Adult ICU Triage During the Coronavirus Disease 2019 Pandemic: Who Will Live and Who Will Die? Recommendations to Improve Survival

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.

Figure 1.

This tool provides an element of objectivity to help enhance consistency. It is not considered, however, a complete substitute for the carefully considered judgment of an experienced intensive care clinician. The presented algorithm is an example and each institution can decide on which performance score, comorbidities, and organ system failures to use based on their experience and what their staff ifs most comfortable using. A triage (prioritization) decision is a complex clinical decision made when ICU beds are limited. A structured decision-making process is important to maximize transparency and improve consistency in decision-making. A clinical estimation of likely benefit (outcomes from ICU admission compared with outcomes expected if the patient remained on the ward/other care area) is necessary so that patients who will benefit most from ICU are given priority. Examples of clinical conditions that the expert group believe would likely result in a failure of a patient to meet sufficient priority for admission is provided (priority 4). This conceptual algorithm outlines a recommended process for making an individual triage decision, based on a likelihood that survival without ICU care would be low (5–10% or less), and if admission criteria as laid out are met, survival would be estimated to be in excess of 50% short- to medium-term survival. The initial exclusion criteria are based on exclusion criteria used under “normal” conditions so that the same patients are eligible during pandemic conditions and given priority based on their likelihood to benefit. Then patients must meet one of the inclusion criteria. Priorities are then based on those to be “considered first” (priority 1 and then priority 2) and “considered last” (priority 3 and then priority 4) with priority ranking from priority 1 to 4. These exclusions should help foster trust in a fairer triage system with less chance of discrimination. Each decision is assisted on the basis of an agreed criterion thresholds for the particular ICU at a specific time and will be dependent on available resources and the number of patients queuing for admission (e.g., stricter thresholds may be required during the peak of the pandemic, and less strict thresholds at the beginning and toward the end). The performance scores, comorbidities, and organ system failure variables chosen for this example are those that are the quickest to assess. Performance scores: The premorbid baseline condition can be assessed using the Eastern Cooperative Oncology Group Performance Score, the Clinical Frailty Score, the Karnofsky Performance Scale, or other functional impairment tool the user is accustomed. Comorbidities can be assessed using the ASA score, number, or severity of comorbidities. Organ system failures can be assessed using the number of organ system failures or Sequential Organ Failure Assessment. Reevaluations for admitted and refused patients should be performed ideally every 24 hr. At reassessment of patients at days 10–14 or if significant deterioration or lack of improvement in the patient’s condition occurs decreasing the patient’s predicted survival to below the current priority group receiving critical care, reallocation of ventilator/ICU bed (following review by triage committee) should be considered. Status/post (S/P) cardiac arrest refers to patients with a recent cardiac arrest or one leading to significant anoxic brain damage.