Arizona Health Care Systems’ Coordinated Response to COVID-19—“In It Together” | Infectious Diseases | JAMA Health Forum | JAMA Network
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Arizona Health Care Systems’ Coordinated Response to COVID-19—“In It Together”

  • 1Cleveland Clinic Center for Bioethics, Cleveland, Ohio
  • 2Clinical Ethics, Banner Health, Phoenix, Arizona

Connectivity is both the cause of and the most powerful response to the COVID-19 pandemic. Through global and social connection, this highly contagious and lethal virus has rapidly devolved into a pandemic. Physical isolation—between countries, states, and our fellow humans—is one of the few tools we currently have to control the spread of COVID-19. However, at a health systems level, isolation may exacerbate its lethal toll. In late March, this phenomenon was tragically demonstrated at Elmhurst hospital in Queens, New York, when hundreds of patients waited for care and many died while 3500 beds were free in other New York hospitals. The lesson was clear: accurately tracking and managing critical resources “becomes a matter of life and death when one hospital encounters a surge”.1

In mid-June, Arizona was one of the hardest hit regions in the world, with 212 cases per million residents. Hospitals across the state enacted their surge plans to increase bed capacity by 50%. Hundreds of crisis assignment health care workers were deployed, and clinicians operated under expanded scopes of practice to care for the patients doubled-up in intensive care unit (ICU) rooms and occupying newly opened ICU wards. Reasons cited for Arizona’s alarming COVID-19 prevalence rate include the governor’s early reopening of the state on May 15 and the absence of a statewide mask mandate. But having learned the importance of regional networking2 from national and global colleagues, leaders from Arizona’s health care systems had already collaborated with one another and the Arizona Department of Health Services to craft an innovative, coordinated response. Recognizing the power of global information sharing,3 3 of Arizona’s key statewide initiatives are shared here in the hope that they will help others.

Arizona Surge Line

On April 21, 2 weeks after it was initially proposed, Arizona launched the Arizona Surge Line, a centralized system for load-balancing COVID-19 patients across the state. This new program required the cooperation and agreement of state health care systems, normally corporate competitors, during a time of acute financial strain. With surge capacity, Arizona has approximately 12 500 licensed hospital beds across 127 hospitals, 18% of which are ICU beds. The majority of the state’s hospital beds are divided among 4 health care systems: Tenet (Abrazo and Carondelet), Banner Health, CommonSpirit (Dignity Health), and HonorHealth. Banner Health is the state’s largest health care system, with a market share of approximately 40%.

Any provider in the state can call the Surge Line to arrange timely transfer of a patient with COVID-19 to an appropriate level of care. Patients with COVID-19 are allocated among Arizona’s health care systems in proportion to the systems’ market shares. The Surge Line also offers frontline clinicians consultative support from critical care and palliative medicine specialists. This system expanded on the existing patient transfer service of Banner Health. Arizona also had a health information exchange system that included 95% of hospitals and provided data on health system resources. As of late July, over 2300 patients with COVID-19 had been transferred through the Surge Line. Notably, this system specifically considers only the patient’s medical condition and needs, ensuring equal treatment for all, including the state’s most vulnerable. Major insurers, including Aetna, Blue Cross Blue Shield, Cigna, and United Healthcare, agreed to waive out-of-network costs for patients transferred through the Surge Line.

Enacting Crisis Standards of Care

In response to the urging of health care leaders across the state, Arizona activated its Crisis Standards of Care plan (CSC plan) on June 20, 2020. Now in its third edition, the CSC plan was developed over multiple years by a multidisciplinary taskforce of stakeholders, drawing heavily from the 2012 Institute of Medicine report.4 Notably, the failure to implement such standards has been identified as a key learning from New York’s early confrontation with COVID-19.5 Arizona’s CSC plan offers templates and tactics for the ethical management of scarce “space, stuff, and staff” during a crisis. The enactment of the CSC plan also provided additional legal protections for health care practitioners acting in good faith during the emergency. These protections were key to enabling health care professionals to embrace the uncomfortable shift from patient- to community-centered care required by the public health crisis.

COVID-19 Addendum

The CSC plan is supplemented by the COVID-19 Addendum, which outlines adult and pediatric triage protocols to be adopted by all acute-care facilities in the state if triage is needed. With this document, Arizona joined the 26 other US states6 currently providing public guidance on how allocation of scarce resources should occur during the pandemic. Notably, the Addendum was an initiative of the state’s health leaders, including chief medical officers or their designees from multiple private and public health care systems, such as the Veteran’s Administration, Indian Health Service, and tribal health agencies. After negotiating terms acceptable to all of Arizona’s health care systems, the document was proposed to the Arizona Department of Health Services and approved on June 12, 2020.

Integral to the Addendum is the intention that all Arizona health care systems coordinate and collaborate to share resources. Rather than working in isolation to design resource allocation policies for patients presenting to individual facilities or systems, Arizona’s health care leaders decided their duty to plan encompassed the entire state. Implementing a statewide allocation protocol helped ensure patients across the state would be treated equally. Health care systems deemed this policy particularly important in a state where 26% of the land is tribal and over 80% of the population lives in just 2 large metropolitan areas, Phoenix and Tucson, where health care resources are focused.

To date, this cooperation has prevented the need to restrict access to ventilators and ICU beds in Arizona. If the state is faced with further resource shortages, the health care systems will again coordinate announcements, governmental notification, and requests for assistance. In the meantime, collaboration among Arizona’s health care systems remains strong and effective.

The Case for Statewide Coordination

Putting their duty to plan, safeguard, and guide the community through this public health emergency above their commercial interests, Arizona’s health systems facilitated the implementation of statewide Crisis Standards of Care, created allocation policies, and supported the development of an efficient patient transfer system. These measures limit duplication of efforts, safeguard the health care workforce, and protect the most vulnerable in the community by ensuring a fair distribution of resources across the state. At a health systems level, statewide coordination serves the fundamental goal of triage to maximize lives saved. The coordination and cooperation among Arizona’s health systems is supporting this essential goal.

Article Information

Corresponding Author: Sharon L. Feldman, LLB, MS, Cleveland Clinic Center for Bioethics, JJ60, 9500 Euclid Ave, Cleveland, OH 44195 (

Acknowledgments: Dr Mayer is involved in Arizona’s COVID-19 response, including preparation of the COVID-19 Addendum to the Arizona CSC plan. During a clinical placement, Ms Feldman observed and supported this work. The authors wish to acknowledge the immense effort, commitment, and expertise of their colleagues and collaborators in the coordinated response of Arizona’s health care systems to COVID-19.

Conflict of Interest Disclosures: None reported.

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