 Hello, everyone, and welcome to the Harvard Organizational Ethics Consortium. Today's topic is the ethics of hospital transfers in the COVID-19 pandemic, Experience and Lessons Learned. I'm Charlotte Harrison, and I have the pleasure of co-chairing this consortium and co-organizing today's program with our moderator, Matt Winia, whom I'll introduce in a moment. I'm an affiliate faculty here at the Center for Bioethics and the Hospital Ethicist at Boston Children's Hospital, where I direct the Office of Ethics and co-chair the Ethics Advisory Committee. I'd like to acknowledge my two consortium co-chairs. One whom you'll hear from later in this program is Dr. Kelsey Berry, associate faculty director of the Master's of Bioethics degree program here at the Medical School. She's co-director of the virtual MBE program and a lecturer in the Department of Global Health and Social Medicine. Our third co-chair is Dr. James Saban, Jim is a professor of population medicine, a psychiatrist at Harvard Medical School, and an early and prominent leader in the field of organizational ethics and health care. He co-wrote a highly influential book setting limits fairly that many of you will be familiar with, co-authored with Norman Daniels. And he and I had the pleasure of starting this consortium about eight years ago. We so appreciate Jim's continued involvement despite other things that he is working with. Before going further with the introductions and the substance of the program, I want to turn briefly to how you can participate, which we hope very much that you'll do. So first, if you have a question for the panel, and we hope you will, please submit it to the Q&A feature at the bottom sort of right-hand side of your screen. If you have any technical issues, you can use the chat feature, and a staff member will respond to you. The chat's also open for comments that you want to make, but not for questions or you may be missing them. OK. Today's program is cosponsored by our consortium and the University of Colorado Center for Bioethics and Humanities. We're grateful to have that Center's director, Dr. Matt Winia, as our moderator today. In a prior life at the AMA, Matt founded its Center for Patient Safety and developed a research and training institute for ethics, professionalism, and policy, among many other initiatives. He's also done extensive work in public health and disaster ethics, and currently serves on the Board of Health Sciences Policy of the National Academies of Sciences, Engineering, and Medicine. Matt's a fellow of the Hastings Center, past president of the American Society for Bioethics and Humanities, and a past chair of the Ethics Forum of the American Public Health Association. Matt's going to frame today's topic and then turn to our four distinguished panelists. I'm going to briefly introduce them now, and they'll let Matt take it away. Dr. Darlene Tadde is a hospitalist at the University of Colorado Hospital. She's also vice president of clinical affairs with the Colorado Hospital Association. In her hospital association capacity, she's been centrally involved with the Statewide Hospital Transfer Arrangements, which she'll be describing. Dr. John Hick is an emergency care physician at Hennepin County Medical Center in Minnesota, where he also teaches in the medical school and has been closely involved in the medical, in the Minnesota transfer system. He and two colleagues first proposed and now widely adopted taxonomy that many of you will be familiar with, the three C's, conventional contingency and crisis capacity, describing three stages in surge capacity that call for a spectrum of responses in public health emergencies. Elke Shah Taluk is the administrator of the Division of Public Health within the Idaho Department of Health and Welfare. Her division leads the response to COVID-19 and she has partnered with the Idaho Hospital Association with respect to the State's Hospital Transfer Arrangements, which she'll be describing. Erin Talati-Pakhet is a critical care attending and associate director of clinical and organizational ethics at Lurie Children's Hospital of Chicago. She's also on the faculties of both medicine and law at Northwestern University. So Matt. My turn. I think together, let's say, thanks for all to all of the panel for this extraordinary range of perspective and experience that we know we're gonna hear and it's your turn, Matt, to open the door. Wonderful. Thank you so much Charlotte for the introductions and for sort of laying the stage for us to have what I hope will be a very productive conversation. Just as background, many of you know, probably everyone knows that hospitals around the country faced tremendous capacity challenges really over the last two years, kind of off and on as different surges have come in in different places. And for those of us who have had to manage the triage type questions that have arisen as a result, one of the core issues of the ethics of triage is that you never wanna do triage and withhold a service from someone when that service would have been available if only they were 10 miles away at a different hospital. And that sort of core issue of you never wanna withhold services from someone thinking there's an absolute shortage when in fact, if you could get them somewhere else, they would be able to get that care is what drives the conversation today. In many states, not all, but in many states and regions, hospitals and health systems have developed really innovative collaborative mechanisms for sharing not just resources, but moving people so that they are where the need is, where the resources are available or where the need is greatest. And so that's what we're gonna talk about today is what have been some of the opportunities? What have been some of the things we've learned? What are some of the things that we've learned during the pandemic that really ought to affect our subsequent ways in which we manage resource shortages and so on? We're gonna, I hope be able to get to all of those. But what I've asked the panelists to do by way of starting us out is to tell us a little bit about the context locally because yes, everyone had an omicron surge, but it didn't play out exactly the same way in every area. So if you could tell us what has happened in your region over the last two to four months and how has your healthcare environment adapted or managed these massive surges? What are the mechanisms that your hospitals and health systems have used to try and move patients or resources around to meet the need? And if you could incorporate into your conversation because this is an ethics conversation, what do you think are some of the underlying values? What are the ethical principles, if you will, that have sort of underlay the actions that you've each taken? And if it's okay, I'm gonna pick on Darlene first because she and I are both in Colorado and so it's the system that I probably know the best. And yet I still feel like I have a lot to learn about the actual operations of our combined hospital transfer center. So is it okay to start with you, Darlene and tell us the environment? What have we been doing and what are the underlying values that you think have driven the decision-making? Sure, Matt, thank you so much and thank you so much for inviting me to share our experience with our combined hospital transfer center with this group. So to start with just some context on what our COVID situation was looking like in Colorado in the past few months, we experienced our Delta wave in the fall. So beginning around Halloween of 2021, so end of October, it became apparent that we were gonna start to see again, a rapid increase in the number of hospitalizations for COVID as we began to see the community cases of COVID across our state begin to increase very, very rapidly as well. We all had learned from our experience in the year before that typically the hospitalizations would follow the cases or the case burden within about 10 to 12 or 14 days. So we had this sense that the first week of November and heading into Thanksgiving that we would be facing another surge beginning to see some of the capacity challenges that we had seen in our prior surges back in the winter of 2020 all over again. What we were then prepared for was to address what we would anticipate would be the extra pressure on our inpatient settings. And thankfully a year prior, so in August of 2020 our state had actually begun discussions with our member hospitals in the state of Colorado to think about how we could work together to move patients throughout our state. Now, I think it's probably helpful to remind everybody that Colorado, we do have big urban centers, Denver, Fort Collins, Colorado Springs and these urban centers are where many of our health systems and larger hospitals are housed. However, we have a very significant portion of our state which is rural or even frontier where we have less access to healthcare just because we have critical access hospitals, rural hospitals, but not large systems. But the key here is that our geography adds an additional, what I would say, barrier or factor to consider. So in the winter our mountains can become impassable, roads close and with winter storms, air travel or emergency air travel for transferring patients can also become very challenging. So with that anticipation of our winter, the possibility of a winter surge in 2020 the state had already asked our hospitals to begin thinking about how we might be able to move patients from these more remote locations into settings where they could get the care that they would potentially need and to have a plan in place to do that. That request gave birth to the Combined Hospital Transfer Center or what we shortened to the CHTC, again Combined Hospital Transfer Center because what it did was it pulled together the transfer centers of all of our larger health systems. So we have five major health systems in Colorado that have multiple hospitals