Article Figures & Tables
Figures
- Figure 1:
Critical care triage stage 4 protocol for patients with coronavirus disease 2019 in Saskatchewan. Note: ACP = advance care planning, Fio2 = fraction of inspired oxygen, GOC = goals of care, SOFA = Sequential Organ Failure Assessment, Spo2 = oxygen saturation. Extracorporeal life support (ECLS) may provide effective treatment for refractory cases, but it requires extensive resources. Each request for ECLS will be reviewed by at least 2 ECLS experts, in addition to the triage team. These ECLS experts will be designated by the area leads of the Department of Critical Care (Regina and Saskatoon). The number of patients that can be placed on ECLS is small and should be decided on a case-by-case basis. Definite exclusion criteria include age older than 60 years; receiving mechanical ventilation for more than 7 days; irreversible neurologic, multiorgan failure; malignancy; cardiac arrest; severe end-stage liver, lung, kidney or heart disease; advanced neurocognitive disease; pregnancy; body mass index > 45; inability to receive anticoagulation or blood products; or ECLS resources not available in city. Legend: red = highest priority patient (most likely to benefit from admission to the intensive care unit [ICU]), yellow = intermediate priority patient (may benefit from ICU care), green = patient does not require ICU care (too well), blue = palliative care only (poor prognosis is likely).
Tables
Criteria Critical care triage stage 1 Critical care triage stage 2 Critical care triage stages 3 and 4 Patient preference As documented by goals-of-care and advance care planning discussions As documented by goals-of-care and advance care planning discussions
As documented by goals-of-care and advance care planning discussions Past medical history Clinician judgment; must be mutually agreed upon by patient and clinician End-stage organ failure*
Heart failure NYHA class IV
Lung disease
COPD with FEV1 < 30% predicted or baseline Pao2 < 55 mm Hg, or secondary pulmonary hypertension
Cystic fibrosis with postbronchodilator FEV1 < 30% predicted or baseline Pao2 < 55 mm Hg
Pulmonary fibrosis with VC or TLC < 60% predicted, baseline Pao2 < 55 mm Hg or secondary pulmonary hypertension
Primary pulmonary hypertension with NYHA class IV symptoms
Cirrhosis with MELD > 20
Metastatic malignant disease with expected survival of < 6 mo
Advanced and irreversible immunocompromise
Severe, irreversible and terminal neurologic event or condition (end-stage dementia)
Advanced untreatable neurodegenerative disease (Parkinson disease, ALS)
End-stage organ failure*
Heart failure NYHA class III or IV
Lung disease
COPD with FEV1 < 30% predicted or baseline Pao2 < 55 mm Hg, or secondary pulmonary hypertension
Cystic fibrosis with postbronchodilator FEV1 < 30% predicted or baseline Pao2 < 55 mm Hg
Pulmonary fibrosis with VC or TLC < 60% predicted, baseline Pao2 < 55 mm Hg or secondary pulmonary hypertension
Primary pulmonary hypertension with NYHA class IV symptoms
Cirrhosis with MELD > 20
Severity of presenting illness Clinician judgment; must be mutually agreed upon by patient and clinician Age > 80 yr and cardiac arrest with 1 of the following poor prognostic factors:†
Unwitnessed cardiac arrest
Any PEA arrest
Recurrent cardiac arrest
Cardiac arrest, regardless of age, with 1 of the following poor prognostic factors:
Unwitnessed cardiac arrest
Any PEA arrest
Recurrent cardiac arrest
Severe trauma or burns
Trauma with ISS > 16, unless determined to be acutely reversible
Burns with 2 of the following:
Age > 60 yr, > 40% BSA, inhalational injury
Severe neurologic injury
TBI meeting all of the following criteria:
Age > 60 yr, GCS < 8, and 1 or both unreactive pupils
SAH with WFNS grade V
CVA
Age > 70 yr with large MCA territory CVA, substantial deficits, not amenable to reperfusion
Posterior circulation stroke with GCS < 8
Age and Clinical Frailty Score Clinician judgment; must be mutually agreed upon by patient and clinician Clinician judgment; must be mutually agreed upon by patient and clinician Age > 80 yr and
Clinical Frailty Score ≥ 5
Note: ALS = amyotrophic lateral sclerosis, BSA = body surface area, COPD = chronic obstructive pulmonary disease, CVA = cerebrovascular accident, FEV1 = forced expiratory volume in 1 minute, GCS = Glasgow Coma Scale, ICU = intensive care unit, ISS = Injury Severity Score, MCA = middle cerebral artery, MELD = Model for End-Stage Liver Disease, NYHA = New York Heart Association, PEA = pulseless electrical activity, SAH = subarachnoid hemorrhage, TBI = traumatic brain injury, TLC = total lung capacity, VC = vital capacity, WFNS = World Federation of Neurosurgical Societies.
