Allocation Of Critical Care Resources Research Articles

Eliminating Categorical Exclusion Criteria in Crisis Standards of Care Frameworks

During public health crises including the COVID-19 pandemic, resource scarcity and contagion risks may require health systems to shift—to some degree—from a usual clinical ethic, focused on the well-being of individual patients, to a public health ethic, focused on population health. Many triage policies exist that fall under the legal protections afforded by “crisis standards of care,” but they have key differences. We critically appraise one of the most fundamental differences among policies, namely the use of criteria to categorically exclude certain patients from eligibility for otherwise standard medical services. We examine these categorical exclusion criteria from ethical, legal, disability, and implementation perspectives. Focusing our analysis on the most common type of exclusion criteria, which are disease-specific, we conclude that optimal policies for critical care resource allocation and the use of cardiopulmonary resuscitation (CPR) should not use categorical exclusions. We argue that the avoidance of categorical exclusions is often practically feasible, consistent with public health norms, and mitigates discrimination against persons with disabilities.

Ethical considerations in the allocation of critical care resources when capacity is overwhelmed.

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Critical Care Resources in Guangdong Province of China: Three Surveys from 2005 to 2015.

Data about the critical care resources in China remain scarce. The purpose of this study was to investigate the variation and distribution of critical care resources in Guangdong province from 2005 to 2015. Data in regard to critical care resources were collected through questionnaires and visits every 5 years from 2005. All hospitals in Guangdong province were screened and hospitals that provide critical care services were enrolled. None. One hundred eleven, 158, and 284 hospitals that provide critical care services were enrolled in the three consecutive surveys respectively. The number of ICUs, ICU beds, intensivists, and nurses increased to 324, 3,956, 2,470, and 7,695, respectively, by 2015. Adjusted by population, the number of ICU beds per 100,000 (100,000) population increased by 147.7% from 2005 to 2015, and the number of intensivists and nurses per 100,000 population increased by 35.3% and 55.1% from 2011 to 2015. However, the numbers in the Pearl River Delta, a richer area, were higher than those in the non-Pearl River Delta area (ICU beds: 4.64 vs 2.58; intensivists: 2.90 vs 1.61; nurses: 9.30 vs 4.71 in 2015). In terms of staff training, only 17.85% of intensivists and 14.29% of nurses have completed a formal accredited critical care training program by 2015. Our study was the first one to investigate the trend and distribution of critical care resources in China. The quantity of ICU beds and staff has been increasing rapidly, but professional training for staff was inadequate. The distribution of critical care resources was unbalanced. Our study can be beneficial for healthcare policymaking and the allocation of critical care resources in Guangdong province and other provinces in China.

Derivation and validation of a preoperative risk model for postoperative mortality (SAMPE model): An approach to care stratification.

Ascertaining which patients are at highest risk of poor postoperative outcomes could improve care and enhance safety. This study aimed to construct and validate a propensity index for 30-day postoperative mortality. A retrospective cohort study was conducted at Hospital de Clínicas de Porto Alegre, Brazil, over a period of 3 years. A dataset of 13524 patients was used to develop the model and another dataset of 7254 was used to validate it. The primary outcome was 30-day in-hospital mortality. Overall mortality in the development dataset was 2.31% [n = 311; 95% confidence interval: 2.06–2.56%]. Four variables were significantly associated with outcome: age, ASA class, nature of surgery (urgent/emergency vs elective), and surgical severity (major/intermediate/minor). The index with this set of variables to predict mortality in the validation sample (n = 7253) gave an AUROC = 0.9137, 85.2% sensitivity, and 81.7% specificity. This sensitivity cut-off yielded four classes of death probability: class I, <2%; class II, 2–5%; class III, 5–10%; class IV, >10%. Model application showed that, amongst patients in risk class IV, the odds of death were approximately fivefold higher (odds ratio 5.43, 95% confidence interval: 2.82–10.46) in those admitted to intensive care after a period on the regular ward than in those sent to the intensive care unit directly after surgery. The SAMPE (Anaesthesia and Perioperative Medicine Service) model accurately predicted 30-day postoperative mortality. This model allows identification of high-risk patients and could be used as a practical tool for care stratification and rational postoperative allocation of critical care resources.

