Scarce Critical Care Resources Research Articles

The role of healthcare providers and caregivers in monitoring critically ill children: a qualitative study in a tertiary hospital, southern Malawi

BackgroundCritically ill children require close monitoring to facilitate timely interventions throughout their hospitalisation. In low- and middle-income countries with a high disease burden, scarce paediatric critical care resources complicates effective monitoring. This study describes the monitoring practices for critically ill children in a paediatric high-dependency unit (HDU) in Malawi and examines factors affecting this vital process.MethodsA formative qualitative study based on 21 in-depth interviews of healthcare providers (n = 12) and caregivers of critically ill children (n = 9) in the HDU along with structured observations of the monitoring process. Interviews were transcribed and translated for thematic content analysis.ResultsThe monitoring of critically ill children admitted to the HDU was intermittent, using devices and through clinical observations. Healthcare providers prioritised the most critically ill children for more frequent monitoring. The ward layout, power outages, lack of human resources and limited familiarity with available monitoring devices, affected monitoring. Caregivers, who were present throughout admission, were involved informally in monitoring and flagging possible deterioration of their child to the healthcare staff.ConclusionBarriers to the monitoring of critically ill children in the HDU were related to ward layout and infrastructure, availability of accurate monitoring devices and limited human resources. Potential interventions include training healthcare providers to prioritise the most critically ill children, allocate and effectively employ available devices, and supporting caregivers to play a more formal role in escalation.

Behind the Scenes: Facilitators and Barriers to Developing State Scarce Resource Allocation Plans for the COVID-19 Pandemic

In response to COVID-19, many states revised, developed, or attempted to develop plans to allocate scarce critical care resources in the event crisis standards of care were triggered. No prior analysis has assessed this plan development process, including whether plans were successfully adopted. How did states develop or revise scarce resource allocation plans during the COVID-19 pandemic and what were the barriers and facilitators to their development and adoption at the state level? Plan authors and state leaders completed a semi-structured interview February to September 2022. Interview transcripts were qualitatively analyzed for themes related to plan development and adoption according to the principles of grounded theory. Thirty-six participants from 34 states completed an interview, from states distributed across all U.S. regions. Among participants' states with plans that existed prior to 2020 (n=24), 17 were revised and adopted in response to COVID-19. Six states wrote a plan de novo, with the remaining states failing to develop or adopt a plan. Thirteen states continued to revise their plans in response to disability or aging bias complaints or to respond to evolving needs. Many participants expressed that urgency in the early days of the pandemic prevented an ideal development process. Facilitators of successful plan development and adoption include: coordination or support from the state department of health and existing relationships with key community partners, including aging and disability rights groups and minoritized communities. Barriers include: lack of perceived political interest in a plan and development during a public health emergency. To avoid repeating mistakes from the early days of the COVID response, states should develop or revise plans with community engagement and consider maintaining a standing committee with diverse membership and content expertise to periodically review plans and advise state officials on pandemic preparedness.

Triage Procedures for Critical Care Resource Allocation During Scarcity

During the COVID-19 pandemic, many US states issued or revised pandemic preparedness plans guiding allocation of critical care resources during crises. State plans vary in the factors used to triage patients and have faced criticism from advocacy groups due to the potential for discrimination. To analyze the role of comorbidities and long-term prognosis in state triage procedures. This cross-sectional study used data gathered from parallel internet searches for state-endorsed pandemic preparedness plans for the 50 US states, District of Columbia, and Puerto Rico (hereafter referred to as states), which were conducted between November 25, 2021, and June 16, 2023. Plans available on June 16, 2023, that provided step-by-step instructions for triaging critically ill patients were categorized for use of comorbidities and prognostication. Prevalence and contents of lists of comorbidities and their stated function in triage and instructions to predict duration of postdischarge survival. Overall, 32 state-promulgated pandemic preparedness plans included triage procedures specific enough to guide triage in clinical practice. Twenty of these (63%) included lists of comorbidities that excluded (11 of 20 [55%]) or deprioritized (8 of 20 [40%]) patients during triage; one state's list was formulated to resolve ties between patients with equal triage scores. Most states with triage procedures (21 of 32 [66%]) considered predicted survival beyond hospital discharge. These states proposed different prognostic time horizons; 15 of 21 (71%) were numeric (ranging from 6 months to 5 years after hospital discharge), with the remaining 6 (29%) using descriptive terms, such as long-term. In this cross-sectional study of state-promulgated critical care triage policies, most plans restricted access to scarce critical care resources for patients with listed comorbidities and/or for patients with less-than-average expected postdischarge survival. This analysis raises concerns about access to care during a public health crisis for populations with high burdens of chronic illness, such as individuals with disabilities and minoritized racial and ethnic groups.

