Empirical Assessment of U.S. Coronavirus Disease 2019 Crisis Standards of Care Guidelines

Bharadwaj, Maheetha; Jezmir, Julia L.; Kishore, Sandeep P.; Winkler, Marisa L.; Diephus, Bradford; Haider, Hibah; Crowley, Conor; Pinilla-Vera, Mayra; Varon, Jack; Baron, Rebecca M.; Feldman, William B.; Kim, Edy Y.

doi:10.1097/cce.0000000000000496

Cited by 3 publications

(7 citation statements)

References 22 publications

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“…Only 28.0%, 60.8%, and 77.6% of the ventilator supply were utilized at 14, 7, and 5 days prior to the crisis period, respectively, emphasizing the rapid escalation of intubated patients leading to the crisis period and the importance of proactive disaster plans. Second, 84.7% of individuals tested positive for COVID-19, challenging conventional thought that surges requiring resource rationing may be related to multiple diseases . Third, we found that ventilator strain stuttered (Figure 3).…”

Section: Discussionmentioning

confidence: 77%

“…[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).…”

Section: Introductionmentioning

confidence: 99%

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

Walsh,

Zhu,

Feng

et al. 2023

JAMA Netw Open

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ImportanceThe spring 2020 surge of COVID-19 unprecedentedly strained ventilator supply in New York City, with many hospitals nearly exhausting available ventilators and subsequently seriously considering enacting crisis standards of care and implementing New York State Ventilator Allocation Guidelines (NYVAG). However, there is little evidence as to how NYVAG would perform if implemented.ObjectivesTo evaluate the performance and potential improvement of NYVAG during a surge of patients with respect to the length of rationing, overall mortality, and worsening health disparities.Design, Setting, and ParticipantsThis cohort study included intubated patients in a single health system in New York City from March through July 2020. A total of 20 000 simulations were conducted of ventilator triage (10 000 following NYVAG and 10 000 following a proposed improved NYVAG) during a crisis period, defined as the point at which the prepandemic ventilator supply was 95% utilized.ExposuresThe NYVAG protocol for triage ventilators.Main Outcomes and MeasuresComparison of observed survival rates with simulations of scenarios requiring NYVAG ventilator rationing.ResultsThe total cohort included 1671 patients; of these, 674 intubated patients (mean [SD] age, 63.7 [13.8] years; 465 male [69.9%]) were included in the crisis period, with 571 (84.7%) testing positive for COVID-19. Simulated ventilator rationing occurred for 163.9 patients over 15.0 days, 44.4% (95% CI, 38.3%-50.0%) of whom would have survived if provided a ventilator while only 34.8% (95% CI, 28.5%-40.0%) of those newly intubated patients receiving a reallocated ventilator survived. While triage categorization at the time of intubation exhibited partial prognostic differentiation, 94.8% of all ventilator rationing occurred after a time trial. Within this subset, 43.1% were intubated for 7 or more days with a favorable SOFA score that had not improved. An estimated 60.6% of these patients would have survived if sustained on a ventilator. Revising triage subcategorization, proposed improved NYVAG, would have improved this alarming ventilator allocation inefficiency (25.3% [95% CI, 22.1%-28.4%] of those selected for ventilator rationing would have survived if provided a ventilator). NYVAG ventilator rationing did not exacerbate existing health disparities.Conclusions and RelevanceIn this cohort study of intubated patients experiencing simulated ventilator rationing during the apex of the New York City COVID-19 2020 surge, NYVAG diverted ventilators from patients with a higher chance of survival to those with a lower chance of survival. Future efforts should be focused on triage subcategorization, which improved this triage inefficiency, and ventilator rationing after a time trial, when most ventilator rationing occurred.

