Abstract
During the coronavirus disease 2019 pandemic, there may be too few ventilators to meet medical demands. It is unknown how many US states have ventilator allocation guidelines and how these state guidelines compare with one another. To evaluate the number of publicly available US state guidelines for ventilator allocation and the variation in state recommendations for how ventilator allocation decisions should occur and to assess whether unique criteria exist for pediatric patients. This systematic review evaluated publicly available guidelines about ventilator allocation for all states in the US and in the District of Columbia using department of health websites for each state and internet searches. Documents with any discussion of a process to triage mechanical ventilatory support during a public health emergency were screened for inclusion. Articles were excluded if they did not include specific ventilator allocation recommendations, were in draft status, did not include their state department of health, or were not the most up-to-date guideline. All documents were individually assessed and reassessed by 2 independent reviewers from March 30 to April 2 and May 8 to 10, 2020. As of May 10, 2020, 26 states had publicly available ventilator guidelines, and 14 states had pediatric guidelines. Use of the Sequential Organ Failure Assessment score in the initial rank of adult patients was recommended in 15 state guidelines (58%), and assessment of limited life expectancy from underlying conditions or comorbidities was included in 6 state guidelines (23%). Priority was recommended for specific groups in the initial evaluation of patients in 6 states (23%) (ie, Illinois, Maryland, Massachusetts, Michigan, Pennsylvania, and Utah). Many states recommended exclusion criteria in adult (11 of 26 states [42%]) and pediatric (10 of 14 states [71%]) ventilator allocation. Withdrawal of mechanical ventilation from a patient to give to another if a shortage occurs was discussed in 22 of 26 adult guidelines (85%) and 9 of 14 pediatric guidelines (64%). These findings suggest that although allocation guidelines for mechanical ventilatory support are essential in a public health emergency, only 26 US states provided public guidance on how this allocation should occur. Guidelines among states, including adjacent states, varied significantly and could cause inequity in the allocation of mechanical ventilatory support during a public health emergency, such as the coronavirus disease 2019 pandemic.
Highlights
Since the advent of worldwide mechanical ventilator use for patients with polio in the 1950s, ventilators have provided life-saving support to millions of people.[1]
Withdrawal of mechanical ventilation from a patient to give to another if a shortage occurs was discussed in 22 of 26 adult guidelines (85%) and 9 of 14 pediatric guidelines (64%). These findings suggest that allocation guidelines for mechanical ventilatory support are essential in a public health emergency, only 26 US states provided public guidance on how this allocation should occur
In this systematic review of publicly available US state guidelines about ventilator allocation, only 26 states provided guidance on how this allocation should occur, and their guidelines varied significantly. Meaning These findings suggest significant variation in US state ventilator guidelines, which could cause inequity in allocation of mechanical ventilatory support during a public health emergency, such as the coronavirus disease 2019 pandemic
Summary
Since the advent of worldwide mechanical ventilator use for patients with polio in the 1950s, ventilators have provided life-saving support to millions of people.[1]. Individual physicians, ethicists, medical societies, and US states have published multiple recommendations regarding how to allocate ventilators in a public health emergency and are largely in consensus that ventilators should be allocated to do the greatest good for the greatest number of people.[3,4,5,6,7,8,9,10,11] it is currently unknown how many US states have translated these ethical standards into practical guidelines for how ventilator support should be allocated during a public health emergency It is unknown how the existing guidelines compare with one another regarding challenging questions, such as the method to rank patients in order of priority; whether it is acceptable to use age, chronic medical conditions, or estimates of remaining life-expectancy in priority scores; and whether it is ethical or legal to withdraw ventilatory therapy from one patient to provide it to another.[12]
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