Variation in Ventilator Allocation Guidelines by US State During the Coronavirus Disease 2019 Pandemic

Abstract

IMPORTANCE During the coronavirus disease 2019 pandemic, there may be too few ventilators to meet medical demands. It is unknown how many US states have ventilator allocation guidelines and how these state guidelines compare with one another. OBJECTIVE To evaluate the number of publicly available US state guidelines for ventilator allocation and the variation in state recommendations for how ventilator allocation decisions should occur and to assess whether unique criteria exist for pediatric patients. EVIDENCE REVIEW This systematic review evaluated publicly available guidelines about ventilator allocation for all states in the US and in the District of Columbia using department of health websites for each state and internet searches. Documents with any discussion of a process to triage mechanical ventilatory support during a public health emergency were screened for inclusion. Articles were excluded if they did not include specific ventilator allocation recommendations, were in draft status, did not include their state department of health, or were not the most up-to-date guideline. All documents were individually assessed and reassessed by 2 independent reviewers from March 30 to April 2 and May 8 to 10, 2020. FINDINGS As of May 10, 2020, 26 states had publicly available ventilator guidelines, and 14 states had pediatric guidelines. Use of the Sequential Organ Failure Assessment score in the initial rank of adult patients was recommended in 15 state guidelines (58%), and assessment of limited life expectancy from underlying conditions or comorbidities was included in 6 state guidelines (23%). Priority was recommended for specific groups in the initial evaluation of patients in 6 states (23%) (ie, Illinois, Maryland, Massachusetts, Michigan, Pennsylvania, and Utah). Many states recommended exclusion criteria in adult (11 of 26 states [42%]) and pediatric (10 of 14 states [71%]) ventilator allocation. Withdrawal of mechanical ventilation from a patient to give to another if a shortage occurs was discussed in 22 of 26 adult guidelines (85%) and 9 of 14 pediatric guidelines (64%). CONCLUSIONS AND RELEVANCE These findings suggest that although allocation guidelines for mechanical ventilatory support are essential in a public health emergency, only 26 US states provided public guidance on how this allocation should occur. Guidelines among states, including adjacent states, varied significantly and could cause inequity in the allocation of mechanical ventilatory support during a public health emergency, such as the coronavirus disease 2019 pandemic.

Mistrust and inconsistency during COVID-19: considerations for resource allocation guidelines that prioritise healthcare workers

“…Another review of US ventilator allocation guidelines found that only 26 states had publicly available documents describing how allocation would or should occur. 24 If transparency is indeed a prerequisite to trust, then it seems many institutions have inconsistently followed their own ethical requirements-and thereby undermined their own trustworthiness.…”

Ethical challenges for women’s healthcare highlighted by the COVID-19 pandemic

“…32 Thus, that many state ventilator allocation policies include prioritisation of the pregnant woman highlights the undercurrent of pronatalism, or the sociopolitical promotion of childbearing and parenthood. [33][34][35] In this way, while not a legally recognised entity, the presence of a fetus may result in a pregnant person receiving prioritisation for a ventilator compared with a non-pregnant person. Some states prioritise pregnant women after the gestational age of fetal viability or later in gestation given the state's interest in a viable fetus, coupled with the medical uncertainty regarding fetal outcomes when there is need for maternal ventilator support early in pregnancy.…”

COVID-19 ventilator rationing protocols: why we need to know more about the views of those with most to lose

“…Approximately half of available state-level guidance (13 of 25) refers to community engagement having informed the guidance, citing three of the six studies included in this review, although the integration of social science evidence is incomplete and untransparent (findings are not publicly available and it is not clear to what extent views of minorities have contributed to their formulation). 1 Further study is needed to elucidate community preferences, especially preferences that may be influenced by systemic inequity. Citation of community support for a specific principle requires context on differing trends across groups, and policy makers should engage more fully with disadvantaged populations.…”

“…In the wake of the initial US surge of the COVID-19 pandemic, numerous hospitals and states developed plans for how to allocate ventilators. [1][2][3][4] We seek to determine what is known about the views of historically and structurally disadvantaged populations on guiding rationing principles. This analysis matters practically for designing and reviewing triage models in the ongoing epidemic, and conceptually for assessing their underlying values.…”