Article Text

Development of a structured process for fair allocation of critical care resources in the setting of insufficient capacity: a discussion paper
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  1. Tim Cook1,
  2. Kim Gupta1,
  3. Chris Dyer2,
  4. Robin Fackrell2,
  5. Sarah Wexler3,
  6. Heather Boyes4,
  7. Ben Colleypriest5,
  8. Richard Graham6,
  9. Helen Meehan7,
  10. Sarah Merritt8,
  11. Derek Robinson9,
  12. Bernie Marden10
  1. 1Anaesthesia and Intensive Care Medicine, Royal United Hospital Bath NHS Trust, Bath, UK
  2. 2Older Persons Unit, Royal United Hospital Bath NHS Trust, Bath, UK
  3. 3Haematology, Royal United Hospital Bath NHS Trust, Bath, UK
  4. 4Legal Department, Royal United Hospital Bath NHS Trust, Bath, UK
  5. 5Gastroenterology, Royal United Hospital Bath NHS Trust, Bath, UK
  6. 6Radiology, Royal United Hospital Bath NHS Trust, Bath, UK
  7. 7Palliative Care, Royal United Hospital Bath NHS Trust, Bath, UK
  8. 8Women and Childrens Services, Royal United Hospital Bath NHS Trust, Bath, UK
  9. 9Orthopaedics, Royal United Hospital Bath NHS Trust, Bath, UK
  10. 10Paediatrics, Royal United Hospital Bath NHS Trust, Bath, UK
  1. Correspondence to Professor Tim Cook, Anaesthesia and Intensive Care Medicine, Royal United Hospital Bath NHS Trust, Bath BA1 3NG, UK; timcook007{at}gmail.com

Abstract

Early in the COVID-19 pandemic there was widespread concern that healthcare systems would be overwhelmed, and specifically, that there would be insufficient critical care capacity in terms of beds, ventilators or staff to care for patients. In the UK, this was avoided by a threefold approach involving widespread, rapid expansion of critical care capacity, reduction of healthcare demand from non-COVID-19 sources by temporarily pausing much of normal healthcare delivery, and by governmental and societal responses that reduced demand through national lockdown. Despite high-level documents designed to help manage limited critical care capacity, none provided sufficient operational direction to enable use at the bedside in situations requiring triage. We present and describe the development of a structured process for fair allocation of critical care resources in the setting of insufficient capacity. The document combines a wide variety of factors known to impact on outcome from critical illness, integrated with broad-based clinical judgement to enable structured, explicit, transparent decision-making founded on robust ethical principles. It aims to improve communication and allocate resources fairly, while avoiding triage decisions based on a single disease, comorbidity, patient age or degree of frailty. It is designed to support and document decision-making. The document has not been needed to date, nor adopted as hospital policy. However, as the pandemic evolves, the resumption of necessary non-COVID-19 healthcare and economic activity mean capacity issues and the potential need for triage may yet return. The document is presented as a starting point for stakeholder feedback and discussion.

  • decision-making
  • allocation of healthcare resources
  • clinical ethics

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Footnotes

  • Twitter @doctimcook

  • Contributors All authors contributed fully to the development of the critical care access document and the submitted manuscript. This included contributing to and reviewing the final document.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement There are no data.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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