Disability bioethics and the commitment to equality.

Robert Veatch’s The Foundations of Justice: Why the Retarded and the Rest of Us Have Claims to Equality (1986) delves into deep questions of justice through the case of a child with disabilities. I describe what is basically right about this vision, as well as what is problematic from the standpoint of contemporary disability bioethics. From there, I dive into the notion of vulnerability that is at play in his work. He describes disability as necessarily a condition of weakness, lesser-than existence, and neediness. When disability is viewed in this way as an inherently vulnerable state of being, the essential sociopolitical dimensions of disability receive inadequate attention, which, in turn, makes it impossible to identify injustices correctly. I connect these points to concrete challenges faced by disability communities during the COVID-19 pandemic, which have raised profound questions about the just use of scarce critical care resources. Any case drawn from the pandemic is a very different kind of case than that of the child in Veatch’s book, but a commonality is the question of who should get what limited resources when needs and urgency vary.

Adding a Correction Factor to the Allocation of Scarce Life-saving Resources in a Pandemic

Adding a Correction Factor to the Allocation of Scarce Life-saving Resources in a Pandemic

Allocation of scarce critical care resources during public health emergencies: which ethical principles support decision making.

To investigate whether and how ten ethical principles are mentioned within documents on critical care resources allocation during public health emergencies. We conducted a search of documents con-cerning critical resources allocation during public emergencies publicly available from Google and two specific international websites, up to November 2020. Each document was analyzed by two independent reviewers to assess whether a reference to any of the 10 key ethical principles indicated by the Northern Italy Ethical Committee could be found in the documents. Cohen's K statistic was used. We obtained 34 documents, of which 19 were allocation frameworks, 15 crisis standards of care, 4 clinical triage protocol, 3 clinical guidelines and 2 public health emergency response plans. The principles most frequently mentioned as important for decision-making was "number of lives saved", followed by "transparency", "equity", "respect of person and their autonomy". The most cited tiebreakers were "younger first/life cycle" and "lottery". All documents aim to protect the life and health of the largest number of people and should be objective, ethical, transparent, applied equitably, and be publicly disclosed. It is plausible that short- and long-term prognostic tools can help allocate critical resources, but it remains strong that the decision-making process must be guided by a multi-principle ethical model that is not always easy to apply.

The fairness of ventilator allocation during the COVID-19 pandemic.

There is ongoing debate on how to fairly allocate scarce critical care resources to patients with COVID‐19. The debate revolves around two views: those who believe that priority for scarce resources should primarily aim at saving the most lives (SML) or at saving the most life‐years, and those who believe that public health should focus on health equity to address health disparities and social determinants of health. I argue that maximizing medical outcomes by saving the greatest number of patients is not a plausible strategy for combating COVID‐19. There are reasons of fairness to give each patient who can meet general eligibility requirements a chance of being saved. Rather than focusing on outcome maximization, a better solution would be the individualist lottery that takes account of probability of survival and duration of treatment. Although the individualist lottery allocates scarce resources in a fair way that is responsive to health equity concerns, it still gives considerable weight to the concern of SML. Thus, this procedure can be reasonably accepted by all key stakeholders.

Structural Inequities, Fair Opportunity, and the Allocation of Scarce ICU Resources.

