Applying crisis standards of care to critically ill patients during the COVID‐19 pandemic: Does race/ethnicity affect triage scoring?

Abstract

Objective Given the variability in crisis standards of care (CSC) guidelines during the COVID‐19 pandemic, we investigated the racial and ethnic differences in prioritization between 3 different CSC triage policies (New York, Massachusetts, USA), as well as a first come, first served (FCFS) approach, using a single patient population. Methods We performed a retrospective cohort study of patients with intensive care unit (ICU) needs at a tertiary hospital on its peak COVID‐19 ICU census day. We used medical record data to calculate a CSC score under 3 criteria: New York, Massachusetts with full comorbidity list (Massachusetts1), and MA with a modified comorbidity list (Massachusetts2). The CSC scores, as well as FCFS, determined which patients were eligible to receive critical care under 2 scarcity scenarios: 50 versus 100 ICU bed capacity. We assessed the association between race/ethnicity and eligibility for critical care with logistic regression. Results Of 211 patients, 139 (66%) were male, 95 (45%) were Hispanic, 23 (11%) were non‐Hispanic Black, and 69 (33%) were non‐Hispanic White. Hispanic patients had the fewest comorbidities. Assuming a 50 ICU bed capacity, Hispanic patients had significantly higher odds of receiving critical care services across all CSC guidelines, except FCFS. However, assuming a 100 ICU bed capacity, Hispanic patients had greater odds of receiving critical care services under only the Massachusetts2 guidelines (odds ratio, 2.05; 95% CI, 1.09 to 3.85). Conclusion Varying CSC guidelines differentially affect racial and ethnic minority groups with regard to risk stratification. The equity implications of CSC guidelines require thorough investigation before CSC guidelines are implemented.

Simulation of New York City’s Ventilator Allocation Guideline During the Spring 2020 COVID-19 Surge

“…Second, our retrospective study suffered from missing SOFA information and is vulnerable to a missing data bias. The missing neurology subscore, similar to other comparable studies, 19 , 27 may be related to practices at the time limiting bedside assessment or that 41.8% of patients required paralytics. Missing laboratory data (such as hepatic function) may be related to the test not being clinically indicated at the time.…”

“…In this simulation study, a crisis period requiring ventilator triage per NYVAG was defined as once ventilator demand exceeded 95% prepandemic ventilators (250 patients) . Patients’ SOFA scores were queried from the health record while ventilated, with missing SOFA subscores presumed normal (ie, scored as 0) . Race and ethnicity were included in study data because of growing concern that existing crisis standards of care protocols might worsen existing social disparities; data were based on self-report by the patient or identified unknown if unable or unwilling to self-identify.…”

“…[12][13][14][15] Despite these potential shortcomings, NYVAG is operationally similar to many other current guidelines. 7,9,[16][17][18] While other studies may have simulated NYVAG [19][20][21][22][23][24][25][26][27][28] or other CSC, [29][30][31][32] most perform a limited analysis of how resources might be allocated to patients not already receiving that resource (front-end triage) and do not consider potential reallocation after a time trial (back-end triage).…”

“…While other studies may have simulated NYVAG 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 or other CSC, 29 , 30 , 31 , 32 most perform a limited analysis of how resources might be allocated to patients not already receiving that resource (front-end triage) and do not consider potential reallocation after a time trial (back-end triage). Triage, a critical component of CSC, includes both front-end and back-end triage.…”

The NCSBN 2022 Environmental Scan: Resiliency, Achievement, and Public Protection

“…Although recommendations for jurisdictions to develop CSC guidelines have been in place for more than 10 years ( Margus et al, 2020 ), the COVID-19 pandemic has laid bare the fact that many states still do not have CSC to guide providers on how to maintain standards of care during a public health emergency or disaster. An online search of all 50 states revealed that 14 states had no discernable plans to develop CSC; among the 17 states that have publicly released CSC protocols and recommendations, risk stratification criteria and allocation principles used to make difficult triage decisions vary greatly ( Margus et al, 2020 ; Molina et al, 2021 ). A lack of preparedness for future disasters, public health or otherwise, was one of the concerns raised in The Future of Nursing 2020–2030 , which called for policy initiatives to bolster the profession’s preparedness (National Academies of Science, Engineering and Medicine, 2021 ).…”