Adult ICU Triage During the Coronavirus Disease 2019 Pandemic: Who Will Live and Who Will Die? Recommendations to Improve Survival*
- 1 August 2020
- journal article
- research article
- Published by Ovid Technologies (Wolters Kluwer Health) in Critical Care Medicine
- Vol. 48 (8), 1196-1202
- https://doi.org/10.1097/CCM.0000000000004410
Abstract
Objectives: Coronavirus disease 2019 patients are currently overwhelming the world's healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions. Data Sources: PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies. Study Selection: Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email. Data Extraction: References and data were based on relevance and author consensus. Data Synthesis: We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. "First come, first served" is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients. Conclusions: Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.Keywords
This publication has 39 references indexed in Scilit:
- Comparison of CATs, CURB-65 and PMEWS as Triage Tools in Pandemic Influenza Admissions to UK Hospitals: Case Control Analysis Using Retrospective DataPLOS ONE, 2012
- The Eldicus prospective, observational study of triage decision making in European intensive care unitsCritical Care Medicine, 2012
- The Eldicus prospective, observational study of triage decision making in European intensive care units. Part IICritical Care Medicine, 2012
- Sequential Organ Failure Assessment in H1N1 pandemic planning*Critical Care Medicine, 2011
- The Simple Triage Scoring System (STSS) successfully predicts mortality and critical care resource utilization in H1N1 pandemic flu: a retrospective analysisCritical Care, 2011
- An observational cohort study of triage for critical care provision during pandemic influenza: ‘clipboard physicians’ or ‘evidenced based medicine’?Anaesthesia, 2009
- A retrospective cohort pilot study to evaluate a triage tool for use in a pandemicCritical Care, 2009
- Variation in critical care services across North America and Western Europe*Critical Care Medicine, 2008
- Simple triage scoring system predicting death and the need for critical care resources for use during epidemicsCritical Care Medicine, 2007
- Mortality predictions in the intensive care unit: Comparing physicians with scoring systems*Critical Care Medicine, 2006