The September-October 2021 issue of the Hastings Center Report highlights the important topic of allocating scarce critical care resources during the Covid-19 pandemic. The article by Alex Rajczi and colleagues urges that policy-makers use public reasoning, not private reasoning, when developing triage policies. We completely agree. We show how the allocation framework we developed as private scholars, the "Pittsburgh framework," has been supported by public reasoning. The article by MaryKatherine Gaurke and colleagues criticizes rationing based on maximizing life-years saved and mistakenly claims that our framework recommended this approach. We explain that our framework never contained such a criterion but instead included a more limited consideration of near-term prognosis. In December 2020, in response to emerging data and important criticisms, we modified our framework to further strengthen equity. We are committed to improving allocation guidelines during crisis standards of care through reflective discussions and debates.

Performance of crisis standards of care guidelines in a cohort of critically ill COVID-19 patients in the United States

SummaryMany US states published crisis standards of care (CSC) guidelines for allocating scarce critical care resources during the COVID-19 pandemic. However, the performance of these guidelines in maximizing their population benefit has not been well tested. In 2,272 adults with COVID-19 requiring mechanical ventilation drawn from the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID) multicenter cohort, we test the following three approaches to CSC algorithms: Sequential Organ Failure Assessment (SOFA) scores grouped into ranges, SOFA score ranges plus comorbidities, and a hypothetical approach using raw SOFA scores not grouped into ranges. We find that area under receiver operating characteristic (AUROC) curves for all three algorithms demonstrate only modest discrimination for 28-day mortality. Adding comorbidity scoring modestly improves algorithm performance over SOFA scores alone. The algorithm incorporating comorbidities has modestly worse predictive performance for Black compared to white patients. CSC algorithms should be empirically examined to refine approaches to the allocation of scarce resources during pandemics and to avoid potential exacerbation of racial inequities.

The trauma burden on a tertiary surgical intensive care unit during the lockdown period in South Africa: A retrospective observational study

Background Trauma places a significant burden on scarce South African critical care resources. The impact of the lockdown period in 2020 on these resources has not been studied. Restrictions on citizen movement and alcohol sales during the lockdown period presented a unique time period to investigate the burden of trauma on a low–middle-income country tertiary hospital intensive care unit. Methods A retrospective observational analysis of all patients admitted to a tertiary hospital surgical intensive care unit during the lockdown period in 2020, compared to the same time period in 2019 and 2018. Data were analysed to detect if a significant difference was present in the number of trauma admissions, length of stay and mechanisms of trauma. Results A significant decrease in the number of trauma admissions to ICU in 2020 was observed as compared to 2018 and 2019 during the same period ( p = <0.001), with a reduction of nearly 50%. The incidence of trauma admissions was lower in all individual lockdown levels in 2020 as compared to 2018 and 2019, and the lowest incidence was recorded in level 5 of 2020. There was no difference among the length of stay of trauma patients in ICU in 2018, 2019 and 2020. There was no difference between the incidence of trauma admissions during lockdown level 3 (with and without alcohol sales) in 2020 compared to 2018. The profile of penetrating and non-penetrating trauma over the 3 years was the same ( p = 0.22). There were no interactions between years, lockdown periods and penetrating trauma ( p = 0.22). Interpretation There was a significant decrease in the trauma burden presented to the surgical ICU during the lockdown period in 2020. Levels with the strictest restrictions on movement and alcohol use had the greatest measurable impact. The decreased number of trauma patients admitted in 2020 was comparable to the national trend of decreased trauma numbers recorded in all levels of the national healthcare system.

Counterpoint: Prioritizing Healthcare Workers for Scarce Critical Care Resources Is Impractical and Unjust.

Counterpoint: Prioritizing Healthcare Workers for Scarce Critical Care Resources Is Impractical and Unjust.

Mitigating Inequities and Saving Lives with ICU Triage during the COVID-19 Pandemic.

The burdens of the coronavirus disease (COVID-19) pandemic have fallen disproportionately on disadvantaged groups, including the poor and Black, Latinx, and Indigenous communities. There is substantial concern that the use of existing ICU triage protocols to allocate scarce ventilators and critical care resources—most of which are designed to save as many lives as possible—may compound these inequities. As governments and health systems revisit their triage guidelines in the context of impending resource shortages, scholars have advocated a range of alternative allocation strategies, including the use of a random lottery to give all patients in need an equal chance of ICU treatment. However, both the save-the-most-lives approach and random allocation are seriously flawed. In this Perspective, we argue that ICU triage policies should simultaneously promote population health outcomes and mitigate health inequities. These ethical goals are sometimes in conflict, which will require balancing the goals of maximizing the number of lives saved and distributing health benefits equitably across society. We recommend three strategies to mitigate health inequities during ICU triage: introducing a correction factor into patients’ triage scores to reduce the impact of baseline structural inequities; giving heightened priority to individuals in essential, high-risk occupations; and rejecting use of longer-term life expectancy and categorical exclusions as allocation criteria. We present a practical triage framework that incorporates these strategies and attends to the twin public health goals of promoting population health and social justice.

