The Iowa Department of Public Health has refused to disclose the state’s pandemic emergency response plan, Barbara Rodriguez reported for the Des Moines Register on April 20.
Bleeding Heartland has tried without success to obtain the department’s current guidance on rationing ventilators, should that become necessary in Iowa hospitals.
HIDING BEHIND A PUBLIC RECORDS EXEMPTION
Under Iowa’s public records law, the Register requested copies of the public health department’s pandemic emergency response plan as well as “reports from the Iowa Department of Homeland Security and Management regarding day-to-day actions from the state on the virus.” The agencies denied the requests, citing the following exemption in state law (emphasis added):
Information and records concerning physical infrastructure, cyber security, critical infrastructure, security procedures, or emergency preparedness developed, maintained, or held by a government body for the protection of life or property, if disclosure could reasonably be expected to jeopardize such life or property.
a. Such information and records include but are not limited to information directly related to vulnerability assessments; information contained in records relating to security measures such as security and response plans, security codes and combinations, passwords, restricted area passes, keys, and security or response procedures; emergency response protocols; and information contained in records that if disclosed would significantly increase the vulnerability of critical physical systems or infrastructures to attack.
A plan for dealing with a public health emergency is not comparable to passwords, security codes, or tactical details on deploying military or law enforcement in a terrorist attack or hostage situation. While novel coronavirus (COVID-19) is endangering lives, it’s hard to see how reading the health department’s plan for dealing with pandemics would endanger anyone. As Rodriguez noted, the Iowa Department of Corrections posted its own pandemic response plan online.
Tom Witosky, a retired journalist and veteran of many public records battles during his long career as an investigative reporter for the Register, commented via Twitter, “I’d like a specific answer as to what life or property is threatened by the disclosure of the requested documents and evidence to support that assertion.”
Iowa Freedom of Information Council executive director Randy Evans told Rodriguez, “I think it’s legitimate for people to wonder whether the state is following that plan the way it was envisioned.” But Amy McCoy, who is handling media inquiries related to COVID-19 for the IDPH, complained in an email that it would be “inaccurate and unfair” to suggest the department is “doing anything short of being transparent.”
Even more absurd: Iowa’s homeland security director would rather not write situation reports than risk letting another one fall into journalists’ hands.
On April 1, Director of Homeland Security Joyce Flinn decided to stop producing the situation reports, according to John Benson, chief of staff at the department. Flinn’s decision came one day after the Register published an article based on one of the reports. The Register, which had obtained the reports from sources, had also previously cited information in the report and sought comment on that information from state officials.
Benson said lawmakers and others who were previously receiving those reports can watch the governor’s news conferences to learn more about the state’s response or contact his office.
GUIDANCE FOR RATIONING VENTILATORS UNCLEAR
I’ve tried without success this month to clarify how IDPH has advised hospitals to allocate ventilators, if critical COVID-19 cases overwhelm the available equipment in our state’s intensive care units.
Liz Essley Whyte of the Center for Public Integrity reported on April 8 that policies in many states “could harm people with disabilities” who need ventilator support.
These policies take into account — in ways that disability advocates say are inappropriate — patients’ expected lifespan; need for resources, such as home oxygen; or specific diagnoses, such as dementia. Some even permit hospitals to take ventilators away from patients who use them as breathing aids in everyday life and give them to other patients.
McCoy declined to send Iowa’s policy on allocating ventilators to the Center for Public Integrity, telling Whyte in an April 1 email, “We continue to collaborate with our healthcare partners on developing crisis standards of care as part of our preparedness and response. I don’t have anything further to share at this time.”
Nevertheless, Whyte was able to get hold of this 2007 report for the IDPH by the Iowa Pandemic Influenza Ethics Committee. Her overview of state standards did not discuss Iowa’s guidelines in detail but marked our state as having a “policy with problems” on an interactive map.
The 2007 report includes several paragraphs about “hospital ventilator rationing,” which indicate that younger patients with better prospects for a full recovery might be prioritized over older patients with health problems. Excerpts (emphasis in original):
Rationing hospitals’ ventilators follow from the principle of beneficience. Triage is an efficient way to avoid providing futile medical care and assuring the provision of humanitarian care and comfort. Triage also helps assure that scarce resources are allocated according to known benefit. […]
In a disaster on the scale of the 1918 influenza pandemic, stockpiles of ventilators would not be sufficient to meet need. Even if the vast number of ventilators needed for a disaster of that scale were purchased, a sufficient number of trained staff may not be available to operate them. If the most severe forecast becomes a reality, Iowa may need to confront the rationing of ventilators.
Situations may arise where a ventilator might be pulled from someone who needs it to survive to use it on a patient who would have more value or survivability. Another possibility could occur when there are more patients needing ventilators than are available or that have available staff to run them. It may become necessary for physicians and other health professionals to consider scoring protocols such as the Sequential Organ Failure Assessment (SOFA)9 system, when rationing ventilators.
Scenario:
The State of Iowa has implemented a SOFA scoring system to be included in assessments of ventilator need during the influenza pandemic. Hospital B in XP County has 10 ventilators and all are in use in the ICU. The pandemic has caused all nearby hospitals to be at capacity as well, so no ventilators are available to borrow. Two patients are brought in with severe respiratory failure and clearly in need of ventilators for survival. When assessed by ICU staff, it becomes apparent that both patients have been healthy individuals who will recover from their ailments if placed on ventilators… One of the patients is a 19 year-old local high school athlete; the other, a 29 year-old elementary school teacher with a 6 month-old son. The ICU staff review and score all patients currently using the 10 ventilators. The review reveals that a 78 year-old patient who is failing and has a SOFA score indicating the patient’s survivability with the ventilator is low. In this case, the decision-maker should not consider factors such as gender, race, sex, or color. It might be ethically appropriate, for the common good of society, to remove the ventilator from the person using, but not benefiting, from its use and apply the ventilator to the new patient.
The report asserted that the general public would accept “difficult decisions” on allocating ventilators, “if made with ethical considerations and openness,” adding, “The decision-maker may rely on determinations such as young and healthy people who have better survivability from respiratory distress than aged or immuno-compromised patients.”
I have been unable to confirm that the 2007 document represents current state policy or that the IDPH has conveyed those principles to hospitals preparing for a possible surge of COVID-19 cases. Neither McCoy nor the Iowa Hospital Association responded to my inquiries. A representative of the Polk County Health Department informed me on April 14 that staff in the county’s Emergency Operations Center “have not received any guidance on ventilator triage as of yet.” UPDATE: As of April 21, the Emergency Operations Center in Iowa’s largest county, where coronavirus infections are rapidly increasing, still had received no ventilator rationing criteria from the IDPH.
Iowa currently has enough ventilators to accommodate the number of hospitalized COVID-19 patients, according to the state’s official website (scroll down and click on the “RMCC Dashboard” tab). The latest data indicate that 214 Iowans are hospitalized with COVID-19, of whom 91 are in the ICU and 58 are on ventilators. Statewide, 552 ICU beds and 691 ventilators are available.
Readers with information on what guidance–if any–Iowa hospitals have received for rationing ventilators can contact Laura Belin confidentially.