Triage Procedures for Critical Care Resource Allocation During Scarcity

Abstract

Importance: During 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.

Objective: To analyze the role of comorbidities and long-term prognosis in state triage procedures.

Design, setting, and participants: This 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 measures: Prevalence and contents of lists of comorbidities and their stated function in triage and instructions to predict duration of postdischarge survival.

Results: Overall, 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 relevance: In 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.

Figure 1.. Identifying States’ Written Triage Procedures

Internet searches for states’ pandemic preparedness plans were conducted; eligible documents were accessed through state government websites or had documentation of state government endorsement. Policies were excluded from analysis if they offered only general ethical guidance and did not contain written triage procedures. Overall, 32 states had publicly available, state-endorsed written triage procedures.

Figure 2.. States Factoring Comorbidities and Postdischarge Prognosis Into Triage

In state triage procedures, lists of conditions played different functions. Eleven states’ triage protocols excluded patients with particular comorbidities (exclusion criteria). Eight states deprioritized patients with particular comorbidities during triage (deprioritization criteria); 1 state listed particular conditions to be considered as a tiebreaker, if more than 1 patient received the same triage score. Kansas, an exclusion state, also included a list of deprioritizing conditions in its Chronic Advanced Organ Dysfunction Score, a component of triage score assignment. Twelve states had written triage procedures that did not list comorbidities that would restrict patients’ access to critical care. Twenty-one states’ written triage procedures incorporated postdischarge prognosis into triage. Twenty jurisdictions, among them Puerto Rico and the District of Columbia, either did not issue pandemic preparedness plans or their plans lacked written triage procedures.

Figure 3.. Prognostic Horizons in Triage

Of the 32 state policies analyzed, most (21) called on triage officers to prognosticate survival beyond hospital discharge. Of these, 15 states called for prognostication to certain end points (6-month, 1-year, 2-year, 5-year). Six incorporated a prognostic assessment using only qualitative terms (near-term, short-term, long-term). Oklahoma and Montana instructed triage officers to consider long-term survival, specifying 10-year survival for the subset of patients with malignant neoplasm.