Simulation of “North Carolina Protocol for Allocating Scarce Inpatient Critical Care Resources in a Pandemic” in a Multi-hospital Health Care System

BACKGROUND An integrated nonprofit health care system with 13 North Carolina medical centers conducted a time-pressured quality improvement simulation of its plan to implement the "North Carolina Protocol for Allocating Scarce Inpatient Critical Care Resources in a Pandemic" attendant to pandemic scenario planning. Simulation objectives included assessing the plan in terms of a) efficiency and effectiveness; b) comorbidity scoring validity; c) impact by race/ethnicity, gender, age, and payer status; and d) simulation participant impressions of potential impact on clinicians.METHOD The simulation scenario involved scoring 14 patients with the constraint that only 10 could be afforded critical care resources. Also included were independent scoring validation by four clinicians, structured debriefs with simulation participants and observers, and tracking patient outcomes for 30 days.RESULTS Triage scoring was identical among four triage teams. Lack of concordance in clinician comorbidity scoring did not alter patient prioritization for withdrawal of treatment in this small cohort. Protocol scoring was not correlated with resource utilization or near-term mortality.LIMITATIONS The simulation sample was small and selected when COVID-19 census was temporarily waning. No protocol for pediatric patients was tested.CONCLUSIONS The simulation yielded resource allocation concordance using comorbidity scoring by attending physicians, which significantly accelerated triage team decision-making and did not result in notable disparities by race/ethnicity, gender, or advanced age. Qualitative findings surfaced tensions in balancing de-identified data with individualized assessment and in trusting the clinical judgments of other physicians. Additional research is needed to validate the protocol's predictive value related to patient outcomes.

Racism, Health Equity, and Crisis Standards of Care in the COVID-19 Pandemic

Long-standing and deeply embedded institutional racism, notably anti-Black racism in US health care, has provided a solid footing for the health inequities by race evident in the COVID-19 pandemic. Inequities in susceptibility, exposure, infection, hospitalization, and treatment reflect and reinforce this racism and cause incalculable and preventable suffering in and loss of Black lives. This paper identifies multiple expressions of racism evident in the crisis standards of care (CSC) created by states and health care institutions to guide the ethical allocation of scarce critical care resources including ventilators. Contextualized within the broad landscape of health inequities pre-COVID-19 as well as during the pandemic, the paper analyzes two manifestations of racism in CSC: 1) the scarce participation of Black health care and public health professionals as well as of Black communities in CSC creation, and 2) the ostensible “objectivity” and “race irrelevancy” of features of CSC. This ethical analysis leads to a proposal for dismantling racism in CSC by embracing antiracism as health equity at the outset of CSC policy-making. An initial exploration of the nature of health equity and related policies and practices in this COVID-19 era support a concluding outline of distinctive “first steps” toward antiracist pro-health equity CSC.

Canadian emergency medicine and critical care physician perspectives on pandemic triage in COVID-19.