within their systems and then about 42 rural independent hospitals throughout our state. And the idea behind the Combined Hospital Transfer Center was that the transfer centers of these larger health systems would work together to plan for and move large numbers of patients from our rural areas into who are needing care or who are unable to provide care for its capability reason or a capacity reason move those patients into our larger urban systems. So fast forward now, we're now in 2021 in the fall of 2021. And we were again in the situation where we could see that we would begin to face a surge in the fall which in this case was our Delta wave. And with that we had already begun to experience some of these rising numbers and the CHTC was activated again in November, the second week of November, early November. And what the activation of the CHTC entailed was bringing together the transfer center leads of the large health systems within our state and then beginning to capture data on what the real time capacity was so what's the bed availability and very specifically what's the staff bed availability within our state hospitals? Where are patients or which hospitals are facing capacity challenges? Where are patients that have COVID that need potentially to be transferred and where might there be the available bed that that patient can be transferred to? So the convening of these transfer center leads of our health systems brought together that data brought together that real time and very nuanced understanding of what the capacity situation was at the front lines of their individual facilities and then allowed them because of their expertise to make decisions about which patients needed transfer when, how immediately and then which bed and which hospital was the most appropriate bed for that patient. The ethical principle underlying this map was that we wanted to make sure that every Coloradan who needed acute care and COVID care could get that care when they needed it and that we would never have a Coloradan in a place in a setting where they were getting not getting the care that they specifically needed in that moment. I think the important thing about the combined hospital transfer center was that it was never mandated by the state. It was a completely voluntary decision to create, to maintain, to build and to carry out the function of it by our transfer center leads. The combined hospital transfer center had three levels of activation with increasing intensity that relied on triggers of how dire was the capacity situation in our state. By the third or fourth week of November, it became clear that our capacity situation this fall was significantly worse than it had been the year before in 2020 because in addition to having a surge of COVID patients in our hospitals, we were also facing a significant staffing shortage because of what we know happened nationwide, which is the loss of healthcare staffing, nursing staff, respiratory therapists, EMS and of course those certainly diminished the number of beds or available beds that we had across the state. So the CHC actually was activated to the highest most intense tier where basically every available bed in Colorado was on deck to potentially receive a transfer. We were able to activate reverse transfers meaning as patients were recovering or getting better in one hospital that was a higher level of care that patient could actually be transferred back to potentially a rural hospital for lower level of care and ongoing convalescent care or recovery care. So by December, we began to see the Omicron surge in our state, which added to the pressure and in those weeks between November and February and through that Delta surge and Omicron surge we transferred almost 45,000 total patients among our rural and urban hospital systems. So Matt, I'm gonna close there. I hope that gives enough of an overview and a little bit of detail on the way our combined hospital transfer center worked in Colorado. Thank you so much. I have so many questions but I wanna get through our opening comments by everyone. So I will come back to you though and just to put a tag on the issue of requirements because there were newspaper articles that suggested not only could people be transferred in Colorado without their first having given permission, the patient's permission, but also that hospitals would be required to accept patients in transfer. So I wanna come back to that because that has been that sort of the autonomy of both patients and institutions, I think is one of the ethical issues we wanna dig into. But first, I'm gonna turn to Elkie next. Darlene is from the Hospital Association. She's also an academic, also a clinician. But Elkie, you are with the state of Idaho and you had maybe the most famous rollout of crisis standards of care across the country. I mean, there were a few but Idaho experienced an enormous and very rapid escalation of a surge which required very rapid response on your part and you're with the state of Idaho. So I'd love to get that sort of other, the other side of this, right? We just heard about the experience on the part of the Hospital Association and the hospitals. What was this like from the point of view of the state trying to provide some framework and coordination around this in Idaho? Great, yeah. Thanks Matt. I appreciate the opportunity to be here today. It seems like in the same to Darlene, we could many of the issues that of course we were dealing with are very much similar to what's happening in Colorado. I wanna take a quick step back and at least set the stage a little bit about the state of Idaho because we do, we're a huge state geographically and we have three disparate areas of the state almost are their own systems, if you will. So that posed some challenges as well but just a little bit of history from Idaho. Really at the start of the pandemic, we didn't have a crisis standards of care plan finalized. We had just transitioned all of our hospitals from a seven regional healthcare coalition to a three healthcare coalition structure through our preparedness program. And we certainly didn't have those day to day working relationships with our hospitals as we do now. We had already a really great relationship with our Idaho Hospital Association but we were just a little bit hit and miss in terms of working with hospitals. There was really great local participation but in terms of bringing everybody together at a statewide level, not quite there. Those regional conversations didn't give us that kind of equitable visibility across the state and what was happening. And as I mentioned, we had a very geographically diverse state and it's very much a local control state. So all that sort of played into how we were functioning originally. We saw, like you said, kind of a dramatic increase in cases in our Delta wave which really struck us the hospital settings from the perspective of there just an overflow of patients coming into the hospital settings. And then kind of the Omicron surge, it was a bit of a different scenario with the hospitals. So we had kind of like as Darlene was saying, we still had high hospital census but with Omicron, it was stressing the hospitals a little bit differently than it was with Delta in the sense that the Omicron surge was really impacting staffing tremendously more than it did in the early days with the Delta wave. We had a large number of staff out across the state that were out sick themselves. They were caring for sick family members or even supporting their children who are home because of school closures and isolation requirements. Excuse me, in January of this year, we wound up declaring crisis standards that care for the third time during the pandemic. So our first time of declaring crisis standards of care was back in September. And we really did that on a regional basis because like I mentioned, our geography is so spread out. It's a huge number of hours and even from a flight perspective or driving perspective to get from one part of the state to the next, big mountain ranges in between and just trying to figure out how best to deal with patient transfers was a challenge. What we were seeing in the north part of the state was not what we were seeing in the southern or eastern part of the state. So our original crisis standards of care declaration came clear back in September with a regional approach. And then a few weeks later, it wound up being a statewide approach. And that was really because of the number of patients that were in the hospital. In November timeframe, we did a deactivation status first at the statewide level and then finally, they're exceeding the regional level and then the statewide level in December. And then with the Omicron surge, we wound up having a second wave of declarations, if you will, in January, January 24th was a different part of the state this time. It was our southern part of the state requesting a hospital requesting crisis standards of care due to severe staffing limitations and the different scenarios, the critical blood size shortage that they were facing and this hospital that initiated this, this time is our largest trauma hospital. So just a little bit more history about how we were organized. So over time with these activations and deactivations, they said we started not really having, you know, coordinated effort at play. We've since then created a great voluntary and sort of relational model. I'm calling it throughout the pandemic to support the hospitals with the response, including our transfers. And the evolution of the model goes like this. So we at the state, we convene to what we call our hospital capacity calls multiple times a week throughout the whole pandemic so far just to create that statewide situational awareness. They're co-hosted with our Idaho office of emergency management and our Idaho hospital association. The state then also convened our state of Idaho Disaster Medical Advisory Committee in