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. 2023 Oct 2;6(10):e2336736.
doi: 10.1001/jamanetworkopen.2023.36736.

Simulation of New York City's Ventilator Allocation Guideline During the Spring 2020 COVID-19 Surge

B Corbett Walsh  1   2   3 , Jianan Zhu  4 , Yang Feng  4 , Kenneth A Berkowitz  1   5   6 , Rebecca A Betensky  4 , Mark E Nunnally  7   8 , Deepak R Pradhan  1   7   9
Affiliations

Simulation of New York City's Ventilator Allocation Guideline During the Spring 2020 COVID-19 Surge

B Corbett Walsh et al. JAMA Netw Open. .

Abstract

Importance: The spring 2020 surge of COVID-19 unprecedentedly strained ventilator supply in New York City, with many hospitals nearly exhausting available ventilators and subsequently seriously considering enacting crisis standards of care and implementing New York State Ventilator Allocation Guidelines (NYVAG). However, there is little evidence as to how NYVAG would perform if implemented.

Objectives: To evaluate the performance and potential improvement of NYVAG during a surge of patients with respect to the length of rationing, overall mortality, and worsening health disparities.

Design, setting, and participants: This cohort study included intubated patients in a single health system in New York City from March through July 2020. A total of 20 000 simulations were conducted of ventilator triage (10 000 following NYVAG and 10 000 following a proposed improved NYVAG) during a crisis period, defined as the point at which the prepandemic ventilator supply was 95% utilized.

Exposures: The NYVAG protocol for triage ventilators.

Main outcomes and measures: Comparison of observed survival rates with simulations of scenarios requiring NYVAG ventilator rationing.

Results: The total cohort included 1671 patients; of these, 674 intubated patients (mean [SD] age, 63.7 [13.8] years; 465 male [69.9%]) were included in the crisis period, with 571 (84.7%) testing positive for COVID-19. Simulated ventilator rationing occurred for 163.9 patients over 15.0 days, 44.4% (95% CI, 38.3%-50.0%) of whom would have survived if provided a ventilator while only 34.8% (95% CI, 28.5%-40.0%) of those newly intubated patients receiving a reallocated ventilator survived. While triage categorization at the time of intubation exhibited partial prognostic differentiation, 94.8% of all ventilator rationing occurred after a time trial. Within this subset, 43.1% were intubated for 7 or more days with a favorable SOFA score that had not improved. An estimated 60.6% of these patients would have survived if sustained on a ventilator. Revising triage subcategorization, proposed improved NYVAG, would have improved this alarming ventilator allocation inefficiency (25.3% [95% CI, 22.1%-28.4%] of those selected for ventilator rationing would have survived if provided a ventilator). NYVAG ventilator rationing did not exacerbate existing health disparities.

Conclusions and relevance: In this cohort study of intubated patients experiencing simulated ventilator rationing during the apex of the New York City COVID-19 2020 surge, NYVAG diverted ventilators from patients with a higher chance of survival to those with a lower chance of survival. Future efforts should be focused on triage subcategorization, which improved this triage inefficiency, and ventilator rationing after a time trial, when most ventilator rationing occurred.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Walsh reported grants from Chest Foundation during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. New York State Ventilator Allocation Guidelines (NYVAG) and Improved Guidelines (iNYVAG) Steps 2 and 3
There were 3 gaps in the original NYVAG that were addressed as follows: (1) patients with a SOFA score of 7 on the day of consideration for intubation were categorized as red; (2) individuals with a SOFA score greater than 7 on any assessment after 5 days of mechanical ventilation were ineligible for a ventilator; (3) patients ventilated for 7 or more days who continued to have a SOFA score ≤7 and decreasing were placed in the yellow category. The improvements to the NYVAG model made by iNYVAG included subcategorization of the blue category into 3 groups (Blue1-Blue3) to incorporate the acuity of illness on the day of evaluation. NA indicates not applicable; SOFA, Sequential Organ Failure Assessment.
Figure 2.
Figure 2.. Total Intubated Patients Throughout the Spring 2020 COVID-19 Surge in a Single New York City Hospital System
The red shading represents the crisis standards of care as they occurred in the simulation model; yellow, contingency standards of care; green, conventional standards of care. The health system had approximately 48 medical intensive care unit (MICU) beds without expansion prior to the pandemic. The New York Ventilator Allocation Guidelines (NYVAG) simulation represents the total number of intubated patients on any day.
Figure 3.
Figure 3.. Triage and Rationing of Intubated Patients by NYVAG During the Crisis Period
See this image and copyright information in PMC

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