Triage of Scarce Critical Care Resources in COVID-19 An Implementation Guide for Regional Allocation: An Expert Panel Report of the Task Force for Mass Critical Care and the American College of Chest Physicians

Abstract

Public health emergencies have the potential to place enormous strain on health systems. The current pandemic of the novel 2019 coronavirus disease has required hospitals in numerous countries to expand their surge capacity to meet the needs of patients with critical illness. When even surge capacity is exceeded, however, principles of critical care triage may be needed as a means to allocate scarce resources, such as mechanical ventilators or key medications. The goal of a triage system is to direct limited resources towards patients most likely to benefit from them. Implementing a triage system requires careful coordination between clinicians, health systems, local and regional governments, and the public, with a goal of transparency to maintain trust. We discuss the principles of tertiary triage and methods for implementing such a system, emphasizing that these systems should serve only as a last resort. Even under triage, we must uphold our obligation to care for all patients as best possible under difficult circumstances.

Keywords: COVID-19 pandemic; disaster preparedness; scarcity of resources; surge capacity; triage.

Figure 1

Impact of triage in crisis surge response to balance demand and capacity, demonstrating different levels of triage depending on the degree of demand in relation to system capacity. LTC = long-term care.

Figure 2

Ethical principles involved in triage systems.

Figure 3

Process for crisis care integration with incident command. EOP = emergency operations plan; HCC = health-care coalition.

Figure 4

Sample hospital decision process (Minnesota Department of Health). CCC = Clinical Care Committee; CV = cardiovascular specialist; ECMO = extracorporeal membrane oxygenation; HICS = Hospital Incident Command System; IC = Incident Commander; MD = medical doctor; OMD = Office of Medical Director; TT = triage team.

Figure 5

Triage decision process flow.

Figure 6

Triage infrastructure.