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Adult ICU Triage During the Coronavirus Disease 2019 Pandemic: Who Will Live and Who Will Die? Recommendations to Improve Survival.

ABSTRACT: OBJECTIVES:Coronavirus disease 2019 patients are currently overwhelming the world's healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions. DATA SOURCES:PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies. STUDY SELECTION:Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email. DATA EXTRACTION:References and data were based on relevance and author consensus. DATA SYNTHESIS:We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. "First come, first served" is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients. CONCLUSIONS:Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.

SUBMITTER: Sprung CL

PROVIDER: S-EPMC7217126 | biostudies-literature | 2020 May

REPOSITORIES: biostudies-literature

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Project description:ObjectivesGiven finite ICU bed capacity, knowledge of ICU bed utilization during the coronavirus disease 2019 pandemic is critical to ensure future strategies for resource allocation and utilization. We sought to examine ICU census trends in relation to ICU bed capacity during the rapid increase in severe coronavirus disease 2019 cases early during the pandemic.DesignObservational cohort study.SettingThirteen geographically dispersed academic medical centers in the United States.Patients/subjectsWe obtained daily ICU censuses from March 26 to June 30, 2020, as well as prepandemic ICU bed capacities. The primary outcome was daily census of ICU patients stratified by coronavirus disease 2019 and mechanical ventilation status in relation to ICU capacity.InterventionsNone.Measurements and main resultsPrepandemic overall ICU capacity ranged from 62 to 225 beds (median 109). During the study period, the median daily coronavirus disease 2019 ICU census per hospital ranged from 1 to 84 patients, and the daily ICU census exceeded overall ICU capacity for at least 1 day at five institutions. The number of critically ill patients exceeded ICU capacity for a median (interquartile range) of 17 (12-50) of 97 days at these five sites. All 13 institutions experienced decreases in their noncoronavirus disease ICU population, whereas local coronavirus disease 2019 cases increased. Coronavirus disease 2019 patients reached their greatest proportion of ICU capacity on April 12, 2020, when they accounted for 44% of ICU patients across all participating hospitals. Maximum ICU census ranged from 52% to 289% of overall ICU capacity, with three sites less than 80%, four sites 80-100%, five sites 100-128%, and one site 289%.ConclusionsFrom March to June 2020, the coronavirus disease 2019 pandemic led to ICU censuses greater than ICU bed capacity at fives of 13 institutions evaluated. These findings demonstrate the short-term adaptability of U.S. healthcare institutions in redirecting limited resources to accommodate a public health emergency.

Project description:ObjectivesTo describe the impact of coronavirus disease 2019 on family engagement among ICUs participating in a multicenter collaborative promoting implementation of family-centered care projects and to report sites' experiences with the collaborative itself prior to its cancelation due to the pandemic in March 2020.DesignCross-sectional survey.SettingTwenty-seven academic and community ICUs in the United States and South Korea.SubjectsSite leaders.InterventionsPrior to March 2020, all sites had participated in 6 months of webinars, monthly calls, and listserv communication to facilitate projects and to collect preimplementation family satisfaction and clinician perception data.Measurements and main resultsPlanned projects included ICU orientation initiatives (12, 44.4%), structured family care conferences (6, 22.2%), and ICU diaries (5, 18.5%). After cancelation of the collaborative, 22 site leaders (81.5%) were surveyed by phone from June 2020 to July 2020. Twenty (90.1%) reported having stopped their site project; projects that continued were 1) a standardized palliative extubation protocol and 2) daily written clinical summaries for families. Sites described significant variability in visitor restriction policies and uncertainty regarding future policy changes. Four sites (18.2%) reported that their hospital did not provide personal protective equipment to visitors. Regarding video conferencing with families, 11 sites (52.4%) reported clinicians' using their own personal devices. Two-hundred twelve family surveys and 346 clinician surveys collected prior to cancelation highlighted a broad need for family support. When leaders were asked on a scale from 0 to 10 how helpful collaborative activities had been prior to cancelation, mean response was 8.0 (sd 2.5).ConclusionsWhile the collaborative model can help promote ICU family engagement initiatives, coronavirus disease 2019 has impeded implementation of these initiatives even among motivated units. ICUs need adequate personal protective equipment for visitors and video conferencing capabilities on hospital devices while strict visitor restrictions continue to evolve.