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Section: Discussionmentioning

confidence: 77%

Section: Introductionmentioning

confidence: 99%

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

Walsh,

Zhu,

Feng

et al. 2023

JAMA Netw Open

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“…During the COVID-19 pandemic, some states used the SOFA score alone to group patients into priority groups for receiving scarce treatments (eg, ventilators), and other states added additional metrics, such as prioritization based on the group to which a patient belongs (eg, essential workers, children, pregnant people). 3 Despite SOFA's widespread use during the COVID-19 pandemic when CSC guidelines were reviewed, limitations of using the SOFA score were noted as early as 2020. 4 Here, we summarize key evidence demonstrating that use of SOFA scores in CSC risks exacerbating inequities, as SOFA scores overestimate the mortality of Black patients, resulting in these patients being placed in lower priority groups and hence having a lower survival rate than White patients, whose care is overprioritized.…”

Section: Commentarymentioning

confidence: 99%

“…13 The hypothetical raw SOFA algorithm followed this same trend, selecting patients most likely to survive more often in the White than in the Black subcohort. 13 Despite the Colorado guideline's slightly better prediction of 28-day survival than the New York State guideline, 3 Colorado's inclusion of comorbidities was flagged as a concern by Bharadwaj et al due to the risk of exacerbating racial and socioeconomic disparities, as "those who are most disadvantaged are most likely to have multiple comorbidities," thereby decreasing their estimated likelihood of short-term survival. 3 Historical context of SOFA harms.…”

Section: Harms Of Using Sofamentioning

confidence: 99%

“…13 Despite the Colorado guideline's slightly better prediction of 28-day survival than the New York State guideline, 3 Colorado's inclusion of comorbidities was flagged as a concern by Bharadwaj et al due to the risk of exacerbating racial and socioeconomic disparities, as "those who are most disadvantaged are most likely to have multiple comorbidities," thereby decreasing their estimated likelihood of short-term survival. 3 Historical context of SOFA harms. Sederstrom and Wiggleton-Little 14 and Cleveland Manchanda et al 4 emphasize that typical uses of the SOFA score in CSC for patients with COVID-19 ignore historical inequities by assuming equivalent baseline health among all patients.…”

Section: Harms Of Using Sofamentioning

confidence: 99%

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What Should Be Roles of Federal Clinician Governors in Motivating Equity in Locally Coordinated Triage Protocols?

Mikell

Hoggard

Schmidt

2023

AMA Journal of Ethics

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This commentary on a case examines racially inequitable outcomes, especially for Black patients, resulting from use of Sequential Organ Failure Assessment (SOFA) scores to triage patients during the COVID-19 pandemic and how inequitable outcomes in triage protocols could be reduced. It also considers the nature and scope of clinician governor responses to members of federally protected classes who are disadvantaged by use of the SOFA score and argues that clinician leaders of the Centers for Disease Control and Prevention, specifically, should provide federal guidance that motivates clear legal accountability.The American Medical Association designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™ available through the AMA Ed Hub TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity. CaseDr D is an infectious disease specialist, an epidemiologist, and the medical director of a state department of health. Following a flu season that was socially and fiscally devastating, Dr D administers budget for essential personnel, surge planning, tertiary triage strategy, and critical care inventory (eg, ventilators, dialysis machines, medications, personal protective equipment). Dr D assembles a central committee of regional triage officers from around the state, which forges consensus about communication plans that activate the triage strategy across the state in response to an emergency (ie, epidemic, multi-locale mass casualty events, natural disaster) and how to train teams to implement protocols efficiently and equitably.State epidemiological data reveal that low-income communities and communities of color were inequitably burdened (in terms of higher morbidity, more complications, higher mortality) by the most recent flu outbreak. Age-adjusted flu hospitalizations were highest among Black persons, second highest among American Indian and Alaska Native persons, and third highest among Latinx persons.

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Protocol to assess performance of crisis standards of care guidelines for clinical triage

et al. 2021

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Empirical Assessment of U.S. Coronavirus Disease 2019 Crisis Standards of Care Guidelines

Abstract: Supplemental Digital Content is available in the text.

Cited by 3 publications

References 22 publications

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

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

What Should Be Roles of Federal Clinician Governors in Motivating Equity in Locally Coordinated Triage Protocols?

Protocol to assess performance of crisis standards of care guidelines for clinical triage

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