Intensive care beds: If COVID cases increase, it’s unclear how patients will be prioritized

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Sydney: Around the world, the coronavirus pandemic has strained critical care resources. In some places, including parts of Italy, the United States, Canada and Asia-Pacific, intensive care units have been overwhelmed. Reports from Italy revealed that doctors were crying in the halls of the hospital because of the choices they were going to have to make.

In this regard, Australia has fared relatively well in the pandemic. Initial modeling suggested Australia’s intensive care units would be overwhelmed in April 2020, but successful public health measures prevented it.

COVID vaccines now offer significant protection against hospitalization. But as Australia prepares to open its borders, experts fear that even with 80% of the population vaccinated, hospitals could still be overcrowded and possibly overwhelmed.

This raises the difficult question of how to undertake triage: who gets scarce vital resources when hospitals are overwhelmed, and how are those decisions made?

So far, the governments of Australian states and territories have not answered these questions.

Resource allocation in the event of a crisis

Health systems can increase their capacity in times of crisis. However, a recent study found that while Australia now has enough intensive care beds and ventilators, we lack the trained staff to operate them. If we are overwhelmed by COVID, not all patients who could benefit from it will be treated.

In some countries, governments have published their triage protocols for such scenarios, documents that set out the process and rules that determine which patients receive treatment if hospitals are overwhelmed.

Most triage protocols aim to prioritize those most likely to benefit from an ICU admission.

For example, a province-wide protocol was published in Alberta, Canada. While not yet activated, the Alberta government is educating clinicians on its use as the province faces a devastating fourth wave.

Alberta’s protocol includes a multi-step process for deciding which patients to admit to intensive care when the demand for resources exceeds supply.

In phase 1 (major increase with 90% or more intensive care bed occupancy), people with certain conditions, including severe dementia, advanced cancer, severe burns or at high risk of stroke, are deprioritized.

During phase 2 (large scale augmentation with 95% or more intensive care bed occupancy), other categories of adult patients are not given priority. Pediatric triage is also activated, using similar criteria related to life expectancy and likelihood of survival of a child.

Benefits of transparent triage protocols

When health system resources are overwhelmed, clinicians may be forced to refuse treatment to patients who would otherwise receive it.

This creates a risk of clinicians facing negligence lawsuits, disciplinary action, or even criminal charges.

These legal risks can be reduced through triage protocols, which can provide clinicians with legal defense.

Another advantage of triage protocols is that they can promote transparent and consistent allocation decisions and minimize perceptions of bias.

Lack of transparent protocols

To maximize consistency and fairness, triage protocols should be published by governments, not by individual hospitals.

However, in Australia, government coronavirus triage protocols either do not exist or have not been made public.

Our research revealed a lack of protocols on state and territory government websites. The ACT, Northern Territory, South Australia, Tasmania, Victoria and Western Australia health services websites did not mention a coronavirus triage protocol.

Queensland Health has released a detailed ethics guidance framework, which was later removed from its website in mid-2020, without an official statement or explanation.

New South Wales Health has created a pandemic response framework, which mentions allocation frameworks and tools, but these have not been made public.

Public review

There are good reasons to prepare and publicly disseminate triage protocols before a health crisis.

First, it allows for debate on the ethical basis of decisions.

While there is broad agreement on some principles (for example, that protocols should apply to all patients, not just those with COVID), considerable debate remains on other issues.

Should we favor the youngest? What about those who are vaccinated? If two patients are eligible for a resource, what factors must play the deciding role? Should priority be given to essential workers?

The timely publication of triage protocols allows for public scrutiny of these ethical issues.

Second, the publication of triage protocols before a health crisis helps determine whether a protocol is legal.

There are inherent risks here. A triage protocol could lead to unlawful discrimination on the basis of age or disability, or violate guardianship laws designed to protect vulnerable people.

Transparency, consultation and litigation all play a role in testing legal boundaries. Guidelines in the UK, for example, were updated after legal action was taken. The proposed challenge argued that the guidelines illegally discriminated against people with long-term disabilities by relying too heavily on a frailty assessment tool. The revised guideline clarifies that the tool should not be used in certain groups.

Third, prior release allows for preparation and education. Triage policy and decision making cannot be left at the doorstep of the ICU.

Clinicians and the public need to know what to expect and have the opportunity to understand the need for triage and the basis for decisions made.

What should happen now?

State and territory governments should publish triage protocols (if they have any), and if not, they should develop them, with public consultation.

Governments can easily learn from the experience of other jurisdictions. They can also turn to professional organizations for advice.

While Australia’s health services may not be overwhelmed, the proposed easing of border and quarantine controls is a clear sign that the pressure will intensify in the coming months.

Setting up unimplemented public triage protocols would be a small problem; not having protocols when they are needed could be devastating. (The conversation)

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