Project description:To create evidence-based consensus statements for restricted ICU visitation policies to support critically ill patients, families, and healthcare professionals during current and future pandemics.DesignThree rounds of a remote modified Delphi consensus process.SettingOnline survey and virtual polling from February 2, 2021, to April 8, 2021.SubjectsStakeholders (patients, families, clinicians, researchers, allied health professionals, decision-makers) admitted to or working in Canadian ICUs during the coronavirus disease 2019 pandemic.Measurements and main resultsDuring Round 1, key stakeholders used a 9-point Likert scale to rate experiences (1-not significant, 9-significant impact on patients, families, healthcare professionals, or patient- and family-centered care) and strategies (1-not essential, 9-essential recommendation for inclusion in the development of restricted visitation policies) and used a free-text box to capture experiences/strategies we may have missed. Consensus was achieved if the median score was 7-9 or 1-3. During Round 2, participants used a 9-point Likert scale to re-rate experiences/strategies that did not meet consensus during Round 1 (median score of 4-6) and rate new items identified in Round 1. During Rounds 2 and 3, participants ranked items that reached consensus by order of importance (relative to other related items and experiences) using a weighted ranking system (0-100 points). Participants prioritized 11 experiences (e.g., variability of family's comfort with technology, healthcare professional moral distress) and developed 21 consensus statements (e.g., communicate policy changes to the hospital staff before the public, permit visitors at end-of-life regardless of coronavirus disease 2019 status, creating a clear definition for end-of-life) regarding restricted visitation policies.ConclusionsWe have formulated evidence-informed consensus statements regarding restricted visitation policies informed by diverse stakeholders, which could enhance patient- and family-centered care during a pandemic.

Project description:The current coronavirus disease 2019 (COVID-19) pneumonia pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is spreading globally at an accelerated rate, with a basic reproduction number (R0) of 2-2.5, indicating that 2-3 persons will be infected from an index patient. A serious public health emergency, it is particularly deadly in vulnerable populations and communities in which healthcare providers are insufficiently prepared to manage the infection. As of March 16, 2020, there are more than 180,000 confirmed cases of COVID-19 worldwide, with more than 7000 related deaths. The SARS-CoV-2 virus has been isolated from asymptomatic individuals, and affected patients continue to be infectious 2 weeks after cessation of symptoms. The substantial morbidity and socioeconomic impact have necessitated drastic measures across all continents, including nationwide lockdowns and border closures. Pregnant women and their fetuses represent a high-risk population during infectious disease outbreaks. To date, the outcomes of 55 pregnant women infected with COVID-19 and 46 neonates have been reported in the literature, with no definite evidence of vertical transmission. Physiological and mechanical changes in pregnancy increase susceptibility to infections in general, particularly when the cardiorespiratory system is affected, and encourage rapid progression to respiratory failure in the gravida. Furthermore, the pregnancy bias toward T-helper 2 (Th2) system dominance, which protects the fetus, leaves the mother vulnerable to viral infections, which are more effectively contained by the Th1 system. These unique challenges mandate an integrated approach to pregnancies affected by SARS-CoV-2. Here we present a review of COVID-19 in pregnancy, bringing together the various factors integral to the understanding of pathophysiology and susceptibility, diagnostic challenges with real-time reverse transcription polymerase chain reaction (RT-PCR) assays, therapeutic controversies, intrauterine transmission, and maternal-fetal complications. We discuss the latest options in antiviral therapy and vaccine development, including the novel use of chloroquine in the management of COVID-19. Fetal surveillance, in view of the predisposition to growth restriction and special considerations during labor and delivery, is addressed. In addition, we focus on keeping frontline obstetric care providers safe while continuing to provide essential services. Our clinical service model is built around the principles of workplace segregation, responsible social distancing, containment of cross-infection to healthcare providers, judicious use of personal protective equipment, and telemedicine. Our aim is to share a framework that can be adopted by tertiary maternity units managing pregnant women in the flux of a pandemic while maintaining the safety of the patient and healthcare provider at its core.