Local and regional policies to guide the allocation of scarce critical care resources have been developed, but the views of prospective users are not understood. We sought to investigate the perspectives of Canadian acute care physicians toward triaging scarce critical care resources in the COVID-19 pandemic. We rapidly deployed a brief survey to Canadian emergency and critical care physicians in April 2020 to investigate current attitudes toward triaging scarce critical care resources and identify subsequent areas for improvement. Descriptive and between-group analyses along with thematic coding were used. The survey was completed by 261 acute care physicians. Feelings of anxiety related to the pandemic were common (65 percent), as well as fears of psychological distress if required to triage scarce resources (77 percent). Only 49 percent of respondents felt confident in making resource allocation decisions. Both critical care and emergency physicians favored multidisciplinary teams over single physicians to allocate scarce critical care resources. Critical care physicians were supportive of decision making by teams not involved in patient care (3.4/5 versus 2.9/5 p = 0.04), whereas emergency physicians preferred to maintain their involvement in such decisions (3.4/5 versus 4.0/5 p = 0.007). Free text responses identified five themes for subsequent action including the need for further guidance on existing triage policies, ethical support in decision making, medicolegal protection, additional tools for therapeutic communications, and healthcare provider psychological support. There is an urgent need for collaboration between policymakers and frontline physicians to develop critical care resource triage policies that wholly consider the diversity of provider perspectives across practice environments.

Age Matters but it should not be Used to Discriminate Against the Elderly in Allocating Scarce Resources in the Context of COVID-19.

A patient’s age serves as a very useful guide to physicians in deciding what disease manifestations to anticipate, what treatment to offer for certain conditions, and how to prepare for possible emergencies. In the context of the COVID-19 pandemic, determining treatment options on the basis of a patient’s chronological age can easily give rise to unjustified discrimination. This is of particular significance in situations where the allocation of scarce critical care resources could have a direct impact on who will live and who will die. This paper examines the fairness of recommendations contained in resource allocation guidelines in the Philippines that have implications for the way elderly patients could be treated or excluded from some forms of critical care treatment in the context of the ongoing Corona virus emergency.

Ethical Challenges Arising in the COVID-19 Pandemic: An Overview from the Association of Bioethics Program Directors (ABPD) Task Force

The COVID-19 pandemic has raised a host of ethical challenges, but key among these has been the possibility that health care systems might need to ration scarce critical care resources. Rationing policies for pandemics differ by institution, health system, and applicable law. Most seem to agree that a patient’s ability to benefit from treatment and to survive are first-order considerations. However, there is debate about what clinical measures should be used to make that determination and about other factors that might be ethically appropriate to consider. In this paper, we discuss resource allocation and several related ethical challenges to the healthcare system and society, including how to define benefit, how to handle informed consent, the special needs of pediatric patients, how to engage communities in these difficult decisions, and how to mitigate concerns of discrimination and the effects of structural inequities.

The Critical Care Society of Southern Africa guidelines on the allocation of scarce critical care resources during the COVID-19 public health emergency in South Africa

Letter byGopalan et al. on article by Singh and Moodley (Singh JA, Moodley K. Critical care triaging in the shadow of COVID-19: Ethics considerations. S Afr Med J 2020;110(5):355-359. https://doi.org/10.7196/SAMJ.2020.v110i5.14778); and response by Singh and Moodley.

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.

Pathways to Care for Critically Ill or Injured Children: A Cohort Study from First Presentation to Healthcare Services through to Admission to Intensive Care or Death.

PurposeCritically ill or injured children require prompt identification, rapid referral and quality emergency management. We undertook a study to evaluate the care pathway of critically ill or injured children to identify preventable failures in the care provided.MethodsA year-long cohort study of critically ill and injured children was performed in Cape Town, South Africa, from first presentation to healthcare services until paediatric intensive care unit (PICU) admission or emergency department death, using expert panel review of medical records and caregiver interview. Main outcomes were expert assessment of overall quality of care; avoidability of severity of illness and PICU admission or death and the identification of modifiable factors.ResultsThe study enrolled 282 children, 252 emergency PICU admissions, and 30 deaths. Global quality of care was graded good in 10% of cases, with half having at least one major impact modifiable factor. Key modifiable factors related to access to care and identification of the critically ill, assessment of severity, inadequate resuscitation, and delays in decision making and referral. Children were transferred with median time from first presentation to PICU admission of 12.3 hours. There was potentially avoidable severity of illness in 185 (74%) of children, and death prior to PICU admission was avoidable in 17/30 (56.7%) of children.ConclusionsThe study presents a novel methodology, examining quality of care across an entire system, and highlighting the complexity of the pathway and the modifiable events amenable to interventions, that could reduce mortality and morbidity, and optimize utilization of scarce critical care resources; as well as demonstrating the importance of continuity and quality of care.