↵* If the patient is currently on a waiting list for organ transplant and admission to the ICU would place them at the top of the waiting list, an exception should be made and the patient should be admitted to the ICU. However, if organ donation programs are put on hold because of the pandemic, this exception is no longer valid.
↵† If the patient’s most responsible physician determines the cause of the cardiac arrest to be acutely reversible, the patient is not excluded from ICU care.
Population Rationale Incorporation into the Saskatchewan Critical Care Resource Allocation Framework Older adults Evidence suggests that risk for poor ICU outcomes is not defined exclusively by age.13 Instead, frailty (defined as CFS ≥ 5) is associated with higher in-hospital and long-term mortality.14 In octogenarians, frailty is predictive of short-term ICU mortality.15,16 Although frailty may portend a poorer outcome in younger patients who are critically ill, the validity of applying the CFS more broadly is still being investigated.17 A combination of age and frailty is used as exclusion criteria in stage 3 (Table 1). Chronically ventilated Palliation for patients on long-term ventilation is not justifiable, even if it allows a greater number of healthier patients to survive. This policy would risk inappropriate quality-of-life judgments and could be seen as disadvantaging vulnerable patients. Patients who are already receiving life-sustaining treatments in long-term care settings or at home are considered to be a different population altogether from the medical patient who is acutely ill. However, should patients receiving long-term ventilation require treatment in an acute care facility, they should be considered part of the acute care cohort and subject to the resource allocation framework.2 Patients with disabilities Patients with intellectual, physical or developmental disabilities are considered vulnerable populations and at risk for discrimination within the health care system.18 Patients with stable, nonprogressive conditions will not be excluded solely on the basis of these conditions. The structure and process of the triage team is meant to form a system of checks and balances to eliminate discrimination based on disability. Pregnant patients A patient who is pregnant and her potentially viable fetus should be considered as 2 separate lives, and therefore these patients can be prioritized based on the life-cycle principle.19 Pregnancy with a potentially viable fetus is included as a tiebreaker in stage 4 (Figure 1). Health care workers Health care workers have instrumental value (i.e., a health care worker who is healthy can save the lives of more patients).10,20 However, during a stage of critical illness, it is unclear whether the health care worker, if saved, would be able to return to work in a timely fashion to help others. Instrumental value is a potentially subjective concept that lends itself too easily to other, potentially extraneous, considerations of social worth. Health care workers are included as tiebreakers in stage 4 (Figure 1). Note: CFS = Clinical Frailty Score, ICU = intensive care unit.
Triage stage Baseline ICU capacity, % Scarcity Inclusion criteria Exclusion criteria overview (see Table 1) Withdrawal of life-supportive treatment 1 100–150 Relative According to usual clinical practice According to usual clinical practice According to usual clinical practice 2 150–200 Relative According to usual clinical practice End-stage organ failure
Cardiac arrest with poor prognostic factors
According to usual clinical practice 3 200–250 Relative According to usual clinical practice End-stage organ failure
Terminal neurologic diseases
Metastatic malignant disease with poor prognosis
Cardiac arrest with poor prognostic factors
Severe trauma or burns
Severe neurologic injury
Age > 80 yr and Clinical Frailty Score ≥ 5
According to usual clinical practice 4 > 250 Absolute Formal inclusion criteria (Figure 1) According to stage 3 exclusion criteria Formalized reassessments and uniform criteria for palliation Note: ICU = intensive care unit.
In this issue
Article tools
Jump to section
- Article
- What are the key ethical principles for resource allocation in a pandemic?
- How was Saskatchewan’s Critical Care Resource Allocation Framework operationalized?
- What are the limitations of our approach?
- How does our COVID-19 resource allocation framework compare with others?
- Conclusion
- Acknowledgements
- Footnotes
- References
- Figures & Tables
- Related Content
- Responses
- Metrics
Related Articles
Cited By...
- No citing articles found.
More in this TOC Section
Similar Articles
Collections
