key: cord-0844973-gafukjbw authors: Gal, Dana B.; Char, Danton S. title: Considerations for Triaging Elective Cases in Children With Cardiac Disease in a Time of Crisis date: 2020-04-13 journal: Circulation DOI: 10.1161/circulationaha.120.047087 sha: bc3bf913fc9af58d429a104151e7f8e9fefac738 doc_id: 844973 cord_uid: gafukjbw nan Circulation. 2020;142:824-826. DOI: 10.1161/CIRCULATIONAHA.120.047087 September 1, 2020 consensus. Individual-led decision-making risks being arbitrary and biased. 3 Lack of transparency is erosive to patient trust in physicians and the healthcare system as well as trust among physicians, when it is most needed. Lastly, patients or surrogates must be notified as soon as the decision is made to ration care. Although media alerts and shelter-in-place orders to "flatten the curve" have likely made patients aware of the incipient COVID-19 healthcare resource crisis, direct communication must occur between pediatric heart centers and patients. Such communication provides clear and necessary guidance amid uncertainty. So how should we triage ECs and what methodologies or data would we base recommendations on? Ethical guidance on mass casualty events and catastrophes (for which COVID-19 qualifies) recommends cohorting patients. 4 Depending on available resources, 1 of 2 groups receives priority: patients with the greatest chance of survival requiring the least expenditure of resources; or, if more resources are available, patients with an increasingly urgent threat to life if not cared for and a reasonable chance of being successfully treated. In pediatric cardiology, we argue that both groups should be given triage priority for ECs. The first group comprises cases requiring minimal intervention with maximal benefit and would be the easiest to perform, such as adolescents needing primary prevention implantable cardioverter defibrillator placement. They could have same-day procedures, not consume inpatient resources, and their lives would be protected. The second group comprises children at high risk of deterioration-those outgrowing shunts or in heart failure from treatable overcirculation, who would require significant intervention (ie, operating room time and intensive care unit beds) but have maximal chance of a successful outcome. If resources allow, these patients warrant being scheduled despite their anticipated resource demand because they can be successfully treated and, if left untreated, they would progressively worsen, possibly consume even more resources through late urgent or emergent surgery, and would have worse morbidity and mortality overall. Existing lesion severity scoring can help in identifying patients in this second group and triaging ECs for them. Depending on resource constraint, some infants with ductal-dependent lesions stable on prostaglandin may need to be considered in this EC group rather than as urgent procedures but could be discharged after recovering from procedural intervention. A third group will also exist and be the most ethically challenging to triage. These are patients for whom intervention cannot guarantee a successful outcome and the likelihood of morbidity requiring ongoing healthcare resources is high. Risk scores provide some guidance in identifying these patients, but clinical acumen will be equally valuable. Recognizing that cardiac ECs are competing for procedural space with ECs from other clinical areas (eg, oncology, neurosurgery), expanded collaboration is needed between heart centers nationwide. COVID-19 will impact regions differently in both timing and severity. Heart centers in certain regions may have more availability to perform ECs than others, and transferring patients between centers may reduce delays in needed care. Further complicating considerations of pediatric cardiac resources is the growing concern that extracorporeal membrane oxygenation may play a rescue role in COVID-19 treatment and evidence of emerging cardiac-specific complications of COVID-19, including myocarditis. 5 Although not ECs themselves, patients requiring extracorporeal membrane oxygenation will place significant demand on resources available for ECs. The prognosis with extracorporeal membrane oxygenation will need to be considered against the needs of waiting EC patients. Implementing cohorting and triage of ECs will require each heart center to form a committee of community members (clinicians, ethicists, and patient advocates) to undertake these tasks. Debates and uncertainties around prognoses are inevitable but must be resolved through combining established rationing and triage approaches with understanding of local patient populations and resource availability. At the national level, dialogue between these committees is also needed to provide additional perspective on triage decisions and assess national resources. The prospect of rationing access to procedures in the face of a pandemic is daunting, especially when ECs in children with cardiac disease are not elective but lifesaving. Using these established approaches of creating triage committees, establishing regional awareness of resources, and drawing on published rationing guidance will maximize the number of children with cardiac disease who can receive needed treatment, minimize the emotional toll of postponing procedures on families and clinicians, and protect individual bedside providers from accusations of misconduct during a time of crisis. 3 We have been fortunate in the United States to avoid significant triaging and rationing in the past. To avoid a battlefield scenario of the decision burden falling on a lone triage officer, we must consider our triage and rationing approach to ECs now, before the full force of the pandemic hits. 4 Like battlefield medicine, needs will exceed resources with the COVID-19 pandemic. We must be prepared to execute triage decisions ethically, using an agreed-on and transparent approach, supported by consensus opinion. Email dbgal@ stanford.edu Affiliations Division of Pediatric Cardiology, Department of Pediatrics COVID-19: Guidance for Triage of Non-Emergent Surgical Procedures Definitions of terms of the Society of Thoracic Surgeons National Cardiac Surgery Database Resolving ethical Dilemmas: A guide for clinicians. 6 th Edition. Lippincott Williams & Wilkins The dynamics and ethics of triage: rationing care in hard times Cardiovascular considerations for patients, health care workers, and health systems during the COVID-19 pandemic None.