P002: Ten patients, one ventilator: how to best allocate critical care resources during mass disaster

Introduction: Any large-scale disaster may place a hospital system in a precarious position. Planning is fundamental to facilitate an equitable process for allocating scarce critical care resources, yet there is a paucity of literature guiding protocol development, and few Canadian hospitals have done this planning. We performed a scoping review of the available literature, and used this data to develop a hospital-wide policy to guide critical care resource allocation as part of the hospital emergency management planning process. Methods: A primary search of MEDLINE (1946-2015), EMBASE (1980-2015), Disaster Lit (2002-2010) and Pubmed focusing on a priori criteria was completed. A secondary search of the grey literature served to increase sensitivity and rigor. Two independent reviewers manually reviewed the citations, and selected eligible abstracts for full-text. Qualitative thematic analysis was undertaken of the selected articles. The results then informed the development of a hospital-wide policy and protocol to guide critical care resource allocation. Results: The search identified 832 citations; 134 papers were reviewed and 11 selected for qualitative analysis. All included papers were expert opinion and reviews. All suggested that an ethical framework be used; eight discussed this in detail. Ten recommended allocating a triage team to implement the protocol. Nine papers recommended specific resource allocation protocols with inclusion/exclusion criteria, physiologic scores, and reassessment at varying time intervals (12-120 hours). Conclusion: Effective planning, prior to a disaster, is critical to saving as many lives as possible. Based on our scoping review, we have developed a hospital-wide protocol that incorporates ethical principles and clear inclusion and exclusion criteria, to help avoid inequity and promote transparent decision-making. Next steps include a public consultation process and review, prior to implementation testing and educational roll-out.

Evidence Based Pediatric Outcome Predictors to Guide the Allocation of Critical Care Resources in a Mass Casualty Event

Evidence Based Pediatric Outcome Predictors to Guide the Allocation of Critical Care Resources in a Mass Casualty Event

Epidemiology of admissions to 11 stand-alone high-dependency care units in the UK.

High-dependency care units (HDUs) are a focus of research to optimize critical care resource allocation. HDUs provide a level of care between the general ward and the intensive care unit (ICU). However, few data report on the case mix and outcomes of patients in these units. Retrospective observational cohort study of patients admitted to 11 stand-alone HDUs in the UK from 2008 to 2011. We stratified patients by location prior to HDU admission and location on discharge from HDU, and we summarized the case mix, transitions of care, and mortality. Of 9008 patients admitted to 11 stand-alone HDUs, 56.5% were male and the mean age was 62.7 ± 17.9 years. The majority of patients admitted to HDUs were non-surgical (59.3%), with 22.4 and 20.1% admitted from the ICU and general ward, respectively; 41.3% were admitted from the operating room or recovery suite. The median length of stay in HDU was 1.8 days (IQR 0.9-3.5) and in-HDU mortality was 5.1%. Among HDU survivors (n = 8551), 8.5% were discharged to an ICU, 80.9% to a general ward, and 10.6% to other care areas. For patients admitted to HDU from an ICU, only 5.8% were readmitted to ICU. Hospital mortality for the HDU population was 14.8%; for patients discharged to an ICU, hospital mortality was 43.6%. In a sample of 11 stand-alone HDUs in the UK, patients are from many different hospital locations. Hospital mortality for patients requiring HDU care is high, particularly for patients who require transfer to an ICU.

Evidence-Based Pediatric Outcome Predictors to Guide the Allocation of Critical Care Resources in a Mass Casualty Event.

ICU resources may be overwhelmed by a mass casualty event, triggering a conversion to Crisis Standards of Care in which critical care support is diverted away from patients least likely to benefit, with the goal of improving population survival. We aimed to devise a Crisis Standards of Care triage allocation scheme specifically for children. A triage scheme is proposed in which patients would be divided into those requiring mechanical ventilation at PICU presentation and those not, and then each group would be evaluated for probability of death and for predicted duration of resource consumption, specifically, duration of PICU length of stay and mechanical ventilation. Children will be excluded from PICU admission if their mortality or resource utilization is predicted to exceed predetermined levels ("high risk"), or if they have a low likelihood of requiring ICU support ("low risk"). Children entered into the Virtual PICU Performance Systems database were employed to develop prediction equations to assign children to the exclusion categories using logistic and linear regression. Machine Learning provided an alternative strategy to develop a triage scheme independent from this process. One hundred ten American PICUs : One hundred fifty thousand records from the Virtual PICU database. None. The prediction equations for probability of death had an area under the receiver operating characteristic curve more than 0.87. The prediction equation for belonging to the low-risk category had lower discrimination. R for the prediction equations for PICU length of stay and days of mechanical ventilation ranged from 0.10 to 0.18. Machine learning recommended initially dividing children into those mechanically ventilated versus those not and had strong predictive power for mortality, thus independently verifying the triage sequence and broadly verifying the algorithm. An evidence-based predictive tool for children is presented to guide resource allocation during Crisis Standards of Care, potentially improving population outcomes by selecting patients likely to benefit from short-duration ICU interventions.

