Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources
Thomas Leclerc, Nicolas Donat, Alexis Donat, Pierre Pasquier, Nicolas Libert, Elodie Schaeffer, Erwan D'Aranda, Jean Cotte, Bruno Fontaine, Pierre-François Perrigault, Fabrice Michel, Laurent Muller, Eric Meaudre, Benoît Veber, Thomas Leclerc, Nicolas Donat, Alexis Donat, Pierre Pasquier, Nicolas Libert, Elodie Schaeffer, Erwan D'Aranda, Jean Cotte, Bruno Fontaine, Pierre-François Perrigault, Fabrice Michel, Laurent Muller, Eric Meaudre, Benoît Veber
Abstract
Background: Relying on capacity increases and patient transfers to deal with the huge and continuous inflow of COVID-19 critically ill patients is a strategy limited by finite human and logistical resources.
Rationale: Prioritising both critical care initiation and continuation is paramount to save the greatest number of lives. It enables to allocate scarce resources in priority to those with the highest probability of benefiting from them. It is fully ethical provided it relies on objective and widely shared criteria, thus preventing arbitrary decisions and guaranteeing equity. Prioritisation seeks to fairly allocate treatments, maximise saved lives, gain indirect life benefits from prioritising exposed healthcare and similar workers, give priority to those most penalised as a last resort, and apply similar prioritisation schemes to all patients.
Prioritisation strategy: Prioritisation schemes and their criteria are adjusted to the level of resource scarcity: strain (level A) or saturation (level B). Prioritisation yields a four level priority for initiation or continuation of critical care: P1-high priority, P2-intermediate priority, P3-not needed, P4-not appropriate. Prioritisation schemes take into account the patient's wishes, clinical frailty, pre-existing chronic condition, along with severity and evolution of acute condition. Initial priority level must be reassessed, at least after 48h once missing decision elements are available, at the typical turning point in the disease's natural history (ICU days 7 to 10 for COVID-19), and each time resource scarcity levels change. For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount.
Perspective: Prioritisation strategy is bound to evolve with new knowledge and with changes within the epidemiological situation.
Keywords: COVID-19; Critical care; Ethics; Pandemic; Prioritisation; Triage.
Copyright © 2020 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
Figures
References
- Yang X., Yu Y., Xu J., Shu H., Xia J., Liu H. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. Lancet Respir Med. 2020 doi: 10.1016/S2213-2600(20)30079-5.
- Ranney M.L., Griffeth V., Jha A.K. Critical Supply Shortages – The Need for Ventilators and Personal Protective Equipment during the Covid-19 Pandemic. N Engl J Med. 2020 doi: 10.1056/NEJMp2006141. [NEJMp2006141]
- Grasselli G., Pesenti A., Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA. 2020 doi: 10.1001/jama.2020.4031.
- Azoulay E., Beloucif S., Vivien B., Guidet B., Pateron D., Le Dorze M. Regional recommendations - ARS; Ile-de-France: 2020. [Decision to admit patients to Intensive care units in COVID-19 pandemic (in French)] [ (accessed March 31, 2020)]
- Comité consultatif national d’éthique . 2020. Ethical considerations in pandemic (in French) [ (accessed March 31, 2020)]
- Comité d’éthique de la S.F.A.R. 2020. About medical decisions regarding admission of patients to critical care units during pandemic (in French) [ March 31, 2020)]
- Commission d’éthique de la S.R.L.F. 2020. Admission criteria and treatment modalities in intensive care units in pandemic (in French) [ (accessed April 10, 2020)]
- de Montgolfier S., Lamblin A., Leport C. 2020. Operational multidisciplinary guideloines: ethical and strategic considerations regarding access to critical carein COVID-19 pandemic (in French) [ (accessed March 31, 2020)]
- Espace éthique région Ile-de-France . 2020. COVID-19 Ethics and community observatory–Ethical decisional considerations in critical care (in French) []
- Emanuel E.J., Persad G., Upshur R., Thome B., Parker M., Glickman A. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020 doi: 10.1056/NEJMsb2005114.
- Swiss Academy Of Medical Sciences COVID-19 pandemic: triage for intensive-care treatment under resource scarcity. Swiss Med Wkly. 2020;150 doi: 10.4414/smw.2020.20229. [w20229]
- White D.B., Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA. 2020 doi: 10.1001/jama.2020.5046.
- Truog R.D., Mitchell C., Daley G.Q. The Toughest Triage - Allocating Ventilators in a Pandemic. N Engl J Med. 2020 doi: 10.1056/NEJMp2005689.
- Henry B.M. COVID-19, ECMO, and lymphopenia: a word of caution. Lancet Respir Med. 2020 doi: 10.1016/S2213-2600(20)30119-3.
- MacLaren G., Fisher D., Brodie D. Preparing for the Most Critically Ill Patients With COVID-19: The Potential Role of Extracorporeal Membrane Oxygenation. JAMA. 2020 doi: 10.1001/jama.2020.2342.
- Combes A., Cholley B., Lebreton G., Leprince P., Longrois D., Schmidt M. 2020. Proposition de plan d’action du groupe de réflexion sur l’usage de l’ECMO pour les patients COVID + [ (accessed March 31, 2020)]
- Bhatraju P.K., Ghassemieh B.J., Nichols M., Kim R., Jerome K.R., Nalla A.K. Covid-19 in Critically Ill Patients in the Seattle Region – Case Series. N Engl J Med. 2020 doi: 10.1056/NEJMoa2004500.
- Christian M.D., Hawryluck L., Wax R.S., Cook T., Lazar N.M., Herridge M.S. Development of a triage protocol for critical care during an influenza pandemic. CMAJ Can Med Assoc J J Assoc Medicale Can. 2006;175:1377–1381. doi: 10.1503/cmaj.060911.
- Christian M.D., Hamielec C., Lazar N.M., Wax R.S., Griffith L., Herridge M.S. A retrospective cohort pilot study to evaluate a triage tool for use in a pandemic. Crit Care Lond Engl. 2009;13:R170. doi: 10.1186/cc8146.
- Vincent J.L., de Mendonça A., Cantraine F., Moreno R., Takala J., Suter P.M. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26:1793–1800.
- Zhu N., Zhang D., Wang W., Li X., Yang B., Song J. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med. 2020;382:727–733. doi: 10.1056/NEJMoa2001017.
- Stevens P.E., Levin A., Kidney Disease: Improving Global Outcomes Chronic Kidney Disease Guideline Development Work Group Members Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 2013;158:825–830. [10.7326/0003-4819-158-11-201306040-00007]
- Christofides C., Moore R., Nel M. Baux Score as a Predictor of Mortality at the CHBAH Adult Burns Unit. J Surg Res. 2020;251:53–62. doi: 10.1016/j.jss.2020.01.018.
- Rockwood K., Song X., MacKnight C., Bergman H., Hogan D.B., McDowell I. A global clinical measure of fitness and frailty in elderly people. CMAJ Can Med Assoc J J Assoc Medicale Can. 2005;173:489–495. doi: 10.1503/cmaj.050051.
- Guan W., Ni Z., Hu Y., Liang W., Ou C., He J. Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 doi: 10.1056/NEJMoa2002032. [0:null]
- Rosenbaum L. Facing Covid-19 in Italy - Ethics, Logistics, and Therapeutics on the Epidemic's Front Line. N Engl J Med. 2020 doi: 10.1056/NEJMp2005492.
Source: PubMed