Resource Allocation

 

 

 

OHPIP Triage Protocol for an Influenza Pandemic [1]:

  • The Ontario Health Plan for an Influenza Pandemic (OHPIP) protocol is intended to provide guidance for making triage decisions during the initial days to weeks of an influenza pandemic if the critical care system becomes overwhelmed

    • The triage protocol has 4 main components:

      • inclusion criteria, 

      • exclusion criteria, 

      • minimum qualifications for survival, and 

      • a prioritization tool

    • The protocol uses the Sequential Organ Failure Assessment Score as it was felt to be the most appropriate scoring system for use in a triage protocol given its basis on physiologic parameters, ease of calculation, requirement for simple laboratory tests and its validation for use in patients with a wide variety of conditions requiring critical care. 

    • OHPIP Triage Protocol:

  • OHPIP has been compared to other protocols, such as the New South Wales triage protocol, in its ability to increase ICU bed availability. In a 2012 study, the OHPIP protocol provided the greatest increase in ICU bed availability, with a 52.8% increase at admission and 65% at 120 hours after admission [2]

Fair Allocation of Scarce Medical Resources in the Time of COVID-19 [3]:

  • Recommendations published in The New England Journal of Medicine to help develop guidelines to ensure individual doctors are not tasked with deciding unaided which patients receive life-saving care and which do not.​

    • Recommendation 1: In the context of a pandemic, the value of maximizing benefits is most important. Priority for limited resources should aim both at saving the most lives and at maximizing improvements in individuals’ post-treatment length of life. Saving more lives and more years of life is a consensus value across expert reports.

    • Recommendation 2: Critical Covid-19 interventions — testing, PPE, ICU beds, ventilators, therapeutics, and vaccines — should go first to front-line health care workers and others who care for ill patients and who keep critical infrastructure operating, particularly workers who face a high risk of infection and whose training makes them difficult to replace. If these workers are incapacitated, all patients — not just those with Covid-19 — will suffer greater mortality and years of life lost. 

    • Recommendation 3: For patients with similar prognoses, equality should be invoked and operationalized through random allocation, such as a lottery, rather than a first-come, first-served allocation process. Treatments for coronavirus address urgent need, meaning that a first-come, first-served approach would unfairly benefit patients living nearer to health facilities. 

    • Recommendation 4: Prioritization guidelines should differ by intervention and should respond to changing scientific evidence. Maximizing benefits requires consideration of prognosis, which may mean giving priority to younger patients and those with fewer coexisting conditions, for example. 

    • Recommendation 5: People who participate in research to prove the safety and effectiveness of vaccines and therapeutics should receive some priority for Covid-19 interventions. Their assumption of risk during their participation in research helps future patients, and they should be rewarded for that contribution. 

    • Recommendation 6: There should be no difference in allocating scarce resources between patients with Covid-19 and those with other medical conditions. If the Covid-19 pandemic leads to absolute scarcity, that scarcity will affect all patients, including those with other serious and life-threatening conditions requiring prompt medical attention. 

 

Allocation of Ventilators in a Public Health Disaster [4,5]

  • Adult (ages 18 and up) ventilator allocation guidelines for ventilator triage released by the New York State Department of Health and the New York State Task Force on Life and the Law 

  • Step 1 – Exclusion Criteria: 

    • A patient is screened for exclusion criteria, and if s/he has a medical condition on the exclusion criteria list, the patient is not eligible for ventilator therapy. Instead, a patient receives alternative forms of medical intervention and/or palliative care. 

    • The purpose of applying exclusion criteria is to identify patients with a short life expectancy irrespective of their current acute illness, in order to prioritize patients most likely to survive with ventilator therapy. The medical conditions that qualify as exclusion criteria are limited to those associated with immediate or near-immediate mortality even with aggressive therapy. While selecting medical conditions that qualify as exclusion criteria is challenging, this list makes essential contributions to the goals of efficient ventilator distribution and saving the most lives.