Project description:ImportanceUnderstanding patterns of e-cigarette use and access during the coronavirus disease 2019 (COVID-19) pandemic is important because e-cigarettes may put users at risk for more severe respiratory effects and other health problems.ObjectiveTo examine whether underage youth and young adults who ever used e-cigarettes self-reported changes in access and use of e-cigarettes since the COVID-19 pandemic began.Design, setting, and participantsA national, cross-sectional online survey study was conducted from May 6 to May 14, 2020. This sample of 4351 participants aged 13 to 24 years across the US included 2167 e-cigarette ever-users. Quota sampling was used to balance for age, sex, race/ethnicity, and 50% having ever used e-cigarettes.Main outcomes and measuresChange in e-cigarette use (increase, decrease, quit, no change, and switch to another product) and access to e-cigarettes (easier or harder, and change in point-of-purchase) before and after the COVID-19 pandemic began, reasons for change, number of times e-cigarettes were used, nicotine dependence, and sociodemographic data.ResultsThis study focused on 2167 e-cigarette ever-users among 4351 participants who completed the survey. Among 2167 e-cigarette users, a total of 1442 were younger than 21 years and 725 were aged 21 years or older; 1397 were female (64.5%) and 438 identified as lesbian, gay, bisexual, transgender, queer (20.2%). The survey completion rate was 40%. Since the COVID-19 pandemic began, 1198 of 2125 e-cigarette users (56.4%) changed their use: 388 individuals (32.4%) quit, 422 individuals (35.3%) reduced the amount of nicotine, 211 individuals (17.6%) increased nicotine use, 94 individuals (7.8%) increased cannabis use, and 82 individuals (6.9%) switched to other products. Participants reported that not being able to go to vape shops and product unavailability were the reasons accessing e-cigarettes was difficult after the pandemic began. Since the COVID-19 pandemic began, individuals reported purchasing from alternative retail stores (disposables, 150 of 632 [23.7%]; pod-based, 144 of 797 [18.1%]; and other e-cigarette, 125 of 560 [22.3%], ie, between 18.1% and 23.7%), purchasing online instead of retail (disposables, 115 of 632 [18.2%]; pod-based, 156 of 797 [19.6%]; and other e-cigarette, 111 of 560 [19.8%], ie, between 18.2% to 19.8%), and shifted to retail instead of online (disposables, 11 of 632 [1.7%]; pod-based, 17 of 797 [2.0%]; and other e-cigarette, 13 of 560 [2.3%], ie, between 1.7%-2.3%). Other individuals reported no change: from retail stores (disposables 262 of 632 [41.5%]; pod-based 344 of 797 [43.2%]; and other e-cigarette, 223 of 560 [39.8%], ie, between 39.8% and 43.2%) and online (disposables 94 of 632 [14.9%]; pod-based 136 of 797 [17.1%]; and other e-cigarette, 88 of 560 [15.8%], ie, between 14.9% and 17.1%). Underage youth reported e-cigarette deliveries from vape shops and/or dealers or friends who received such deliveries, and 63 of 229 (27.5%) self-reported accessing e-cigarettes without age verification. e-Cigarette users were 52% less likely to quit or reduce their use if they previously used e-cigarettes between 11 and 99 times (adjusted odds ratio, 0.48; 95% CI, 0.30-0.78), 68% less likely to quit if they previously used e-cigarettes more than 100 times (adjusted odds ratio, 0.32; 95% CI, 0.20-0.51), and 51% were less likely to quit if they were nicotine dependent (adjusted odds ratio, 0.49; 95% CI, 0.35-0.70).Conclusions and relevanceDuring the COVID-19 pandemic, youth e-cigarette users reported changes in e-cigarette use, point-of-purchase, and ability to purchase e-cigarettes without age verification. The US Food and Drug Administration and local policy makers may find these data useful to inform policies to prevent e-cigarette sales to underage youth.

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Adult ICU Triage During the Coronavirus Disease 2019 Pandemic: Who Will Live and Who Will Die? Recommendations to Improve Survival.

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