Developing a Thai national critical-care allocation guideline during the COVID-19 pandemic: a rapid review and stakeholders’ consultation 

Abstract

Background: At the height of the COVID-19 pandemic, Thailand had almost depleted its critical care resources, particularly ICU beds and ventilators. This prompted the necessity to develop a national guideline for resource allocation. This paper describes the development process of a national guideline for critical resource allocation in Thailand during the COVID-19 pandemic. Methods: The guideline development process consisted of three steps (1) rapid review of existing rationing guidelines and literature; (2) interviews of Thai clinicians experienced in caring for COVID-19 cases; and (3) multi-stakeholder consultations. At steps 1 and 2, data was synthesized and categorized using a thematic and content analysis approach and this guided the formulation of the draft guideline. Within Step 3, the draft Thai critical care allocation guideline was debated and finalized before entering the policy-decision stage. Results: Three-order prioritization criteria consisting of (1) clinical prognosis using four tools (Charlson Comorbidity Index, Sequential Organ Failure Assessment, Frailty Assessment, and Cognitive Impairment Assessment); (2) number of life years saved; and (3) social usefulness, were proposed by the research team based on literature reviews and interviews. At consultations, stakeholders rejected using life years as a criterion due to potential age and gender discrimination, as well as social utility due to a concern it would foster public distrust as this judgment can be arbitrary. It was agreed that attending physician is required to be the decision maker in the Thai medico-legal context while a patient review committee would play an advisory role. Allocation decisions are to be documented for transparency and no appealing mechanism is to be applied.This guideline will be triggered only when demand exceeds supply after the utmost efforts to mobilize surge capacity. Once implemented, it is applicable to all patients, COVID-19 and non-COVID-19, requiring critical care resources prior to ICU admission and during ICU stay.Conclusions: The guideline development process for the allocation of critical care resources in the context of the COVID-19 outbreak in Thailand was informed by scientific evidence, medico-legal context, existing norms and societal values to reduce risk of public distrust given the sensitive nature of the issue and ethical dilemmas of the guiding principle though it was conducted at recorded speed. Our lessons can provide an insight for the development of similar prioritization guidelines, especially in other LMICs.

Estimation of excess all-cause mortality due to COVID-19 in Thailand

“…People, who are ill with other diseases, may struggle to find treatment as the impact of disruptions to the healthcare system during the COVID-19 outbreak (26,27). There have been reports of inadequate intensive care unit (ICU) beds and ventilators in Thailand (6). A shortage of ICU resources may lead to an increased risk of death for critically ill patients.…”

“…To mitigate the disease transmission, the Thai government implemented social distancing and stringent lockdown measures throughout the country and imposed international travel restrictions and nighttime curfews (3). Even though the interventions have proven to be effective in slowing down the spread of the disease, during the peak of the epidemic wave, hospitals in Thailand were running out of beds to accommodate COVID-19 patients and patients of other diseases (4)(5)(6). Although the Thai government had set up the field hospitals (7) for treating COVID-19 patients, the disease's toll on mortality was still high (8).…”