Disaster Triage

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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

Key principles

  • 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):

  1. 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
  1. Patient has fluid-refractory shock requiring vasopressors

Exclusion criteria (patient must have NONE):

  1. Cardiac arrest
    1. Unwitnessed
    2. Recurrent
    3. Not responsive to electrical therapy / standard therapy
  2. Severe trauma (Revised Trauma Score < 2)
  3. Burns
    1. With inhalational injury
    2. With both age >60 and >40% BSA
  4. Metastatic malignancy
  5. DNR status
  6. Requires ICU after elective palliative surgery
  7. End-stage organ failure including:
    1. NYHA III/IV
    2. Chronic lung disease with FEV < 25% or PaO2 < 55
    3. Severe pulmonary hypertension
    4. MELD > 20
    5. Severe baseline cognitive impairment
    6. Severe, irreversible neurologic condition
    7. Advanced untreatable neuromuscular disease
    8. Severe irreversible immunocompromise

Process

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:

  1. Patient no longer meets inclusion criteria
  2. Patient meets exclusion criteria
  3. SOFA score >11 at any time, or is flat or rising since last assessment
  4. Expectation of prolonged critical care resource need
  5. 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.

Don’t want to comment?  Take the survey instead, and then get a chance to see how other people have responded.  Take me to the survey!

References:

1. Komaroff AL. Analysis and Reconstruction of the 1918 Pandemic Flu Virus. J Watch Gastroenterol. October 2005. doi:http://dx.doi.org/10.1056/JG200510250000011.

2. Rubinson L, Hick JL, Curtis JR, et al. Definitive care for the critically ill during a disaster: medical resources for surge capacity: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. Chest. 2008;133(5 Suppl):32S – 50S.

3. Devereaux A V, Dichter JR, Christian MD, et al. Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. Chest. 2008;133(5 Suppl):51S – 66S. doi:10.1378/chest.07-2693.

4. Davis V et al. A Failure of Initiative. US House Represent 109th Congr. 2006;2nd Session.

5. Pou A. Ethical and legal challenges in disaster medicine: are you ready? South Med J. 2013;106(1):27-30.

6. State of Louisiana. State of Louisiana v. Anna M. Pou, Affadavit and Arrest Warrant. 2006.

7. Rubinson L, O’Toole T. Critical care during epidemics. Crit Care. 2005;9(4):311-313.

8. Levin D et al. Altered standards of care during an influenza pandemic: Identifying ethical, legal, and practical principles to guide decision making. Disaster Med Public Health Prep. 2009;3(SUPPL.2):S132-S140.

9. Florida Department of Health. Pandemic Influenza: Triage and scarce resource allocation guidelines. 2011.

10. Utah Department of Health. Utah pandemic influenza hospital and ICU triage guidelines. 2009:1-8.

11. Wisconsin Division of Public Health – Hospital Preparedness. Guidelines for the Triage of Patients. 2007;(March):1-4.

12. Powell T et al. Allocation of ventilators in a public health disaster. Disaster Med Public Health Prep. 2008;2(1):20-26.

13. Minnesota Department of Health. Patient care strategies for scarce resource situations. 2013;Version 4. http://www.health.state.mn.us/oep/healthcare.

14. Altevogt B et al. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations:: A Letter Report.; 2009:0-92.

15. Devereaux A V. Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care. Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. Chest. 2008;133(5 Suppl):51S – 66S.

16. Christian MD, Hawryluck L, Wax RS, et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ. 2006;175(11):1377-1381.

17. Hamilton Health Sciences. Adult critical care triage and resource allocation protocol for pandemic influenza. 2009:1-30.

18. Christian M et al. Chapter 7. Critical care triage. Recommendations and standard operating procedures for intensive care unit and hospital preparations for an influenza epidemic or mass disaster. Intensive Care Med. 2010;36 Suppl 1:S55-S64. doi:10.1007/s00134-010-1765-0.

19. Upshur R SP. Stand on guard for thee: ethical considerations in preparedness planning for pandemic influenza: a report of the University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group. Univ Toronto Jt Cent Bioeth. 2005;(November).

20. Gostin LO, Powers M. What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Aff (Millwood). 2006;25:1053-1060. doi:10.1377/hlthaff.25.4.1053.

21. Tai DYH. SARS plague: Duty of care or medical heroism? Ann Acad Med Singapore. 2006;35:374-378.

22. Frolic A et al. Development of a Critical Care Triage Protocol for Pandemic Influenza: Integrating Ethics, Evidence and Effectiveness. 2009;12(4):54-63.

23. Ruderman C, Tracy CS, Bensimon CM, et al. On pandemics and the duty to care: whose duty? who cares? BMC Med Ethics. 2006;7:E5. doi:10.1186/1472-6939-7-5.

24. White DB, Katz MH, Luce JM, Lo B. Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med. 2009;150:132-138.

25. Kohlenberger C, Sprung CL, Danis M, et al. Consensus statement on the triage of critically ill patients. J Am Med Assoc. 1994;271:1200-1203.

26. Tabery J, Mackett CW. Ethics of triage in the event of an influenza pandemic. Disaster Med Public Health Prep. 2008;2:114-118. doi:10.1097/DMP.0b013e31816c408b.

27. Alabama Public Health. Criteria for Mechanical Ventilator Triage Following Proclamation of Mass-Casualty Respiratory Emergency. ESF 8 of the State of Alabama Emergency Operations Plan. Clanton, Alabama. 2012. http://ema.alabama.gov/filelibrary/Alabama_EOP.pdf

28. Sprung, Charles L., et al. Consensus Statement on the Triage of Critically III Patients. JAMA 271.15 (1994): 1200-1203.

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