Pediatric triage and allocation of critical care resources during disaster: Northwest provider opinion.

Following Hurricane Katrina and the 2009 H1N1 epidemic, pediatric critical care clinicians recognized the urgent need for a standardized pediatric triage/allocation system. This study collected regional provider opinion on issues of care allocation and pediatric triage in a disaster/pandemic setting. This study was a cross-sectional survey of United States (US) health care providers and public health workers who demonstrated interest in critical care and/or disaster care medicine by attending a Northwest regional pediatric critical care symposium on disaster preparation, held in 2012 at Seattle Children's Hospital in Seattle, Washington (USA). The survey employed an electronic audience response system and included demographic, ethical, and logistical questions. Differences in opinions between respondents grouped by professions and work locations were evaluated using a chi-square test. One hundred and twelve (97%) of 116 total attendees responded to at least one question; however, four of these responders failed to answer every question. Sixty-two (55%) responders were nurses, 29 (26%) physicians, and 21 (19%) other occupations. Fifty-five (51%) responders worked in pediatric hospitals vs 53 (49%) in other locations. Sixty-three (58%) of 108 successful responses prioritized children predicted to have a good neuro-cognitive outcome. Seventy-one (68%) agreed that no pediatric age group should be prioritized. Twenty-two (43%) of providers working in non-pediatric hospital locations preferred a triage system based on an objective score alone vs 14 (26%) of those in pediatric hospitals (P = .038).

Evaluating Outcomes and Costs in Perioperative Care

Evaluating Outcomes and Costs in Perioperative Care

Critical care resource allocation: trying to PREEDICCT outcomes without a crystal ball

Despite pandemic influenza's long reign atop the list of potential medical catastrophes, the first protocol designed to support critical care triage in a pandemic was published only in 2006. InFACT (the International Forum of Acute Care Trialists) was formed in 2009 and provided a platform for international critical care research collaboration during the 2009-2010 Influenza A(H1N1) pandemic. Over the past 2 years, a number of working groups have emerged from InFACT focused upon improving the investigation and care of patients with severe respiratory illness. Arising from these efforts, in June of 2012, an international group of clinicians convened the first meeting of the PREEDICCT (Providing Resources for Effective and Ethical Decisions In Critical Care Triage) study group. The group's aim is to develop decision support tools appropriate for use in triaging critically ill adult patients during epidemics, mass-casualty scenarios or other resource limited settings. This meeting identified a number of knowledge gaps and research priorities in this area, and suggested a revised framework for the requirements of an adequate triage decision support tool.

What factors affect mortality after surgery?

For decades, researchers have used mortality as an objective outcome measure in medicine. The difference in mortality after surgery between countries, hospitals, and surgeons is of interest to all parties, including patients, health-care providers and payers, and governments. In The Lancet, Rupert Pearse and colleagues1 present results of a large prospective analysis measuring national in-hospital mortality and investigating allocation of critical care resources. The study was done during 7 days in April, 2011, during which almost 50 000 surgical patients were enrolled from nearly 500 hospitals in 28 European countries.

Centralized Triage for Multiple Intensive Care Units: The Central Intensivist Physician

Subspecialization of critical care units and overall increasing demand for critical care services has led to inefficiencies in allocation of critical care resources with potential impacts on hospital economics and patient outcomes. Centralized management of critical care resource allocation within an institution may improve use while simultaneously ensuring quality of patient care. The authors' institution has implemented a Central Intensivist Physician (CIP) program to oversee resource allocation within the adult surgical intensive care units (ICUs). The result has been an improvement in patient flow throughout the surgical ICUs manifested by steady case cancellation rates despite increasing acuity and length of stay. Additionally, triage duties have been shifted from the individual unit physician to the CIP, resulting in improved provider satisfaction from improved continuity of rounds. The authors conclude that the CIP program may improve overall critical care resource use while maintaining unit specialization within a large tertiary care hospital setting.