the very early stages of the pandemic to create our crisis standards of care plan and our patient care strategies for care resources guidelines that was based on Minnesota's plan. So I'm glad that John is on here to help provide guidance for hospitals, which of course is all laid out under an ethical framework. So for several months, we were working with our hospitals, helping them navigate in this sort of loose relationship and really letting the hospitals navigate these issues amongst themselves regionally. We did not have a state collective body that had the skills and expertise to be that single center helping. But what we did do last summer in July is that we had a hospital that ran into a situation of meeting help with a patient transfer. They were doing their normal, we're making 24 calls trying to find a way to transfer this patient. We need EMS to help us. So we have a very robust state communication center that can quickly convene calls. We have great protocols that are available through that state comm center. So we hold them all together to help with problem solving. We had all the EMS and hospitals in that region available, help them do that problem solving, got the transfers made, transfer made. And then in August, we had our hospitals during one of our capacity calls that I mentioned, talk about the need to expand that load leveling across the entire state. Instead of making it just regional, we needed to be able to do some sort of statewide effort. So we, the state then created a medical operations coordination cell call platform, if you will, we have a call every single day, a 30 minute call in this mock or medical operations cell coordination cell structure that brings together the transfer centers from the hospitals, some of their administrations and bedside physicians, whomever they think are the appropriate people to be in these calls. We facilitate them, we have an agenda. They, each of the hospitals report on key metrics, whether that's available beds, transfer needs, blood supply, whatever it is that we need to be talking about. We also have our Idaho inventory or our resource tracking system. We can also walk through to see better availability. So during these calls, daily calls, there's constant communication and consultation, requests for assistance. And we try to connect those needs during the day, during that call, if a solution can be obtained, where there's some great, they'll start exchanging phone numbers and conversations in the chat. They'll call each other afterwards. But if they can't support that during that quick call, we've also created what's called the AlertSense app. So a few weeks after we started these coordination cell calls, we found there's a need to make this available 24 seven. So we worked with our vendor called Conexus to build out their AlertSense app to allow push messages and polling options within that app to help with load loving. So we can then see even pop up on our phones and states are also involved, where we can see X hospital has patient, X, Y and Z, that needs to be transferred for the following reasons. And then that allows reciprocating hospitals to respond to that 24 seven. We also have staff available to help facilitate if those calls should go unanswered. And then that, I just wanted to kind of wrap up with a couple of things that medical operations cell coordination process along with our healthcare capacity calls that we're having. While we don't have a very, a structure at the state level where we have physician team physically making those calls on how a patient should be transferred. We do have an environment where we have all the players at the table on a daily basis and at the leadership level multiple times a week where we've been able to create this environment of trust, accountability, relationship building, that's really led to a lot of transparent and collective problem solving, mentoring, support, resource sharing. We even had some of our largest competitors that are famous even for some of their competition really working together as a team. They've shared blood conservation protocols with all the hospitals. They'll say, does anybody have any needs? Here's how we can help you. So that's sort of the environment that we have right now and I'm sure that as we get through further into the conversation, there's a lot more that we can talk about in terms of that ethical framework. But really the platform is just like you mentioned at the very beginning, we don't want anyone in our state to go without care and have set up a structure that really allows that instantaneous and less conversation across the hospitals. Excellent. Again, I've, oops, sorry, I have to restart my video. You also have raised half a dozen different things that I'd love to dig into a little bit more. And so just as a, again, because I gave Darlene a marker for something I'll definitely want to ask you about later. Think about the across the state issues because that is kind of where I would like to also ask John Hick to weigh in as he turns his video on and we move to his perspective. John, I think you've maybe as much as anyone in the country done more thinking around how to make these kinds of systems actually functional. And in particular, the issues of cross-state transfers. I think we've heard from both Colorado and Idaho, both of whom have some of these unique geographical issues, but it turns out they're not that unique because I know you've dealt with some of these same issues in your state, which of course has a similar geographic makeup in terms of big mountains and a lot of barriers to moving people around all that easily. So what's been the circumstance in your area and how have you managed it? What have been the underlying ethical principles driving that? Yeah, thanks, Matt. It's, we don't have any mountains in Minnesota. We got to 10,000 lakes. We have to circumvent it. That's what it is. I knew it was something. And there's always cross-border transfers and issues. Those are happening every day from Western Wisconsin in and from our state into Southern North Dakota and vice versa. So it's complicated, no question. I think it's been the best of times and the worst of times. Between the late Delta surge that we got moving right into the Omicron surge, we started up on our case counts in June of 2020 and we are just now coming down. I think we're still on the way down but we still have well over 600 COVID cases hospitalized and that's a significant undercounting because once they get past their infectious period they don't count on the numbers anymore. So the longer-term players in the ICU aren't really showing up on those counts. So glad to be on the way down but man it's been a long six months of really protracted stress on the healthcare system. So we're fortunate to have pretty robust healthcare coalitions in eight regions of the state. And those came together along with the Minnesota Hospital Association and the Minnesota Department of Health early on to form the statewide healthcare coordination center. We recognize pretty much right away that we were going to need basically a one-call system to place patients in available beds. So we came up with the Critical Care Coordination Center or C4 and for a time that was run out of the state of OC and a forwarded phone number, but we realized that with the ebbs and flows of COVID-19 we needed that to be embedded in a patient transfer center. So the state contracted with MHealth Fairview Systems that has multiple hospitals and has a robust system operation center where we could run that call center out of. So that call center then was designed to be used when the usual referral methods like you called your usual partner and if they said, no, we got nothing for you, then you could call the C4. And so the C4 also in addition to that call function had either three times a week to once a week to daily touch bases with the major systems. That was an invaluable platform for sharing subjective as well as objective information. We coupled that with a real-time bed board that was put together that was utilized very heavily as well as evolving consensus on what constituted crisis staffing, what were we gonna do about agreements on non-emergency procedures and how to ratchet those back because that created quite a bit of controversy during the first surge because when we looked at the acuity of the patients in the ICUs, the number of patients intubated and things like that, it was pretty clear that a couple of the systems were continued to do significant numbers of elective cardiac procedures that I think the relative risk analysis and benefit of those has to be very carefully calculated but when you're essentially out of ICU beds and it's very clear there's a very disproportionate distribution of acuity across the hospitals, then something needs to be done about that. And so that led to some pretty difficult conversations but we got that worked out. Early on, we were really blessed during the governor's declaration of emergency, we had critical care physicians available to help broker transfers when beds were not available and to help prioritize transfers when we had multiple transfers pending. We also had an agreement amongst the hospitals on a rotation system by which if the critical care physician felt that the patient could not receive the care they needed in place at the hospital they were at, usually a critical access or smaller community hospital that we could essentially force a transfer to a larger facility. Once the governor's declaration went away the healthcare system is backed away from that plan and it kind of, it wound up being a problem during Delta and Omicron because we wound up in much more of a first come first serve situation that we were not intending. So I think a number of things, one, in the end, I think the C4 was a success in a lot of ways from August of 2020 through the end of 2021. It handled about 5,000 requests for transfers. Of those 2,851 