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# 15,129
It is a bit sobering to realize that if I were living in some parts of Northern Italy right now, and had severe COVID-19 respiratory disease, I might not qualify for an ICU bed or a ventilator given my age (66), and moderate comorbidities.
Of course, I'm lucky enough to live in Florida, and probably need not worry about that for another month, maybe longer.Welcome to ventilator triage, a world where medical needs exceed immediately available resources, and very tough decisions have to be made. As a former paramedic, I understand the realities facing us - because in the past - I've had to make similar decisions, albeit not very often, and on a much smaller scale.
We aren't talking about withholding last ditch, heroic treatments from terminal patients, or from those so badly injured where such measures are deemed futile. That happens all the time, in hospitals, ambulances, and hospices across the country.With triage, you are confronted with more potentially-salvageable severely ill or injured patients than you can possibly care for, and you must prioritize who gets treated, and who doesn't. Normally, we think of this occurring in a mass casualty incident, like on a battlefield, at a train wreck, plane crash, or a building collapse, or in a multi-car pile up on the Interstate.
In some hospitals in Italy right now, they have far more critically ill COVID-19 patients than they have ICU beds, ventilators, and trained personnel to care for them. And according to multiple media reports, they are having to decide which patients to treat, and which to allow to die.
The same scenario is likely playing out in Iran, undoubtedly occurred in Wuhan City, China at the height of their epidemic, and will very likely start happening with greater frequency around the world as COVID-19 spreads.The reason behind the `flatten the curve' strategy being adopted by governments around the world is to try to avoid the `Italy scenario', by limiting the number of severely ill cases needing ICU treatment at any given time.
In normal times, ICU beds and ventilators are assigned on first-come-first serve basis. If you are put on a vent, you stay on the vent until you improve, or a decision is made by the patient's doctors and family that improvement is no longer likely.During a pandemic, or other surge event, decisions are far less clear-cut. Deciding who gets a vent, and for how long, becomes an ethical minefield. We've talked about this nightmare scenario many times over the past 14 years, but most recently in Ventilator Shortages And Pandemic Triage.
Different countries will use different criteria for deciding how to prioritize patients, and while many nations are still debating the issue, the UK has apparently adopted a two-pronged approach.The first involves determining a patient's Clinical Frailty Scale (CFS) or score.
NICE (The National Institute for Health and Care Excellence) has published guidelines using the above Frailty score, to help clinicians prioritize COVID-19 patients for critical care treatment.
Admission to critical care
See the critical care admission algorithm.
2.1 Discuss the risks, benefits and possible likely outcomes of the different treatment options with patients, families and carers using decision support tools (where available) so that they can make informed decisions about their treatment wherever possible. See information to support decision making.
2.2 Involve critical care teams in discussions about admission to critical care for a patient where:
- the CFS score suggests the person is less frail (for example the score is less than 5), they are likely to benefit from critical care organ support and they want critical care treatment or
- the CFS score suggests the person is more frail (for example the score is 5 or more), there is uncertainty regarding the likely benefit of critical care organ support, and critical care advice is needed to help the decision about treatment.
Take into account the impact of underlying pathologies, comorbidities and severity of acute illness on the likelihood of critical care treatment achieving the desired outcome.
2.3 Support non-critical care healthcare professionals to discuss treatment plans with patients who would not benefit from critical care treatment or who do not wish to be admitted to critical care.
2.4 Sensitively discuss a possible 'do not attempt cardiopulmonary resuscitation' decision with all adults with capacity and a CFS score suggestive of increased frailty (for example of 5 or more). Include in the discussion:
- the possible benefits of any critical care treatment options
- the possible risks of critical care treatment options
- the possible likely outcomes.
Involve a member of the critical care team if the patient or team needs advice about critical care to make decisions about treatment.
2.5 Ensure healthcare professionals have access to resources to support discussions about treatment plans (see for example decision-making for escalation of treatment and referring for critical care support, and an example decision support form).
2.6 Ensure that when treatment outside critical care is the agreed course of action, patients receive optimal care within the ward.If all of this seems somewhat cold and calculated. It is.
But it beats assigning ICU beds based on non-medical criteria, like how much money someone has, or how `connected' they are (not that I don't expect that will happen).
Personally, if I were in charge, I would put all active 1st responders and HCWs at the top of the list. Then triage the rest. But that's just me.In the months ahead we may see 3 , 4, 5 . . . or even more critically ill patients for every available ventilator. And while I've seen some interesting schemes for maximizing ventilators (such as 4 patients on 1 vent), some people simply aren't going to get the lifesaving treatment they need.
Of course the more staffed and equipped ICU beds we can bring online in the weeks and months ahead, the fewer heartbreaking decisions will have to be made. The longer we can delay the rise of COVID-19 cases, the more lives we can save.In many parts of the world, however, ICU beds are almost non-existent, and prospects for adding more are slim at best. COVID-19 will undoubtedly hit these ill equipped regions the hardest.
While I'm in no hurry to shuffle off this mortal coil, I have to admit that if I'm denied an ICU bed because of an agreed upon, and reasonably fair triage scheme, I'll take some solace in knowing someone with a better shot of survival was given a chance.
And I can live with that.
