What happens during a mass disaster when your hospital starts to run out of resources? Perhaps you are running out of beds, or ventilators or blood. Who decides which patient gets the bed? What criteria do they use? Are there guidelines to follow?
Very few jurisdictions have developed clear criteria to guide this process, which leaves individual physicians at risk. Developing consensus on appropriate triage criteria is the first step towards creating local or national guidelines for triage of scarce resources during mass disasters.
In the ideal world, these are criteria that we will never need to use. I firmly believe that we need to exhaust every possible mitigation strategy before considering this type of triage. But it would be short-sighted to ignore this issue, and just hope it never happens. It’s already happened, in numerous places around the world. And using triage guidelines can help us make clearer, more objective, ethical decisions, in order to achieve the best possible outcomes during terrible circumstances.
After a scoping review of the relevant literature (see references below), a colleague and I have developed the following draft guidelines, which we call the TACTIC protocol, based on the available evidence.
————————-TACTIC (draft) Protocol—————————
Triage Allocation CriTeria for Intensive Care
- Crisis standards of care for health facilities should be declared by the provincial or state government.
- Legal protection should be offered by the government for healthcare providers during crisis standards of care.
- Clear triggers for activation of TACTIC protocol are mandatory. All possible mitigation strategies must be attempted before activating TACTIC.
- The utilitarian ethical framework should be used to guide decisions.
- Guidelines should be reviewed by members of the public before the final draft is approved, to ensure transparency and equitable process.
- In the ideal world, this protocol is never activated.
Criteria for ICU admission
(From our scoping review, these criteria were identified in ≥ 50% of the published documents that included criteria)
Inclusion criteria (patient needs at least ONE):
- Patient requires invasive ventilation:
- Refractory hypoxemia (SpO2 <90% on NRB or FiO2 >0.85)
- Refractory hypercarbia (pH < 7.2)
- Clinical evidence of impending respiratory failure
- Patient has fluid-refractory shock requiring vasopressors
Exclusion criteria (patient must have NONE):
- Cardiac arrest
- Not responsive to electrical therapy / standard therapy
- Severe trauma (Revised Trauma Score < 2)
- With inhalational injury
- With both age >60 and >40% BSA
- Metastatic malignancy
- DNR status
- Requires ICU after elective palliative surgery
- End-stage organ failure including:
- NYHA III/IV
- Chronic lung disease with FEV < 25% or PaO2 < 55
- Severe pulmonary hypertension
- MELD > 20
- Severe baseline cognitive impairment
- Severe, irreversible neurologic condition
- Advanced untreatable neuromuscular disease
- Severe irreversible immunocompromise
1.A 3-4 member team must be formed to implement the TACTIC protocol and triage potentially eligible patients.
- Members should not be treating clinicians during the event
- Lead triage officer should be a consultant intensivist
- Potential team members: critical care nurse or physician, respiratory therapist, hospital administrator, ethicist, social worker, community member
2. A retrospective review board should be created to ensure that the triage team is implementing the protocol fairly and ethically. A real-time appeals process is not recommended, as it may decrease efficiency of the triage team and therefore risk patient welfare.
3. General medical care or palliative care options must be available for patients who do not meet critical care criteria
4. All ICU patients should be reassessed for continuing eligibility every 24 – 48 hours. After reassessment, resources may be re-allocated to new patients if the current ICU patient meets any of the following criteria:
- Patient no longer meets inclusion criteria
- Patient meets exclusion criteria
- SOFA score >11 at any time, or is flat or rising since last assessment
- Expectation of prolonged critical care resource need
- Poor response to mechanical ventilation (worsening ventilator parameters over time)
OK, that’s the draft protocol.
My goal is to kickstart this conversation among the medical community and anyone else who is interested. What do you think of this draft? How would you make it better? Do you have a protocol to share? Let’s start debating the issues, finding common ground and developing consensus.
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