  • Step 2 – Mortality Risk Assessment Using SOFA (Sequential Organ Failure Assessment): 

    • A patient is assessed using SOFA, which may be used as a proxy for mortality risk. A triage officer/committee examines clinical data from Steps 1 and 2 and allocates ventilators according to a patient’s SOFA score. 

    • A clinical scoring system, SOFA, is used to assess a patient’s likelihood of survival. SOFA is simple to use, with few variables or lab parameters, and the calculation of the score is straightforward, which makes SOFA a good tool to provide a consistent, clinical approach to allocate ventilators. A SOFA score adds points based on clinical measures of function in six key organs and systems: lungs, liver, brain, kidneys, blood clotting, and blood pressure. A patient’s SOFA score determines the level of access (high, intermediate, or low) to ventilator therapy. 

  • Step 3 – Time Trials: 

    • Periodic clinical assessments at 48 and 120 hours using SOFA are conducted on a patient who has begun ventilator therapy to evaluate whether s/he continues with the treatment. The decision whether a patient remains on a ventilator is based on his/her SOFA score and the magnitude of change in the SOFA score compared to the results from the previous official clinical assessment.

Utah Pandemic Influenza Hospital and ICU Triage Guidelines

  • Prepared by Utah Hospitals and Health Systems Association for the Utah Department of Health (2009) [6]

  1. OHPIP triage protocol for an Influenza Pandemic [1]                                                              

  2. Fair Allocation of Scarce Medical Resources in the Time of Covid-19 [3]                                

  3. Allocation ventilators in a public health disaster [4,5]                                                             

  4. Utah Pandemic Influenza Hospital and ICU Triage Guidelines                                                 

  5. Additional Resources                                                                                                                 

  6. References

 
 
 
 

●      See also: Utah Pandemic Influenza Hospital and ICU Triage Guidelines for Pediatrics

Additional Resources

  • NHLBI ARDS Network 

  • Critical care capacity in Canada [7]

    • Fowler et al. (2015) conducted a cross-sectional study identifying the number of ICUs and mechanical ventilation and oxygenation capacity across provinces in Canada in 2015. This study illustrates and discusses the substantial variation in capacity to provide critical care among provinces and territories

    • 2101 ventilators capable of invasive ventilation in Ontario and a total of 4982 in Canada

  • Therapeutic and triage strategies for COVID-19 in fever clinics [8]

    • One effective strategy to control the SARS epidemic in China was the establishment of fever clinics for triaging patients. Zhang et al. (2020) have established clinical strategies in adult fever clinics and outline a strategy (flowchart) for the treatment of COVID-19 in fever clinics in Wuhan, China

References

[1] Christian, Michael D., et al. "Development of a triage protocol for critical care during an influenza pandemic." Cmaj 175.11 (2006): 1377-1381.

 

[2] Cheung, Winston K., et al. "A multicentre evaluation of two intensive care unit triage protocols for use in an influenza pandemic." Medical journal of Australia 197.3 (2012): 178-181.

 

[3] Emanuel, Ezekiel J., et al. "Fair allocation of scarce medical resources in the time of Covid-19." (2020).

 

[4] Zucker, Howard A., et al. “Ventilator Allocation Guidelines.” New York State Task Force on Life and the Law New York State Department of Health. (2015): 12-17.

 

[5] Powell, Tia, Kelly C. Christ, and Guthrie S. Birkhead. "Allocation of ventilators in a public health disaster." Disaster Medicine and Public Health Preparedness 2.1 (2008): 20-26.

 

[6] Utah Hospitals and Health Systems Association. “Utah Pandemic Influenza Hospital and ICU Triage Guidelines.” (2009): 4-5. 

 

[7] Fowler, Robert A., et al. "Critical care capacity in Canada: results of a national cross-sectional study." Critical care 19.1 (2015): 133.

 

[8] Zhang, Jinnong, et al. "Therapeutic and triage strategies for 2019 novel coronavirus disease in fever clinics." The Lancet Respiratory Medicine 8.3 (2020): e11-e12.

 
 

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