Abstract
BackgroundThe COVID-19 pandemic has placed sustained demand on health systems globally, and the capacity to provide critical care has been overwhelmed in some jurisdictions. It is unknown which triage criteria for allocation of resources perform best to inform health system decision-making. We sought to summarize and describe existing triage tools and ethical frameworks to aid healthcare decision-making during infectious disease outbreaks.MethodsWe conducted a rapid review of triage criteria and ethical frameworks for the allocation of critical care resources during epidemics and pandemics. We searched Medline, EMBASE, and SCOPUS from inception to November 3, 2020. Full-text screening and data abstraction were conducted independently and in duplicate by three reviewers. Articles were included if they were primary research, an adult critical care setting, and the framework described was related to an infectious disease outbreak. We summarized each triage tool and ethical guidelines or framework including their elements and operating characteristics using descriptive statistics. We assessed the quality of each article with applicable checklists tailored to each study design.ResultsFrom 11,539 unique citations, 697 full-text articles were reviewed and 83 articles were included. Fifty-nine described critical care triage protocols and 25 described ethical frameworks. Of these, four articles described both a protocol and ethical framework. Sixty articles described 52 unique triage criteria (29 algorithm-based, 23 point-based). Few algorithmic- or point-based triage protocols were good predictors of mortality with AUCs ranging from 0.51 (PMEWS) to 0.85 (admitting SOFA > 11). Most published triage protocols included the substantive values of duty to provide care, equity, stewardship and trust, and the procedural value of reason.ConclusionsThis review summarizes available triage protocols and ethical guidelines to provide decision-makers with data to help select and tailor triage tools. Given the uncertainty about how the COVID-19 pandemic will progress and any future pandemics, jurisdictions should prepare by selecting and adapting a triage tool that works best for their circumstances.
Highlights
The COVID-19 pandemic has placed sustained demand on health systems globally, and the capacity to provide critical care has been overwhelmed in some jurisdictions
Viral infections caused by influenza or coronavirus may lead to organ failure, including respiratory illness, which can progress to hypoxemic respiratory failure and the acute respiratory distress syndrome, requiring admission to an intensive care unit (ICU) [5]
In light of the ongoing COVID-19 pandemic, we conducted a rapid review of the published triage literature to evaluate the validity of published triage protocols and the mortality prediction embedded within them to help inform health system-decisionmaking
Summary
The COVID-19 pandemic has placed sustained demand on health systems globally, and the capacity to provide critical care has been overwhelmed in some jurisdictions. It is unknown which triage criteria for allocation of resources perform best to inform health system decision-making. It is essential that hospitals have a strategy to ensure equitable and ethical resource allocation if the demand for ICU resources exceeds supply [11] One such strategy is a triage protocol, which is a set of criteria that are enacted during resource scarcity to determine which patients should be admitted to an ICU or continue to receive care in an ICU. In light of the ongoing COVID-19 pandemic, we conducted a rapid review of the published triage literature to evaluate the validity of published triage protocols and the mortality prediction embedded within them to help inform health system-decisionmaking
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