Adult ICU Triage During the Coronavirus Disease 2019 Pandemic

Who Will Live and Who Will Die? Recommendations to Improve Survival

Charles L. Sprung, MD, MCCM; Gavin M. Joynt, MBBCh; Michael D. Christian, MD, FCCM; Robert D. Truog, MD; Jordi Rello, MD, PhD; Joseph L. Nates, MD, MBA, CMQ, MCCM

Disclosures

Crit Care Med. 2020;48(8):1196-1202. 

In This Article

Abstract and Introduction

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.

Introduction

Patients with life-threatening illnesses admitted to ICUs have lower mortalities than patients not admitted.[1,2] Despite international variations in ICU services,[3] demand for ICU beds frequently exceeds their supply.[1,2] Whereas resource-driven triage decisions are uncommon in North America, they are more frequent in Europe.[2] During a pandemic or mass disaster medical resources may become desperately inadequate with patients dying because of the lack ventilators or ICU beds as is currently occurring in the coronavirus disease 2019 (COVID-19) pandemic.[4] The present recommendations are based on the joint collaboration of several worldwide clinicians who have been involved in ICU triage during epidemics and other surge conditions for several decades.

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