Prioritising ‘already-scarce’ intensive care unit resources in the midst of COVID-19: a call for regional triage committees in South Africa

Abstract

Background The worsening COVID-19 pandemic in South Africa poses multiple challenges for clinical decision making in the context of already-scarce ICU resources. Data from national government and the last published national audit of ICU resources indicate gross shortages. While the Critical Care Society of Southern Africa (CCSSA) guidelines provide a comprehensive guideline for triage in the face of overwhelmed ICU resources, such decisions present massive ethical and moral dilemmas for triage teams. It is therefore important for the health system to provide clinicians and critical care facilities with as much support and resources as possible in the face of impending pandemic demand. Following a discussion of the ethical considerations and potential challenges in applying the CCSSA guidelines, the authors propose a framework for regional triage committees adapted to the South African context. Discussion Beyond the national CCSSA guidelines, the clinician has many additional ethical and clinical considerations. No single ethical approach to decision-making is sufficient, instead one which considers multiple contextual factors is necessary. Scores such as the Clinical Frailty Score and Sequential Organ Failure Assessment are of limited use in patients with COVID-19. Furthermore, the clinician is fully justified in withdrawing ICU care based on medical futility decisions and to reallocate this resource to a patient with a better prognosis. However, these decisions bear heavy emotional and moral burden compounded by the volume of clinical work and a fear of litigation. Conclusion We propose the formation of Provincial multi-disciplinary Critical Care Triage Committees to alleviate the emotional, moral and legal burden on individual ICU teams and co-ordinate inter-facility collaboration using an adapted framework. The committee would provide an impartial, broader and ethically-sound viewpoint which has time to consider broader contextual factors such as adjusting rationing criteria according to different levels of pandemic demand and the latest clinical evidence. Their functioning will be strengthened by direct feedback to national level and accountability to a national monitoring committee. The potential applications of these committees are far-reaching and have the potential to enable a more effective COVID-19 health systems response in South Africa.

Health System- and Patient-Related Factors Associated with COVID-19 Mortality among Hospitalized Patients in Limpopo Province of South Africa’s Public Hospitals

“…Burnout has been a major health care issue that has intensified with additional stressors arising from the COVID-19 pandemic. The findings are similar to existing literature which reported common knowledge that frontline health care workers had one of the highest incidences of burnout even before the pandemic [ 38 , 39 ]. Being at the frontline in direct contact with patients suspected or confirmed to have a COVID-19 infection exacerbates this.…”

Who gets the ventilator? A multicentre survey of intensivists' opinions of triage during the first wave of the COVID‐19 pandemic

“…may contribute to feelings of loss of influence on work situation and burnout. Naidoo et al suggested increased use of triage committees to alleviate emotional burden 36 …”

“…Naidoo et al suggested increased use of triage committees to alleviate emotional burden. 36 Hospitals worldwide have had to increase their ICU capacity during the pandemic. However, there is a limit to how ICU capacity can be stretched, even if physical space in the hospital is available.…”

Characterization of epidemiological distribution and outcome of COVID-19 in patients with hereditary hemorrhagic telangiectasia: a nationwide retrospective multi-centre study during first wave in Italy

“…As COVID-19 spreading rapidly exceeds hospital capacities, the decision between hospitalization or domiciliary management is crucial to relieve hospitals from overload [ 44 ]. Additionally, limited resource allocation poses a challenging issue in terms of clinical decision-making, in contexts where intensive care admission entails priority scores based on age, survival prognosis and pre-existing illnesses [ 45 ]. HHT is a rare disease potentially involving chronic conditions with a reduced life-expectancy, especially in absence of appropriate pre-emptive management [ 46 – 48 ].…”