key: cord-0935213-xwjndrl8
authors: Wunsch, Hannah; Hill, Andrea D.; Bosch, Nicholas; Adhikari, Neill K. J.; Rubenfeld, Gordon; Walkey, Allan; Ferreyro, Bruno L.; Tillmann, Bourke W.; Amaral, Andre C. K. B.; Scales, Damon C.; Fan, Eddy; Cuthbertson, Brian H.; Fowler, Robert A.
title: Comparison of 2 Triage Scoring Guidelines for Allocation of Mechanical Ventilators
date: 2020-12-14
journal: JAMA Netw Open
DOI: 10.1001/jamanetworkopen.2020.29250
sha: 8102ff6f5af60196b38dbb1f4734de0bc219fba3
doc_id: 935213
cord_uid: xwjndrl8

IMPORTANCE: In the current setting of the coronavirus disease 2019 pandemic, there is concern for the possible need for triage criteria for ventilator allocation; to our knowledge, the implications of using specific criteria have never been assessed. OBJECTIVE: To determine which and how many admissions to intensive care units are identified as having the lowest priority for ventilator allocation using 2 distinct sets of proposed triage criteria. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study conducted in spring 2020 used data collected from US hospitals and reported in the Philips eICU Collaborative Research Database. Adult admissions (N = 40 439) to 291 intensive care units from 2014 to 2015 who received mechanical ventilation and were not elective surgery patients were included. EXPOSURES: New York State triage criteria and original triage criteria proposed by White and Lo. MAIN OUTCOMES AND MEASURES: Sequential Organ Failure Assessment (SOFA) scores were calculated for admissions. The proportion of patients who met initial criteria for the lowest level of priority for mechanical ventilation using each set of criteria and their characteristics and outcomes were assessed. Agreement was compared between the 2 sets of triage criteria, recognizing differences in stated criteria aims. RESULTS: Among 40 439 intensive care unit admissions of patients who received mechanical ventilation, the mean (SD) age was 62.6 (16.6) years, 54.9% were male, and the mean (SD) SOFA score was 4.5 (3.7). Using the New York State triage criteria, 8.9% (95% CI, 8.7%-9.2%) were in the lowest priority category; these lowest priority admissions had a mean (SD) age of 62.9 (16.6) years, used a median (interquartile range) of 57.3 (20.1-133.5) ventilator hours each, and had a hospital survival rate of 38.6% (95% CI, 37.0%-40.2%). Using the White and Lo triage criteria, 4.3% (95% CI, 4.1%-4.5%) were in the lowest priority category; these admissions had a mean (SD) age of 68.6 (13.2) years, used a median (interquartile range) of 61.7 (24.3-142.8) ventilator hours each, and had a hospital survival rate of 56.2% (95% CI, 53.8%-58.7%). Only 655 admissions (1.6%) were in the lowest priority category for both guidelines, with the κ statistic for agreement equal to 0.20 (95% CI, 0.18-0.21). CONCLUSIONS AND RELEVANCE: Use of 2 initially proposed ventilator triage guidelines identified approximately 1 in every 10 to 25 admissions as having the lowest priority for ventilator allocation, with little agreement. Clinical assessment of different potential criteria for triage decisions in critically ill populations is important to ensure valid and equitable allocation of resources.

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.

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.

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.

Handling of missing data:

For SOFA components: those missing information were assumed to be normal.

For Care Preferences: admissions with missing values were categorized as "Full Therapy". For patients with more than one care preference specified, the most restrictive preference was used. 

Yellow = lowest priority; Orange = intermediate priority; Red = highest priority. STEP 1: Calculate each patient's priority score using the multi-principle allocation framework. This allocation framework is based primarily on two considerations: 1) saving the most lives; and 2) saving the most life-years. Patients who are more likely to survive with intensive care are prioritized over patients who are less likely to survive with intensive care. Patients who do not have serious comorbid illness are given priority over those who have illnesses that limit their life expectancy. As summarized in Table 1 , the Sequential Organ Failure Assessment (SOFA) score (or an alternate, validated, objective measure of probability of survival to hospital discharge) is used to determine patients' prognoses for hospital survival. In addition, the presence of life-limiting comorbid conditions, as determined by the triage team, is used to characterize patients' longer-term prognosis. 

Ventilator Allocation Guidelines: New York State Task Force on Life and the Law New York State Department of Health

Duration of resuscitation efforts and survival after inhospital cardiac arrest: an observational study

Regional variation in out-of-hospital cardiac arrest incidence and outcome

A Framework for Rationing Ventilators and Critical Care Beds During the COVID 19 Pandemic

Functional trajectories among older persons before and after critical illness