Roman Catholic norms and the allocation of critical care resources.

Roman Catholic norms and the allocation of critical care resources.

Allocation of critical care resources: Entitlements, responsibilities, and benefits

Determination of allocation of limited critical care resources appears to be an inevitable development. Criteria proposed to assign such limited resources among patients are not defined. It has been argued that allocation of critical care resources could be based on the principals of patient entitlements to health care, responsibilities of the physician to the critically ill patient, and benificence. However, based on an analysis of the philosophical tenants of the Hippocratic Oath, there is little to support the concept of “sin” taxes or patient triage on the basis of judgment on the moral merit of the patient.

Commentary On the allocation of critical care resources

0 AREA of medicine has escaped the rising tide of ethical concerns wrought by our present health care system, particularly those brought about by an increasing commitment on the part of many health care providers to some form of health care rationing. This fact is certainly true for critical care medicine. The very nature of critical care, however, makes it inordinately difficult to objectively address any idea of rationing health care resources. To begin with, the idea of restricting such resources is prima facie antithetical to our understanding of the philosophy and moral principles that undergird the discipline. In addition, the public’s expectations are tied to the traditional Hippocratic patient-centered model of commitment on the part of the clinician, a commitment that has no room for withholding any beneficial resources from a patient in need. Nonetheless, recognition of the ethical dilemmas created by the national belief that health care rationing is inevitable, and their impact on the care of patients and the ethics of the physician-patient relationship are matters of wide public concern. Among these concerns are many serious questions pertaining to rationing of critical care resources that need to be examined at some depth. For example, how can critical care practitioners be equipped to practice moral medicine when they are besieged to practice cost-efficient and profitable medicine? How can the moral dimension of medicine be preserved in a cost-conscious and cost-driven environment? These are not easy questions to respond to in a time of unparalleled structural and economic uncertainty in the delivery of health care.

Respiratory Failure in the Patient with AIDS: Is Critical Care Warranted?

The issue of whether or not the life-sustaining treatments (LST) of critical care is warranted for patients with the acquired immunodeficiency syndrome (AIDS) experiencing acute respiratory failure has been raised. Factors that have contributed to this issue include the AIDS epidemic, the high costs of critical care, limited intensive care resources, high mortality, prolonged suffering, and the effects on caregivers in delivering futile care. This article examines this issue from the ethicality of the decision-making process regarding LST in context with medical futility, patient autonomy, and discussion among patients and caregivers. The allocation of critical care resources for AIDS patients with respiratory failure is analyzed from the viewpoint of distributive justice. The nursing implications of providing critical care to these patients and their families are discussed as well as needed areas of research.

Outcome of self-inflicted gunshot wounds of the brain.

A consecutive series of 67 patients who had sustained self-inflicted gunshot wounds of the brain was reviewed retrospectively to evaluate factors determining outcome. Weapon caliber, site of bullet entry, degree of brain wounding on computerized tomographic scan, and presenting Glasgow Coma Scale (GCS) score were examined. Overall mortality, degree of disability in survivors, and survival time after injury in fatally wounded patients were assessed. Ninety-eight percent of all patients with an initial GCS score of 8 or less died. When the GCS score was more than 8, 91% of patients survived (P less than .0001). Survival rate was significantly increased in patients with injury limited to one lobe of the brain, compared with patients with brain wounds of greater severity demonstrated on computerized tomographic scan (P less than .05), while a missile crossing both vertical anatomic planes of the brain or coming to rest in the posterior fossa was lethal in 100% of cases. Survivors scored relatively well on the Glasgow Outcome Scale. Almost all (98%) fatally injured patients maintained vital functions for a time ample for transportation and evaluation at a major referral center. These findings hold important implications for trauma center and critical care resource allocation as well as organ transplantation programs.

Admitting Cancer Patients to the Intensive Care Unit

The allocation of critical care resources must follow criteria of distributive justice. Because most societies cannot indefinitely expand medical care costs, difficult decisions on the quality and quantity of care that can be rendered to each patient are inevitable. Data on which objective decisions can be based are currently being gathered at many levels. It is reasonable to anticipate that over the next few years regulations will be formulated to decide which patients can be admitted to the ICU. Critical care physicians have the right and obligation to be involved in all aspects of these decision-making processes.