Recommendations from the Spanish Society of Intensive Medicine, Critical and Coronary Unities—published on March 2020
| Spain | |
| How | What |
| Planning ahead | Establish, in all patients admitted to hospital for COVID-19 or other reasons, advance planning with a clear definition of whether or not there is an indication for invasive mechanical ventilation (IMV) and/or admission to ICU and communicate it to the team. In the ICU, establish, at admission, whether or not the patient is subject to invasive measures and cardiopulmonary resuscitation. Anticipate the need for family attention and the possibility of professional burnout. |
| Proportionate care | Respiratory insufficiency is a high mortality and morbidity situation and so only some patients will benefit from IC treatment. There should always be an expected benefit and possibility of reversibility. |
| Distributive justice and triage procedures: | Establish an admission triage based on the principle of distributive justice, avoiding the use of the ‘first to arrive is the first to receive assistance’. |
| Maximising the global benefits | Apply strict ICU admission criteria based on maximising the benefit of the common good. Priority should be given to admitting those who may benefit most or have the highest life expectancy, at the time of admission. For two similar patients, priority should be given to the person with the most quality-adjusted life years saved. Admit the patient in a conditional manner in the first 48 hours, valuing the organic failure measured by the SOFA, if the benefit is not clear. Have in mind other facts, such as people dependent of the patient, to make decisions maximising the benefit of all; consider the social value of the sick person. Specific recommendations: only patients’ priority 1 or 2 (1—need IC and follow-up, 2—need intensive follow-up and may need immediate intervention) should be admitted. Patients over 80 years with comorbidities will preferably receive a high concentration oxygen mask, high flow oxygen therapy and non-invasive mechanical ventilation (NIMV). Patients between 70 and 80 years with acute respiratory insufficiency without important pathology are indicated for IMV. Patients between 70 and 80 years, who present moderate-severe comorbidities, will be preferably treated with NIVM or similar. Any patient with cognitive impairment, due to dementia or other degenerative diseases, will not be subsidiary to IMV. |
| Protection of professionals | The safety of health professionals is a priority in order to avoid diminishing human resources. Make efforts to prevent situations of burnout, including contributions of moral stress. |
| Precaution | The temporary and exceptional modification of admission criteria to the ICU, should be shared by all intervening parties. Contact the Ethics Committee to help prevent and resolve conflicts between participants in decision-making (professional, patients, family and institution). It should be verified if the patient has anticipated treatment provision. |
| Respect for patient autonomy | |
| Transparency | The patients, to whom these criteria are applied, should be informed about the extraordinary nature of the situation and the decisions made, in order to maintain transparency and trust in the health system. |
IC, intensive care; ICU, intensive care unit; SOFA, Sequential Organ Failure Assessment Score.