were ICU transfer requests and we placed 1,073 of those. So about two thirds of the requests were placed but some months we had a 92% success rate like May of last year and then a 16% placement success rate in December which tells you that we had a lot of patients sitting in the hospitals awaiting transfers. So at that point we changed our policies so that we would only accept transfer requests from hospitals that did not provide tertiary ICU services to really focus our requests on those patients who would most benefit from transfer and we were successful in getting a hospitalist to help prioritize those transfers. But without a mechanism to get the systems to accept those patients, the larger systems we still had a lot of situations where the providers were quite desperate to get their patients into a higher level of care and that was very morally distressing and problematic. So a few things over the course of the last six months just to reflect on, I think there's been a lot more welcome discussion of end of life issues with patients on admission to the hospital. I think we also need to have discussions around consent to transfer at the time of admission because we ran into even though we wanted to reverse transfer folks out of the tertiary centers, a lot of times the families would refuse. We had issues with EMS system reimbursement and so we wound up having to use federal transport or disaster reimbursement mechanisms to pay for those transfers. And a lot of times the systems did not want the patients to be transferred out of system. So even though we felt we had some way to kind of open the drain a little bit, that was a problem. Honestly, that wasn't as big a problem on the back end is trying to get patients into long-term care facilities. That's a whole nother topic for a whole nother day, but a huge issue. I do feel though that the ability to load balancing, the ability to get patients transferred to the correct level of care is the number one thing that we can do to establish equity during these type of incidents. And it is incumbent on us to get the mechanisms figured out by which we can manage these transfers. During the early, the first surge, we saw disproportionate impacting of our urban centers and our minority populations, our non-majority populations. That was particularly exacerbated by the civil unrest that followed George Floyd's murder. And so we actually use the C4 to help load balance a couple of our urban trauma centers that were already full with COVID. And for example, I work one of those shifts and we admitted 26 patients to the trauma service in the space of 12 hours. We just did not have room to accommodate that many casualties. And so we had to make transfers out to other hospitals and we're grateful for the cooperative agreement to do that. I do really fear that patients did not in a lot of situations get equivalent care at the smaller hospitals they were at and that a number of implicit triage decisions were made which we would really prefer to avoid and make sure that we're providing a level of consistency and accountability and awareness of resources that will avoid that. Patient prioritization is key, as I mentioned. And I think too, we really need to start thinking more carefully about who, not only who benefits the most from advanced care but who will suffer the least if such care is withdrawn. And some of you may have seen we had a case while we had pretty large lists of patients waiting to be transferred into tertiary centers. We had a patient who in the interpretation of the care teams was receiving futile care for COVID had been hospitalized and intubated receiving maximal support for months. The care team told the family that they wished to withdraw care because it was futile and the family obtained a restraining order from the court forcing the hospital continued to ventilate him. The family was successful in getting him transferred to Texas where he died within days of arriving there. But it just really, I think overtly raised the question of do we allow an individual infinite access to resources despite a futile outcome or even in cases where there is competition for resources are we providing inappropriate care in some cases in the ICU while others in rural hospitals are suffering the consequences of not having access to those services. So a very pointed example a few weeks ago about the competition for these resources. So we got a lot of work to do. I think we've done a lot of good work. I think we've got to get better about our policies and protocols about our triggers for crisis about our agreement on restrictions and non-emergency procedures. All of these things I think will help reduce our providers moral distress will restore confidence to the patients they're getting at the best care that's possible. And hopefully result in more consistent response next time. I think we put a lot of good tools in place but no question we can refine them in the future. Thanks Matt. Thank you. So I'm gonna turn now to Aaron even though just like the other two John has raised a couple of really important issues that we're gonna have to return to in particular those difficult conversations around so-called elective procedures. And also I think we'll probably wanna come back to some of the challenges around transfers to long-term care facilities. Cause I think all of us have probably had to address those issues as well. But Aaron, let me turn to you. You do not have mountains in Chicago. And so there are not so much that that kind of literal geographic barriers to transfers. But I know that you also around the Chicago area really faced some of the problems later on that were so prevalent in New York very early in the pandemic. Where you knew that there were beds available in some locations but blocks away sometimes there were places that were completely swamped and unable to make those transfers. So how has the health system or the set of systems around the Chicago area and Illinois managed these recent surges? Thanks Matt for the question and the opportunity to share among this group of speakers that have had such phenomenal experience at their state and local levels with managing transfers and resource utilization throughout the pandemic. I will have to say the best I could describe the experience and I'll speak to Chicago because we are a state but one of the things that I wanna highlight is the best way I could describe the experiences the uncoordinated response to COVID-19 because there has not been really a central throughout this there hasn't been a central site that has assisted with direct transfer of patients. I'll say patients specifically because there are there is within our state system a catastrophic response plan that includes I believe as Alki spoke to includes regional areas where hospitals that are in crisis standards of care can reach out to their regional coordinating center for assistance with resources which may call on national stockpiles or otherwise in order to promote to provide resources at an institution but it doesn't necessarily help with issues of specific issues of staffing and patient transfer. So I do wanna highlight as John spoke to that one of the things we were battling in the city of Chicago is that just six months before the pandemic hit we were already talking about how the lifespan gap across a few miles within the city was vaster than any other place in the country and that a large part of this was whether all groups were getting adequate access to attaining their best health including access to hospital systems that were sufficient for what their needs were. As the initial COVID surge struck in early 2020 there were calls that individual hospitals might need to enter crisis standards of care and that's the first point that I'll highlight is that within our state despite there being a catastrophic response plan and a requirement that all individual hospitals have disaster response plans it fell to the individual hospital and was declared by the state that the individual hospital was best suited to know when it would enter crisis standards of care. Now, what that left you with is that if a local or a community hospital felt that it was in crisis standards of care and wanted to reach out for help to other larger hospital systems those hospital systems may not be experiencing that same strain at that same period of time and there was no local or regional declaration that the region was in crisis standards that might promote individuals turning to those disaster plans and being more I think amenable to working together to ensure that across that local or regional area wherever that crisis was declared that those resources including staffed beds were shared appropriately. So that's the first point that I wanted to make is that I think declaration at the individual hospital level really puts much more of an onus on those hospital systems to be able to coordinate resources which I think could be better done where there's a central coordinating system. The second point I wanted to make is that over the course of the pandemic many of us, so I'm an ethicist I chair our ethics committee and I direct our organizational ethics for the hospital those of us on the ethics side were watching the pandemic unfold and watching maps of the city of Chicago that began to mirror that lifespan map where we saw higher cases and areas of lower resource availability we saw higher deaths in those same environments we knew there was less, you know through anecdotal stories we knew there were less access to resources many of the hospitals were reaching out for help and not able to get it. So, concordant with the initiation of the pandemic one of the members actually at our hospital found out what has become known as the Chicago Bioethics Coalition which was a voluntary group of individuals that came together across more than 12 healthcare systems and involved more than 50 people to share ideas and resources about what was