Preparing for the Worst-Case Scenario in a Pandemic: Intensivists Simulate Prioritization and Triage of Scarce ICU Resources*

Abstract

OBJECTIVES: Simulation and evaluation of a prioritization protocol at a German university hospital using a convergent parallel mixed methods design. DESIGN: Prospective single-center cohort study with a quantitative analysis of ICU patients and qualitative content analysis of two focus groups with intensivists. SETTING: Five ICUs of internal medicine and anesthesiology at a German university hospital. PATIENTS: Adult critically ill ICU patients ( n = 53). INTERVENTIONS: After training the attending senior ICU physicians ( n = 13) in rationing, an impending ICU congestion was simulated. All ICU patients were rated according to their likelihood to survive their acute illness (good-moderate-unfavorable). From each ICU, the two patients with the most unfavorable prognosis ( n = 10) were evaluated by five prioritization teams for triage. MEASUREMENTS AND MAIN RESULTS: Patients nominated for prioritization visit ( n = 10) had higher Sequential Organ Failure Assessment scores and already a longer stay at the hospital and on the ICU compared with the other patients. The order within this worst prognosis group was not congruent between the five teams. However, an in-hospital mortality of 80% confirmed the reasonable match with the lowest predicted probability of survival. Qualitative data highlighted the tremendous burden of triage and the need for a team-based consensus-oriented decision-making approach to ensure best possible care and to support professionals. Transparent communication within the teams, the hospital, and to the public was seen as essential for prioritization implementation. CONCLUSIONS: To mitigate potential bias and to reduce the emotional burden of triage, a consensus-oriented, interdisciplinary, and collaborative approach should be implemented. Prognostic comparative assessment by intensivists is feasible. The combination of long-term ICU stay and consistently high Sequential Organ Failure Assessment scores resulted in a greater risk for triage in patients. It remains challenging to reliably differentiate between patients with very low chances to survive and requires further conceptual and empirical research.

Single-rater reliability of a three-dimensional instrument for decision-making in tertiary triage and ICU- prioritization—a case vignette simulation study

“…This was especially the case for patients with preexisting comorbidities and physical impairment who maintained psychological abilities. However, length of stay combined with the SOFA-score showed prognostic properties in research of other groups [ 34 ], so this parameter should be focused on in future research.…”

Different Pathways to the Most Difficult Decisions*

“…Health systems and critical care leaders around the world need to take this moment to reassess our crisis plans and to decide what was effective and what was not. This article ( 1 ), along with the work and sacrifices of so many others, will contribute to that honorable goal.…”

“…Triage is thus an important part of crisis standards of care (CSC), a response to a situation in which the needs of large numbers of patients exceed the resources available to meet them. The implementation of CSC, including triage protocols as described in the article by Knochel et al ( 1 ) in this issue of Critical Care Medicine , is an attempt to ensure that health systems provide the best possible care under the worst possible circumstances. In the United States, the Institute of Medicine stated in 2009 that adopting CSC during a disaster “is not optional—it is a forced choice, based on the emerging situation.…”

“…It is important to note that the system described by Knochel et al ( 1 ) does not rely on SOFA at presentation but rather over the course of an admission. Unfortunately, although changes in SOFA over time appear to be predictive of outcomes in a general critical care population ( 9 ), analyses in patients with COVID-19 do not support the prognostic value of serial SOFA measurements ( 10 ).…”

“…We must not extrapolate too much from the excellent article by Knochel et al (1). They describe a simulation exercise in a single hospital, with colleagues who presumably know one another and have a shared institutional culture.…”