{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,17]],"date-time":"2026-05-17T03:56:06Z","timestamp":1778990166889,"version":"3.51.4"},"reference-count":49,"publisher":"Wiley","issue":"3","license":[{"start":{"date-parts":[[2026,1,20]],"date-time":"2026-01-20T00:00:00Z","timestamp":1768867200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"},{"start":{"date-parts":[[2026,1,20]],"date-time":"2026-01-20T00:00:00Z","timestamp":1768867200000},"content-version":"tdm","delay-in-days":0,"URL":"http:\/\/doi.wiley.com\/10.1002\/tdm_license_1.1"}],"funder":[{"DOI":"10.13039\/100000049","name":"National Institute on Aging","doi-asserted-by":"publisher","award":["K24AG068312"],"award-info":[{"award-number":["K24AG068312"]}],"id":[{"id":"10.13039\/100000049","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000049","name":"National Institute on Aging","doi-asserted-by":"publisher","award":["R03AG073987"],"award-info":[{"award-number":["R03AG073987"]}],"id":[{"id":"10.13039\/100000049","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000871","name":"Mayo Clinic","doi-asserted-by":"publisher","id":[{"id":"10.13039\/100000871","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["agsjournals.onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["J American Geriatrics Society"],"published-print":{"date-parts":[[2026,3]]},"abstract":"<jats:title>ABSTRACT<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>The COVID\u201019 pandemic presented unprecedented challenges to hospital system and critical care resources, leading to significant changes to operations and patient care. There are limited national data on these changes and instances of unsanctioned deviations from patient care, yet understanding the COVID response is key to future preparedness efforts. We sought to understand how hospitals and states navigated scarcity during COVID\u201019, particularly in the absence of a declaration of crisis standards of care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Between February 2022 and September 2022 we conducted 34 interviews with 36 leaders of U.S. states' COVID\u201019 planning and response efforts. Interviews were transcribed verbatim and verified. We analyzed interviews using iterative inductive thematic analysis for descriptions of resource scarcity and changes to policies and procedures to prevent rationing lifesaving care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Nearly all participants described equipment and personnel scarcity in their home institution or state during COVID\u201019. Hospitals across regions and states developed formal and informal coordination processes for load and resource sharing in response to influxes of high\u2010acuity patients, avoiding formal rationing of lifesaving resources in many regions. Participants also described unsanctioned patient triage, early discharge, and patients counseled to accept less aggressive care (e.g., premature transition to hospice) in states that had not declared crisis standards of care.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>Extending limited resources and inter\u2010institutional collaboration helped avoid formal rationing. Yet, patient care was unquestionably impacted due to scarcity, both real and perceived. Reports of using hospital triage protocols to deny patients lifesaving care outside of formally recognized crisis conditions and attempts to nudge patients to accept less\u2010resource\u2010intensive care are concerning. This may have had disproportionate effects on older adults, individuals with disabilities, and racial and ethnic minoritized groups. To avoid unsanctioned deviations from standard practice in future health emergencies, we recommend that transparent and equitable triage protocols are implemented with robust oversight.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/jgs.70300","type":"journal-article","created":{"date-parts":[[2026,1,20]],"date-time":"2026-01-20T15:00:38Z","timestamp":1768921238000},"page":"729-737","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["\u201cBy the Skin of Our Teeth\u201d: U.S. Hospital, Regional, and State Experiences of Scarcity During the\n                    <scp>COVID<\/scp>\n                    \u201019 Pandemic"],"prefix":"10.1111","volume":"74","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1338-212X","authenticated-orcid":false,"given":"Jackson S.","family":"Ennis","sequence":"first","affiliation":[{"name":"Biomedical Ethics Research Program Mayo Clinic  Rochester Minnesota USA"},{"name":"Warren Alpert School of Medicine Brown University  Providence Rhode Island USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kirsten A.","family":"Riggan","sequence":"additional","affiliation":[{"name":"Biomedical Ethics Research Program Mayo Clinic  Rochester Minnesota USA"},{"name":"Health Ethics &amp; Policy Lab, Department of Health Sciences and Technology ETH Z\u00fcrich  Z\u00fcrich Switzerland"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nicholas V.","family":"Nguyen","sequence":"additional","affiliation":[{"name":"Biomedical Ethics Research Program Mayo Clinic  Rochester Minnesota USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander K.","family":"Smith","sequence":"additional","affiliation":[{"name":"Department of Medicine, Division of Geriatrics University of California, San Francisco  San Francisco California USA"},{"name":"San Francisco Veterans Affairs Medical Center  San Francisco California USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel B.","family":"Kramer","sequence":"additional","affiliation":[{"name":"Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School  Boston Massachusetts USA"},{"name":"Harvard Medical School Center for Bioethics  Boston Massachusetts USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel P.","family":"Sulmasy","sequence":"additional","affiliation":[{"name":"Department of Medicine and Philosophy Georgetown University  Washington DC USA"},{"name":"Kennedy Institute of Ethics Georgetown University  Washington DC USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jon C.","family":"Tilburt","sequence":"additional","affiliation":[{"name":"Biomedical Ethics Research Program Mayo Clinic  Rochester Minnesota USA"},{"name":"Division of General Internal Medicine Mayo Clinic  Scottsdale Arizona USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Erin S.","family":"DeMartino","sequence":"additional","affiliation":[{"name":"Biomedical Ethics Research Program Mayo Clinic  Rochester Minnesota USA"},{"name":"Division of Pulmonary and Critical Care Medicine Mayo Clinic  Rochester Minnesota USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2026,1,20]]},"reference":[{"key":"e_1_2_11_2_1","doi-asserted-by":"publisher","DOI":"10.1097\/CCM.0000000000005013"},{"key":"e_1_2_11_3_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajem.2020.05.059"},{"key":"e_1_2_11_4_1","doi-asserted-by":"publisher","DOI":"10.1017\/ice.2021.280"},{"key":"e_1_2_11_5_1","doi-asserted-by":"publisher","DOI":"10.1097\/MCC.0000000000001001"},{"key":"e_1_2_11_6_1","unstructured":"L.Leatherby J.Keefe L.Tompkins C.Smart andM.Conlen \u201c\u2018There's no Place for Them to Go\u2019: I.C.U. 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