happening at individual hospitals and to try to bring back in our respective roles within the hospital, basically pleased to the leadership to help with a more coordinated response we were anecdotally hearing stories that there were people lined up at doors and in hallways that were clearly in need of higher level resources in community hospitals and that some of those hospitals were calling six, seven, eight times this was written about in a few articles and op-eds that came out around this time that there were people that were begging for resources and hospitals that were begging on their behalf but it was reliant upon the individual receiving hospitals to accept those patients. I would love to say that over the course of the surges of the pandemic there's been a change in the way that's been approached and unfortunately I can't tell you that that's the case what I can tell you is that there have been what we've learned I think a bit through this pandemic is that sometimes you have to insert yourself into local, regional or more organized public health processes in order to try to get a voice at the table and to move things along. So as part of this coalition one member of our coalition sat in on weekly calls that were held by the Chicago Department of Public Health that were designed to discuss what's the availability of resources there was through that system a bed availability database that was created but there were no facilitating initiatives to have clinicians or other people prioritizing individuals for transfer based on what that bed availability is at the different systems. So what ended up happening I think with an individual systems was decisions about some of the things that John raised including whether or not again to hold or halt elective services, surgical services during this time rather than potentially being able to move patients and free up bed availability. I will say on the pediatric side there was an agreement among children's facilities that one of the local hospitals one that I work at which was the largest children's facility in the area would try to decompress adult systems by taking additional pediatric patients and an adult hospital also one of the adult quaternary care facilities also made a statement that they would make their beds available to patients that needed transfer they very quickly filled up, we did not. And I think that raises another issue to talk about which is what are the barriers to facilitating transfer of patients when you have systems which I believe many of us operate in where individual hospital systems have this catchment area that they generally serve people see that as their hospital how do you get them to in a setting where there may be other hospitals in crisis how do you get them to agree to transfer even to a facility of equal level but that is not their home facility. So I think how we think about public messaging and these situations and quickly making the public aware of the need to sort of allocate resources where they're needed which may not be along the usual lines of care is really important. And the last thing I think that I'll say is that one of the things we found important to getting our voice heard was different people actually stepping into public media. So writing up ads about the problems that were existing in the city the difficulties with allocating resources appropriately and then alongside that reaching out to our local representatives and being very clear about the fact that the responsibility was on us to coordinate resources between institutions and local regional public health authorities and government authorities to ensure that if things weren't happening on a voluntary basis that more coordinated efforts needed to happen. Many of those conversations are still ongoing. I like John fear that as we're starting to see our surge decline we've hit our lowest percent positivity in the last couple of days and are now lifting some of the other mask mandates and other measures that were put in place. I worry that the impetus to continue those conversations will also wane but there's some hope in me that trying to continue them will put us in a better position when the next crisis hits. Once again, a lot to chew on there. Start my video and actually I'll ask everyone to go ahead and restart their videos. We've got some really good questions coming in through the Q and A but I would actually like to go back to one thing that I think all of you mentioned in one way or another. Elkie, it most stood out to me in your comments where you said someone had done the usual thing and made their 20 different phone calls trying to find a place to transfer and it struck me because the primary motivation as Darlene told us of all of these systems is to make sure people don't sit in one location where they're unable to get the services that they really need and are moved as quickly as possible. But there is a second motivation here which is about the fact that you've got limited numbers of providers who are really struggling to keep up with the work and they are spending hours on the phone looking around for a place to send a patient. It's a terrible use of their time. And I'm just wondering, did anyone track that? Like was that a success metric for any of these transfer centers that the people who were using it on the provider side found that it was an efficient way and that it actually saved them time and allowed them to provide better care to the people they were responsible to? And or did you anecdotally see that it was successful in terms of people saying, yeah, I love that I don't have to make 20 calls, I make one call? And I'll open that to anyone or at least the three of you that have experience with a formal transfer center, was that an explicit aim? And if so, did you track in terms of your success in meeting that aim? Matt, I'll just say it was a specific aim for sure because usually, especially in the small hospitals, it's a solo provider, tremendous waste of time for them to be making 50 phone calls. So when we did send out a survey last year and just said, how has this helped you? That was definitely a strong message was that has been a time saver and a great help. Now I will say that as our placement success decreased, I think the trust that they were going to get a bed also decreased and people would not only lodge a referral request with C4, but then they would continue to call around to call. And I think, part of the problem was a lot of the health systems, the hospital operator, the transfer center operator would just flat out tell the referring doctor, no. And it never got through to a clinician. Our health system always allows a clinician to speak to a clinician. And so a lot of times we were able to negotiate something with them or figure something out or I could give them a direct contact at a different healthcare system. And usually once the need for the referral was understood, whether it was dialysis or emergent surgery or things like that, if it really needed to happen, we figured out a way to get it to happen. But it was usually on the basis of personal relationships. So the system worked to a point. And then after that, it kind of came down to pleading your case to as many people as you could. Matt, that was actually one of the main reasons that we were asked by the state to do this was because one of the initial cries from our rural hospitals was that we are overrun with these transfer requests. And we is taking us 16, 17, 18 hours to get a patient safely to a facility that can actually provide the care that they need. The tier one activation of the CHTC or the Combined Hospital Transfer Center in Colorado was specifically meant to solve that issue. And the way that that tier one worked was that each rural hospital, every single, all 42 rural hospitals were selected a preferred hospital partner or system partner that was then their first and only call. And those hospital systems committed to that rural hospital that if we can't find a bed for your patient in one of our facilities in our system, we will work with the other systems to find a place, find a home for your patient in their system. So that the onus and our responsibility of making all those 500 phone calls went to the system that had a lot more staff and a dedicated transfer center to do that work. I think initially some of the things that became challenging was that rural hospitals at the frontline, like they're overnight docs, they're ED docs or they're hospitalists who are on didn't necessarily get the memo that you now just have to call, there's just one call you have to make. So they were still doing the process where they would call eight hospitals or eight systems, all systems, just to get the call out there, which then made it challenging because then all those systems would start to work on finding a bed, only then to find out that, okay, that hospital's partner is actually system A. And so that was one of the hurdles that we had to get through. But the feedback after four months of activation has been that the relationship between that individual rural hospital and that system has become that much stronger. And now with much more facility and understanding that process and who is our one partner, people are very happy with it. That's interesting, John, you put in the chat that you thought about this, but the rural hospitals actually bulked. Can you tell us what happened? Why would they bulk? Yeah, so the independent hospitals, we had kind of a similar system set up when the hospitals were affiliated with the parent system. When they weren't, we offered to those hospitals to basically establish a partnership that it's like you guys would be linked for the purpose of the pandemic. And basically through the Minnesota Hospital Association, they said, no, we don't wanna do that. We feel that will restrict our options. And we'd be more comfortable kind of going on our own with the C4. Oh. This going alone thing