the COVID-19 Pandemic on the Hospital and Outpatient Clinician Workforce: Challenges and Policy Responses. ASPE. https://aspe.hhs.gov/reports/covid-19-health-care-workforce [12] Executive Office of Health and Human Services. (2021). Baker-Polito Administration Provides COVID-19 Update on Mask Advisory, Hospital Support | Mass.gov. https://www.mass.gov/news/baker-polito-administration-provides-covid-19-update-on-mask-advisory-hospital-support [13] The Lancet Rheumatology. (2021). Too long to wait: The impact of COVID-19 on elective surgery. The Lancet Rheumatology, 3(2), e83. https://doi.org/10.1016/S2665-9913(21)00001-1 [14] For an example of transition planning between crisis and contingency standards, see Minnesota Department of Health. (2021). Ethical Framework for Transitions Between Conventional, Contingency, and Crisis Conditions in Pervasive or Catastrophic Public Health Events with Medical Surge Implications (Minnesota Crisis Standards of Care). https://www.health.state.mn.us/communities/ep/surge/crisis/framework_transitions.pdf [15] Powell, T., & Chuang, E. (2020). COVID in NYC: What We Could Do Better. The American Journal of Bioethics, 20(7), 62–66. https://doi.org/10.1080/15265161.2020.1764146 [16] Persoff, J., & Wynia, M. K. (2021). Ethically Navigating the Murky Waters of “Contingency Standards of Care.” The American Journal of Bioethics, 21(8), 20–21. https://doi.org/10.1080/15265161.2021.1939810 [17] Board on Health Sciences Policy & Institute of Medicine. (2013). Indicators and Triggers. In Crisis Standards of Care: A Toolkit for Indicators and Triggers. National Academies Press (US). http://www.ncbi.nlm.nih.gov/books/NBK202381/ [18] Frith, L., Draper, H., Fovargue, S., Baines, P., Redhead, C., & Chiumento, A. 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K., & Sottile, P. D. (2020). Ethical Triage Demands a Better Triage Survivability Score. The American Journal of Bioethics, 20(7), 75–77. https://doi.org/10.1080/15265161.2020.1779412 [26] Fink, S. (2020). Ethical Dilemmas in Covid-19 Medical Care: Is a Problematic Triage Protocol Better or Worse than No Protocol at All? The American Journal of Bioethics, 20(7), 1–5. https://doi.org/10.1080/15265161.2020.1788663 [27] Knighton, A. J., Savitz, L., Belnap, T., Stephenson, B., & VanDerslice, J. (2016). Introduction of an Area Deprivation Index Measuring Patient Socioeconomic Status in an Integrated Health System: Implications for Population Health. EGEMS (Washington, DC), 4(3), 1238. https://doi.org/10.13063/2327-9214.1238 [28] Kurani, S. S., Lampman, M. A., Funni, S. A., Giblon, R. E., Inselman, J. W., Shah, N. D., Allen, S., Rushlow, D., & McCoy, R. G. (2021). Association Between Area-Level Socioeconomic Deprivation and Diabetes Care Quality in US Primary Care Practices. 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