Triage Procedures for Critical Care Resource Allocation During Scarcity

Abstract

ImportanceDuring the COVID-19 pandemic, many US states issued or revised pandemic preparedness plans guiding allocation of critical care resources during crises. State plans vary in the factors used to triage patients and have faced criticism from advocacy groups due to the potential for discrimination.ObjectiveTo analyze the role of comorbidities and long-term prognosis in state triage procedures.Design, Setting, and ParticipantsThis cross-sectional study used data gathered from parallel internet searches for state-endorsed pandemic preparedness plans for the 50 US states, District of Columbia, and Puerto Rico (hereafter referred to as states), which were conducted between November 25, 2021, and June 16, 2023. Plans available on June 16, 2023, that provided step-by-step instructions for triaging critically ill patients were categorized for use of comorbidities and prognostication.Main Outcomes and MeasuresPrevalence and contents of lists of comorbidities and their stated function in triage and instructions to predict duration of postdischarge survival.ResultsOverall, 32 state-promulgated pandemic preparedness plans included triage procedures specific enough to guide triage in clinical practice. Twenty of these (63%) included lists of comorbidities that excluded (11 of 20 [55%]) or deprioritized (8 of 20 [40%]) patients during triage; one state’s list was formulated to resolve ties between patients with equal triage scores. Most states with triage procedures (21 of 32 [66%]) considered predicted survival beyond hospital discharge. These states proposed different prognostic time horizons; 15 of 21 (71%) were numeric (ranging from 6 months to 5 years after hospital discharge), with the remaining 6 (29%) using descriptive terms, such as long-term.Conclusions and RelevanceIn this cross-sectional study of state-promulgated critical care triage policies, most plans restricted access to scarce critical care resources for patients with listed comorbidities and/or for patients with less-than-average expected postdischarge survival. This analysis raises concerns about access to care during a public health crisis for populations with high burdens of chronic illness, such as individuals with disabilities and minoritized racial and ethnic groups.

Health Professional vs Layperson Values and Preferences on Scarce Resource Allocation

“…Exploration of the potential for racial bias in these algorithms has been undertaken in limited degree, demonstrating a possible difference in model performance across racial groups . Ongoing concerns about how minoritized communities may be disproportionately affected are raised throughout recent literature and our findings continue to demonstrate lack of consensus in both SRA policy and among critical care resource use in general . While determination of how racial bias should be mitigated was not directly addressed in our study, we did find that both HCPs and laypersons felt less strongly about deprioritizing people with a shorter expected lifespan if a patient were also a member of a minoritized group, living with a disability, or living in poverty (eTable 2 in Supplement 1).…”

“… 39 Ongoing concerns about how minoritized communities may be disproportionately affected are raised throughout recent literature and our findings continue to demonstrate lack of consensus in both SRA policy and among critical care resource use in general. 40 , 41 , 42 , 43 While determination of how racial bias should be mitigated was not directly addressed in our study, we did find that both HCPs and laypersons felt less strongly about deprioritizing people with a shorter expected lifespan if a patient were also a member of a minoritized group, living with a disability, or living in poverty (eTable 2 in Supplement 1 ). With multiple policies using organ failure acuity scores whose validity across populations and conditions have been called into question, 44 , 45 including that of UC Health, empirical evidence on optimizing SRA algorithms is sorely needed.…”

Learning from COVID‐19 triage schemes to face the next public health emergency

“…Listed comorbidities differ in severity from state to state ("cirrhosis with ascites" results in deprioritization in Arkansas, "MELD >20 [Model for End-Stage Liver Disease]" results in deprioritization in New Mexico); vary widely in associated likelihood of hospital survival ("recurrent cardiac arrest" and "dialysis dependent" both exclude patients from critical care access in South Carolina); and are vague ("metastatic malignancy" features heavily in states' lists). 7 Because older adults, patients with disabilities, and minoritized racial and ethnic groups bear high burdens of comorbidities, 8,9 they stand to lose access to life-saving care under many triage schemes.…”

Faktor – Faktor yang Berhubungan dengan Kinerja Perawat dalam Melakukan Triase di IGD Rumah Sakit Kutacane

“…Perawatan intensif Efisiensi dalam triase adalah prosedur sulit yang memerlukan perencanaan dan persiapan yang cermat (Ennis et al, 2023). Saat ini, sebagian besar negara kekurangan alat prognostik, infrastruktur, prosedur, perlindungan hukum, dan pelatihan yang diperlukan untuk membuat sistem pendukung keputusan yang efisien (protokol triase).…”