just keeps coming back as a theme, right? That the idea that the best way to manage a pandemic is to let each hospital decide how they wanna manage their piece of the pandemic. I mean, this isn't just this part of the pandemic, right? This has been a larger societal conversation about to what extent can we cohere as a community and make shared plans? And to what extent are we each, at a lone ranger making our own decisions? So this is a reflection of that larger conversation. And Matt, what I will say is there was tremendous divergence between the emergency department clinicians is sort of the bedside to the boardroom. What the CEOs wished for and wanted to implement was often very different from what the frontline providers were asking for. And sorting out that dichotomy and that discrepancy. And it was very challenging from the sort of Department of Health trying to figure out what the ask was from the hospitals because they were being hit with so many mixed messages from the administrative level versus the clinician level and certain systems were coping better than others. And so when are you gonna declare a crisis? What are you gonna do versus why are you talking about the fact that we're struggling? That's gonna make patients think the care is unsafe. That's not the case. So I felt badly for everyone, but the amount of mixed communications was extraordinary. I wanna get to a number of people now have asked about this issue of requirements around transfers. And I think there's two aspects to that. The one that came up immediately was what about patients who would rather not be transferred? And I know we've definitely dealt with this here in Colorado, but I expect others have as well. And John, you gave us maybe the paradigm example. It's sort of the worst case example where someone is literally refusing and going to court. But how have each of the systems, I guess, that we're talking about manage this issue of requirements that you be moved? Usually this is requiring that you be moved to the so-called lower level of care, which I'll put that in scare quotes because it's not always lower level care, but to a different facility that may be further away than you would like from your hometown or those kinds of things. So Darlene, I know you've struggled with this with us. Yeah, absolutely. So a few things. The state did support that. So while the CHTC did not belong to the state, so unlike John's process, this process was totally voluntary. It belonged to the hospitals and the health systems. And the way the state was able to lend their support was to issue executive orders and public health orders that said, okay, number one, if the transfer center makes a decision to transfer a patient from one facility to another, that decision is enforceable, meaning they would enforce it if there was some sort of conflict about that. So this leads to the discussion around patient choice and it did happen where we had a patient who said, no way, that Denver place is too far from where I live, it's over three passes and I'm not going there. And it landed on the hospital then to talk with that patient about why the transfer needed to happen and then what their options were. Cause then it happened then that EMS came to pick up that patient for transport and the patient said, I refuse to go. And EMS said, well, I can't take this patient against their will cause that would be assault and or battery and so, or kidnapping, which we thought was fascinating. And so it led to this concept that we had to do informed consent properly. And we had to partner with the state to communicate to our communities and our patients at large this seriousness and the true calamity of our capacity situations across our hospitals and that this transfer wasn't meant to be punitive. It wasn't meant to remove their patient rights but that it was our effort to get them to a place where they could get the care that they need properly. That was the only time that that situation came up because after that we realized that we had to have a much better messaging campaign that the state needed to be with us and stand behind us. And that led to the options where like the hospital your options then are you can discharge this patient AMA which feels terrible of course to your clinicians because you know that this patient needs the care that you're wanting to provide but cannot or you then just have to discharge the patient and then escort them out for trespassing when they refuse to leave, which nobody wanted that. So in the end for that first patient the patient stayed there or I think actually may have left AMA against medical advice and for subsequent situations we were able to get ahead of it by actually having a prospective discussion with the patient about this is gonna be a possibility just recognize that if you're coming here we may need to transfer you to other places. On the flip side on the discharge end we had to have the same conversations with patients about we may need to discharge you you might I know you live here in Denver but we may actually need to discharge you sooner or transfer you to a further rural community to finish the rest of your care because you're better in terms of your clinical progress than the five other patients who need the much higher level of care. So we're gonna send you there and we'll make arrangements to transport you back. That was the other place where our state was very helpful in providing the support where they said that any transfers that happened during this timeframe and under this PHO or this public health order would be considered to be emergency medical conditions and with that can and should be reimbursable by the payer including the admission or for the facility to accept this patient and also the payment for the transport. I'd love to get to the other angle on this which is the receiving of a patient that you may already be in a facility that is a little bit overwhelmed or maybe a lot overwhelmed and yet you are the facility that can take care of this patient best given the overall environment and a nuanced piece of the executive order in Colorado was that you will do this if the combined hospital transfer center says you take them and I'm wondering, so it was required to take them but it was also under a voluntary arrangement. So it's kind of both required and voluntary but it happened because of state level support for this voluntary arrangement. And I'm wondering, I wanna turn back to Elke because we got a question in the comments also about how this, what is the state's role in this and did you see similar activation of protections for transfer systems like this or were those discussed and decided against what, how was your state's sort of approach to this in terms of supporting these transfer systems? It's a great question. Thanks Matt. Yeah, in terms of the state's role, we've mostly been outside of working with our governor's office and making sure that we have the right executive orders in place, the ability to declare crisis standards of care actually comes through the director of our agencies in rule that if we have this process built out where we can make the declaration for crisis standards of care, which then of course gives hospitals protections to be able to operate in crisis units of care. So kind of coupled with that, we have our scarce resources and patient care guidance that I talked about earlier. Our role has really been in providing the guidance pieces for the hospitals, facilitating those conversations, trying to help, it's a horrible way to say it, but I kind of felt like our medical operations coordination cells were really like brokerings or horse trading. I've got this patient, can you take this patient if we take this patient over here? And so we were just assuring that there was the environment to have those conversations because it didn't really exist before, but we've also tried to, because some of these patient transfer situations came up, for example, someone doesn't wanna go somewhere, kind of similar conversations where, all right, I've got this patient, they refuse to be transferred because our hospital is two hour plane ride away and many, many, many, many hours drive away from the receiving hospital. Can we force them to go? And so we had the hospitals were kind of working that out and so we updated our guidance document that says when crisis standards of care are in effect, patients opting to receive care may at times need to be transferred whether voluntarily or involuntarily to other facilities. So our role is kind of giving that hermitsimus, I guess, for that to occur. That's how we've been looking at it. But fortunately, we've only had really one notable situation where we've had that patient refusal to go to a different facility. So what was sort of brokered is what other patients, types of patients can be transferred to different locations to alleviate some of the burdens that hospital could keep that patient there. So that's what we're trying to help make sure happens. Yeah, Erin, I wanna turn to you because you spoke a little bit during your opening comments about the variation in outcomes for healthcare that we see at baseline before the pandemic. Huge outcome differences between patients who receive care and live in one neighborhood versus those who live and receive care in another neighborhood. In Chicago, I've seen these maps. I've seen them in New York. I've seen them in Boston. Pretty much every city has these maps that show, you can travel 10 miles and lose 10 years of life expectancy by living in one neighborhood versus another. So to some extent, those disparities are driven by the lack of access to high quality care for people who live in those neighborhoods. And during the pandemic, as with so many things, that just got blown up. Sorry, blown up sounds like it got destroyed. It became exaggerated, right? It was even worse than under normal circumstances. And Darlene, you talked a little about triggers for