Triage and Allocation of Neurocritical Care Resources During the COVID 19 Pandemic - A National Survey

Abstract

Objective: In light of the ongoing COVID-19 pandemic and the associated hospitalization of an overwhelming number of ventilator-dependent patients, medical and/or ethical patient triage paradigms have become essential. While guidelines on the allocation of scarce resources do exist, such work within the subdisciplines of intensive care (e.g., neurocritical care) remains limited.Methods: A 16-item questionnaire was developed that sought to explore/quantify the expert opinions of German neurointensivists with regard to triage decisions. The anonymous survey was conducted via a web-based platform and in total, 96 members of the Initiative of German Neurointensive Trial Engagement (IGNITE)-study group were contacted via e-mail. The IGNITE consortium consists of an interdisciplinary panel of specialists with expertise in neuro-critical care (i.e., anesthetists, neurologists and neurosurgeons).Results: Fifty members of the IGNITE consortium responded to the questionnaire; in total the respondents were in charge of more than 500 Neuro ICU beds throughout Germany. Common determinants reported which affected triage decisions included known patient wishes (98%), the state of health before admission (96%), SOFA-score (85%) and patient age (69%). Interestingly, other principles of allocation, such as a treatment of “youngest first” (61%) and members of the healthcare sector (50%) were also noted. While these were the most accepted parameters affecting the triage of patients, a “first-come, first-served” principle appeared to be more accepted than a lottery for the allocation of ICU beds which contradicts much of what has been reported within the literature. The respondents also felt that at least one neurointensivist should serve on any interdisciplinary triage team.Conclusions: The data gathered in the context of this survey reveal the estimation/perception of triage algorithms among neurointensive care specialists facing COVID-19. Further, it is apparent that German neurointensivists strongly feel that they should be involved in any triage decisions at an institutional level given the unique resources needed to treat patients within the Neuro ICU.

Implementation, relevance, and virtual adaptation of neuro-oncological tumor boards during the COVID-19 pandemic: a nationwide provider survey

“…The tremendous impact on daily living during the COVID-19 pandemic resulted primarily in shifts in medical care [23][24][25][26]. However, the results of our survey impressingly demonstrate that NTBs were maintained during this period.…”

Ethical Management of COVID-19 Pandemic at a Neurological Hospital: The Ethicovid Report

“…This remains consistent with the result of a survey of neurointensive care practitioners, who considered frailty and severity scores in addition to age as essential for the triage of neurologic and COVID-19 patients. 14 However, among the initial factors, only the Simplified Acute Physiology Score II, but not the frailty scores, tended to differ between the decisions made (Table 1). This likely reflects that, unintentionally, we favored short-term rather than long-term survival, that is, giving as many people as possible the opportunity to get through the crisis.…”

“…As such, it may consider prioritizing certain groups of people (eg, family caregivers, health caregivers or political leaders) and is recommended by only a very few experts in the context of the COVID-19 pandemic. 1,14 Because we believed it to be more relevant and fair, despite some authors highlighted its limitations, 15 we adopted a pragmatic approach mainly based on utilitarianism, and built a system for allocating available resources on a case-by-case assessment based on medical necessity and focused on the expected benefit of care, in a similar manner to that reported by Blot et al 12 The issue of taking age into account in the treatment decision is debated. 4 There are 2 aspects to age, ethical and medical.…”

“…4 There are 2 aspects to age, ethical and medical. From the ethical perspective, some authors consider it fair to give as many people as possible the same chances to reach the same age ("life cycle" or "fair innings" approach), 5,14,16 whereas others consider this approach is unfair because it systematically discriminates against older and disabled persons. 15,17 The question is, whether to prioritize maximizing the number of lives saved rather than the number of years of lives saved.…”

Neurointensivmedizin und COVID-19

“…Neurointensivmediziner in Deutschland haben Patientenwünsche, Vorzustand, Sequential Organ Failure Assessment Score (SOFA) und Alter als die wichtigsten Einflussfaktoren identifiziert. Zudem wurde dem Konzept „first-come, first-serve“ Vorrang gegenüber einem Losverfahren eingeräumt [ 15 ]. Zuletzt birgt die Erfahrung der Pandemie die Gefahr, dass etablierte Strukturen zur Versorgung kritisch kranker neurologischer Patienten infrage gestellt werden.…”