Ethical triage during the COVID-19 pandemic: a toolkit for neurosurgical resource allocation

Hulsbergen, Alexander; Eijkholt, Marleen; Balak, Naci; Brennum, Jannick; Bolger, Ciarán; Bohrer, Anna Margarete; Feldman, Zeev; Holsgrove, Daniel; Kitchen, Neil; Mathiesen, Tiit; Moojen, Wouter A.; Samprón, Nicolás; Sameš, Martin; Sandvik, Ulrika; Tisell, Magnus; Broekman, Marike L D

doi:10.1007/s00701-020-04375-w

Cited by 33 publications

(33 citation statements)

References 2 publications

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“…In Helsinki, we did not end up in a situation where patient flow (of SARS-CoV-2 and non-SARS-CoV-2 patients) would have pushed the limits of our treatment capacity. Thus, any out of the normal ethical triage was not needed [ 8 ].…”

Section: Discussionmentioning

confidence: 99%

Intensive care of traumatic brain injury and aneurysmal subarachnoid hemorrhage in Helsinki during the Covid-19 pandemic

et al. 2020

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Background To ensure adequate intensive care unit (ICU) capacity for SARS-CoV-2 patients, elective neurosurgery and neurosurgical ICU capacity were reduced. Further, the Finnish government enforced strict restrictions to reduce the spread. Our objective was to assess changes in ICU admissions and prognosis of traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (SAH) during the Covid-19 pandemic. Methods Retrospective review of all consecutive patients with TBI and aneurysmal SAH admitted to the neurosurgical ICU in Helsinki from January to May of 2019 and the same months of 2020. The pre-pandemic time was defined as weeks 1–11, and the pandemic time was defined as weeks 12–22. The number of admissions and standardized mortality rates (SMRs) were compared to assess the effect of the Covid-19 pandemic on these. Standardized mortality rates were adjusted for case mix. Results Two hundred twenty-four patients were included (TBI n = 123, SAH n = 101). There were no notable differences in case mix between TBI and SAH patients admitted during the Covid-19 pandemic compared with before the pandemic. No notable difference in TBI or SAH ICU admissions during the pandemic was noted in comparison with early 2020 or 2019. SMRs were no higher during the pandemic than before. Conclusion In the area of Helsinki, Finland, there were no changes in the number of ICU admissions or in prognosis of patients with TBI or SAH during the Covid-19 pandemic.

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Section: Discussionmentioning

confidence: 99%

Intensive care of traumatic brain injury and aneurysmal subarachnoid hemorrhage in Helsinki during the Covid-19 pandemic

et al. 2020

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“…The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19) pandemic has forcibly affected healthcare in other subspecialties than the primarily involved: intensive care, infectious diseases, and general practice. Neurosurgery is influenced by the redistribution of medical resources to those acutely needing Covid-19 care and by the need to handle or prevent Covid-19 among neurosurgical patients and staff [1][2][3][4][5].…”

Section: Introductionmentioning

confidence: 99%

A snapshot of European neurosurgery December 2019 vs. March 2020: just before and during the Covid-19 pandemic

et al. 2020

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Background Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or Covid-19), which began as an epidemic in China and spread globally as a pandemic, has necessitated resource management to meet emergency needs of Covid-19 patients and other emergent cases. We have conducted a survey to analyze caseload and measures to adapt indications for a perception of crisis. Methods We constructed a questionnaire to survey a snapshot of neurosurgical activity, resources, and indications during 1 week with usual activity in December 2019 and 1 week during SARS-CoV-2 pandemic in March 2020. The questionnaire was sent to 34 neurosurgical departments in Europe; 25 departments returned responses within 5 days. Results We found unexpectedly large differences in resources and indications already before the pandemic. Differences were also large in how much practice and resources changed during the pandemic. Neurosurgical beds and neuro-intensive care beds were significantly decreased from December 2019 to March 2020. The utilization of resources decreased via less demand for care of brain injuries and subarachnoid hemorrhage, postponing surgery and changed surgical indications as a method of rationing resources. Twenty departments (80%) reduced activity extensively, and the same proportion stated that they were no longer able to provide care according to legitimate medical needs. Conclusion Neurosurgical centers responded swiftly and effectively to a sudden decrease of neurosurgical capacity due to relocation of resources to pandemic care. The pandemic led to rationing of neurosurgical care in 80% of responding centers. We saw a relation between resources before the pandemic and ability to uphold neurosurgical services. The observation of extensive differences of available beds provided an opportunity to show how resources that had been restricted already under normal conditions translated to rationing of care that may not be acceptable to the public of seemingly affluent European countries.

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“…2051–2054). Their recommendations have been deemed to provide a triage structure during the present COVID‐19 situation (Hulsbergen et al., 2020, p. 1486). The recommendations are grounded on four values consisting of (a) maximising the most benefits from the use of the resources available by securing the greatest amount of lives; (b) treating all patients in an equal manner; (c) rewarding those who have saved the lives of other people and/or are in a position to do the same in the future; and (d) giving precedence to those patients worst off in terms of health or age (Emanuel et al., 2020, p. 2051).…”

Section: Recommendations In the Context Of Covid‐19mentioning

confidence: 99%

The principle of salvage in the context of COVID‐19

Kearns

2020

Nursing Inquiry

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The prioritisation of scarce resources has a particular urgency within the context of the COVID‐19 pandemic crisis. This paper sets out a hypothetical case of Patient X (who is a nurse) and Patient Y (who is a non‐health care worker). They are both in need of a ventilator due to COVID‐19 with the same clinical situation and expected outcomes. However, there is only one ventilator available. In addressing the question of who should get priority, the proposal is made that the answer may lie in how the pandemic is metaphorically described using military terms. If nursing is understood to take place at the ‘frontline’ in the ‘battle’ against COVID‐19, a principle of military medical ethics—namely the principle of salvage—can offer guidance on how to prioritise access to a life‐saving resource in such a situation. This principle of salvage purports a moral direction to return wounded soldiers back to duty on the battlefield. Applying this principle to the hypothetical case, this paper proposes that Patient X (who is a nurse) should get priority of access to the ventilator so that he/she can return to the ‘frontline’ in the fight against COVID‐19.

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Ethical triage during the COVID-19 pandemic: a toolkit for neurosurgical resource allocation

Cited by 33 publications

References 2 publications

Intensive care of traumatic brain injury and aneurysmal subarachnoid hemorrhage in Helsinki during the Covid-19 pandemic

Intensive care of traumatic brain injury and aneurysmal subarachnoid hemorrhage in Helsinki during the Covid-19 pandemic

A snapshot of European neurosurgery December 2019 vs. March 2020: just before and during the Covid-19 pandemic

The principle of salvage in the context of COVID‐19

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