moving from tier one of transfer to tier two of transfer to tier three of transfer. Do we always live at tier one of the need to be able to transfer people better between areas where they cannot get the quality care they actually need and another area? What's the, how do we think about inequities in care that we're trying to mitigate during the pandemic but existed before the pandemic? That's a great question, Matt. And I think I would answer your question, wanting there to be better equity between populations to say, yes, like we always live at that most, that highest level tier to try to get patients that need a higher level of care to those facilities. We don't, let me say this differently. We didn't use to think about racism and structural inequities in healthcare as public health emergencies. I think some of the more recent conversation has changed that a bit. And I think that there is a growing acceptance that these are public health emergencies in the same way that an infectious threat becomes a public health emergency. They just exist over much longer periods of time and will require many, many, many more ways of coordinating local, neighborhood, community resources as well as access to good healthcare in order to address them. And so I think we have a couple of options. One is to say, well, we didn't create these problems with the COVID crisis they existed before and we're just gonna accept that there will be differences because they, we've always had differences. I think another thing to say is the pandemic has really brought back the conversation or highlighted the conversation again about the inequities that we see in medicine, particularly for minoritized communities. And I was actually struggling this morning. I was reading a couple of articles that were written about the today one of these days recently is the 20th anniversary of unequal, the report by the IOM of unequal treatment 20 years ago, noting this very same conversations that we're having today and the lack of significant change that has occurred over those two decades. And so I think complacency is one approach to that situation and saying, we can't change it. It's always been there and it's always gonna be there or we can take the opportunity to really continue pushing the envelope on these conversations, keeping them in the public dialogue and in the dialogue of our public health officials as well as governing officials to put policies in place that will help us mitigate if not eliminate many of those disparities. Darlene, could you tell us what the triggers were for moving from into tier one and then tier one to tier two, tier two to tier three? And I just wanna put this in the context of like how bad do things have to be, right? Cause things are bad at the baseline. How bad do they have to be to trigger implementation of this? So I think this was a critical thing. So remember that the original onus for creating the combined hospital transfer center and then the various tiers within that was really COVID and the pandemic. And so the triggers within each tier and even for activation itself was hospital med surge or acute care bed capacity, ICU bed capacity and then staffing shortages. So like taking it to consideration those factors and oh, sorry, and then also hospitalizations. So availability of beds and COVID hospitalizations were the original triggers for activation. So when it reached a certain threshold of cases, but we still had a lot of capacity, the CHTC did not need to be activated. But once we had a certain threshold of numbers of community cases and also COVID hospitalizations and then also a decline in the capacity, that was the trigger for the activation of the CHTC at tier one. Now in 2021, the CHTC leads recognized that COVID hospitalizations were at most 20% of the cases that were becoming hospitalized. And we're not gonna be the major driver of capacity issues in this year. Were they gonna add to the fire? Yeah, make it hotter? Yeah, absolutely. But they made the decision in 2021 to expand what could be transferred through the CHTC and remove the limitation or restriction that it could only be COVID patients and open it up to everything. So yeah, I would say those were the triggers and the thresholds originally. What remained in terms of the triggers and moving from tier one to tier three then became ICU and bed capacity and really honing in on those things because those are what would precipitate a hospital to say, I don't have the staff or the beds available to care for this patient, I need to transfer that. So as we were seeing those levels happening statewide, that's what triggered us to move from the tier one where it was just the partnership to tier three where it's statewide, all hands are on deck, every bed is on deck for examination as a possible available bed. John, did you have a similar set of triggering events that led to escalations of the sort of enforcement of the C4 operations? Well, again, we didn't have any, once the governor's emergency orders went away, we didn't have any involuntary actions that the C4 could take. So basically the C4 was always open for business. It's just the volume of business they received was definitely was directly related to what the conditions in the hospitals were. The daily conversations though amongst the critical care and bed placement folks on our daily calls, the tenor of those obviously changed dramatically as the surges became more intensive and impressive. And again, there was a lot of great collegial problem solving, but like many states, Arizona, Utah, others found some limits to the voluntary actions. I just wanna make a quick comment about the equity issues. It's funny because at least in our area, we have really good cooperation amongst the hospitals. So I mean, Sherry Fink's article about the Los Angeles hospital situation, I think was very instructive. That's not the case necessarily in all metro areas, but from an emergency care standpoint, our non-majority populations in inner city Minneapolis are always minutes away from some of the most outstanding trauma and critical care facilities in the state. And yet, our rural populations, while they might have better access in some ways to primary care or monoclonal antibodies or things like that because they have a car and they have a primary care provider. But if they get severely ill or injured, they're not going to get on any given day, they're not gonna get the timeliness and the aggressiveness of care that they would if they happen to be in a downtown metropolitan area. And with COVID, we saw pretty significant transfer delays that compounded some of those things. Despite the best efforts, and I will call out, I mean telemedicine and other techniques can help to keep patients in place at some of these facilities, but it has its limits. I mean, you can't operate on somebody remotely, you can't do dialysis and most of the time, it was better for me at Hennepin to add one more intubated patient to the patients I was boarding in the ED, then let that patient sit in a rural emergency department with providers that had extraordinarily limited critical care experience, even if they were getting good advice over the phone, they just couldn't match the transfusion, laboratory and other resources that we had. So, but at the same time, we couldn't accept an unlimited number of those patients as soon as you would take a patient and we got our hands slapped for this all the time, but you just try to do the right thing in a moment. If we really felt like we were uniquely able to provide the resource, we would try to do that. And C4 accepted all medical transfer requests, COVID and non-COVID, but trauma burn pediatric, those needed to go directly to the specialty facilities. And so we really tried to make sure that we always took the bad trauma, the bad burns, hyperbaric, things that we were uniquely positioned to accept. So, but it was, you know, I tell you, I mean, some of the, Matt, I, we all have tough shifts in the ED, but, you know, for a couple of months there, like every shift he walked into, you just knew it was going to be one of the worst shifts of your life. And you were just struggling, you know, to hang on to, okay, I've got a dialysis patient who's in an abnormal rhythm. I've got no monitor beds to put them in the ED. I guess we'll put him in a chair here temporarily until we can, you know, get this person moved. It was, you know, really some of the most difficult medicine, chaotic medicine I've ever practiced. So I'm pretty grateful that we're on the downswing now. Yeah. Yeah, you know, I think one of the things you're raising to John is the layered nature of the problem here and the transferring patients from one place to another. It has to be a component. The telemedicine is also a component. One of the questions that came up in the chat is around EMS strategies because transferring people takes an EMS resource. And during these surges, our EMS teams were swamped as well. And I don't know if anyone would like to try and address that, but how did, you know, how did the different locales represented here deal with EMS limitations in the context of, you know, maybe a need for more transfers than they normally would be doing? And by the way, some of these transfers are long distance. So you're taking an EMS crew out of operation for a day. Yeah, we were really burning out a lot of the rural EMS agencies and a lot of the limited critical care transport resources we had were pretty overwhelmed to the point where we actually brought in some federal ambulance contract teams in order to support them and supplant them in some cases. And initially that was a little bit controversial, but in the end, a lot of the municipalities were really grateful not to have to worry about us. They could maintain their 911 coverage and not have to worry about, you know, being out of their service area for six hours. But day after day, you know, often these volunteer or smaller services would be out of their, you know, immediate response area for the better part of a day, making a transfer halfway across the state. So I think that's something we really need to continue, to work on. At the same time, some of our flight crews were getting called into hospital saying, hey, we've got to transfer from this place to this place. And when they get there, it was really clear they'd get the patient intubated and all that, but it was really clear that no transfer had been accepted. And then they were stuck in a situation where we can't remain out of service, you know, is this patient abandonment? And it's like, well, technically no. I mean, there's a doctor there, but it led to some pretty dicey circumstances sometimes. And I can chime in on that a little bit also. I mean, definitely echo many of John's comments, you know, in Idaho, I think about 40% of our EMS providers are volunteer EMS providers as well, which also layers in another issue that we have to address. But in our, at the state, we license all EMS facilities and personnel as well. So we have a really good, you know, pulsing what's going on with our EMS providers and similar conversations being pulled out of their, you know, their community service opportunity by needing to transfer patients, things like that. But luckily the volume of our transfers wasn't so extensive that we were really taxing our EMS personnel for long periods of time like that. And just as a, you know, I kept continually asking our staff, how are EMS doing? How are they handling this? And for the most part we've experienced is that they are so anxious and eager to step up to the plate that they were kind of thriving in the environment. In sort of a, I don't want to say a weird way, but they were, you know, proud and happy to be part of the solution. So we didn't really have any major issues, but that might also just be the luck of the draw for our state that we didn't have quite the volume of patient transfer needs that many of the other states have had. I realize we're getting very close unfortunately to the end. So I would like though for each of you to have an opportunity to say a word in closing about, maybe we can tackle one of the questions in the chat while also tackling what we said we were going to. One of the questioners asked, what are the barriers to learning from this experience and applying what we've learned to the usual care that we provide in normal crises, American healthcare? And what is the lesson that has been learned? What will we take forward out of this? Not just for pandemic, but for the post-pandemic era. What are we gonna have learned from this? Maybe I'll start with Erin because we haven't heard from you in a couple of minutes. What do you think we ought to take from this into the future? Thanks, Matt. I think that's a great question to end on. I think for me, and I'll start with what you questioned earliest which is what are the ethical underpinnings of the work that we're doing. And I think for me, one of the barriers and ways to move forward is getting better public recognition and dialogue around principles of communitarianism, of solidarity, of ideas that are less driven by individual interest, which is how we operate, I think, in the healthcare system on a regular basis. That's not to say that individuals should not want their own healthcare addressed but that I think that we have to be able to have a conversation in a dialogue that's readily accessible, like good public messaging in the onset of a public health emergency that we're moving to a state where our individual interests might not be, maybe serve but not in the way that we're used to in order to make sure that other people in the public community that we live in and we're part of and we have some obligation towards, may need those resources that we usually would get, that we might need a substitute that will be good enough but not maybe what we expected. And I think being able to have messaging and conversations that gets that point out early in a public health emergency will overcome one barrier and potentially help us move forward. I have a ton of other barriers but I'm sure they're gonna come up in other comments. So I'll stop there. Elki, I know you have a hard stop in just a couple of minutes. So why don't we go to you next? If I can get myself off mute here, my apologies. I would say, I'll start with for me lessons learned and kind of moving forward out of this is having experienced our healthcare system here in the state prior to this and that kind of that isolating, we're gonna do it on our own. What we are really learning is that hospitals don't need to feel alone in making some of these hard decisions that they have now this infrastructure and established system and relationships that we hope it will continue well beyond the pandemic. So that if a doctor or hospital needs help, they know they have a network of peers that can help them. So to me, that's like our biggest win out of this. We have problem solving channels, barriers I would say that at least at the state level we don't have at least the technical experts on my own staff that can stand up a transfer center like this other than helping be a facilitator of those conversations. And what would it take to be able to do something like that in the future? When I look at what Minnesota is doing, for example, or a state of Washington has something similar, what would it take to stand that up? Just a couple of things that come to mind. Thank you, John, I know you also have to chair another meeting in just a minute. So we'll go to you next and then Darlene will get the last word. Yeah, I think we've got to figure out how to maintain like the C4 and some of these concordant operations. I've never seen during this pandemic such incredible examples of selflessness combined with examples of selfishness in sort of the same vein. And it's really gonna take a public private partnership in order to make these systems function the way they're intended to. In the absence of the correct immunity protections from the things like the restraining order that was put in place, we really aren't gonna be able to do any kind of effective allocation of resources. And so finding the right orders versus the right degree of voluntary cooperation amongst the private sector entities is critical. And the same goes from an equity lens. We have so much to do from an equity standpoint but the private sector is not gonna solve that. And so unless we have a major public commitment near to solving some of these issues, it's not gonna happen. But I think we have a lot of things that were done right that we can build on but we got to make some tweaks and make sure that that Delta, when the system is at the verge of falling apart that we really are trying to offer as consistent care as possible to everyone. Yeah, it's really, you're making me think this really is one of those paradigm issues of structures underlying legal structures even that end up driving, people have to behave in their individual interests which will lead inevitably to disparities and the neglect of already underserved and under resourced communities. So it takes proactive intervention not just letting the system run as it does because the system running as it does is what has created these disparities to begin with. So sorry, darling, that was my last comment. I'll go to you for the actual last word. Yeah, I will say that to me, the lesson that we have to take away from this is that we need to continue to elevate the core mission that we all have together the healthcare industry, which is every patient deserves to get the care that they need at that moment at the right time. And that was the center of the commitment and in my mind was the public private partnership that John described that we should be seeking all the time. That was the core principle that brought our hospitals and health systems together and allowed us to partner with the state and the state provided the foundation for us to continue that and to innovate around that core principle. Well, thank you all so much for joining. I will turn back to Charlotte. I think there's a closing comment on the part of the program. Yes, thank you, Matt. And thanks to the panelists remaining with us and recently with us for this really wonderful exploration of the experience that people have had, which we know is gonna be important to learn from for the perhaps very near and certainly foreseeable future as these circumstances recur. And we wanted to invite our participants this time to come to next month's or the following month's programs. And Kelsey Berry is gonna tell you about that program. Absolutely, thank you so much, Charlotte. And thank you, Matt and all the panelists for really helping us explore this cooperative approach to regional resource scarcity. I think that both the possibilities and the ethical complexities that it raises are really ripe for continuing to discuss them. So we do hope you will enjoy the upcoming consortium events. The next one's in March and it's gonna continue today's theme of innovative organizational responses to COVID-19. So we're welcoming Dr. Susan Miller, who will share how Houston Methodist developed the nation's first mandatory vaccination policy for a healthcare system. And then in April, which is the last meeting of the Organizational Ethics Consortium, we're going to come back to themes of trust, trustworthiness and how health organizations can publicly communicate to serve those ends. And for that, we're gonna have a really unique case of a biopharmaceutical manufacturer kind of looking internally at their communications and thinking through trustworthiness and trust. So the dates for those programs can be found on our websites and via the listserv. And we're just so thrilled to have you as part of our learning community and look forward to seeing you at these upcoming events of the consortium. So thank you so much and have a good afternoon.