Chest
Volume 155, Issue 4, April 2019, Pages 848-854
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Contemporary Reviews in Critical Care Medicine
Too Many Patients…A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters

https://doi.org/10.1016/j.chest.2018.09.025Get rights and content

The threat of a catastrophic public health emergency causing life-threatening illness or injury on a massive scale has prompted extensive federal, state, and local preparedness efforts. Modeling studies suggest that an influenza pandemic similar to that of 1918 would require ICU and mechanical ventilation capacity that is significantly greater than what is available. Several groups have published recommendations for allocating life-support measures during a public health emergency. Because there are multiple ethically permissible approaches to allocating scarce life-sustaining resources and because the public will bear the consequences of these decisions, knowledge of public perspectives and moral points of reference on these issues is critical. Here we describe a critical care disaster resource allocation framework developed following a statewide community engagement process in Maryland. It is intended to assist hospitals and public health agencies in their independent and coordinated response to an officially declared catastrophic health emergency in which demand for mechanical ventilators exceeds the capabilities of all surge response efforts and in which there has been an executive order to implement scarce resource allocation procedures. The framework, built on a basic scoring system with modifications for specific considerations, also creates an opportunity for the legal community to review existing laws and liability protections in light of a specific disaster response process.

Section snippets

Framework

The framework of this program is based first on a scoring system that primarily takes into account the two ethical considerations that are both most commonly used in existing guidance and also were of greatest importance to those who participated in the Maryland community engagement project: (1) likelihood of short-term survival (with the support of the scarce resource in question and other intensive care services) and (2) likelihood of long-term survival (based on presence of comorbid

Prospects for Short-Term Survival

The most straightforward measure of whether a patient will benefit from intensive care is whether that patient survives as a consequence of this care. Patients who are more likely to survive with intensive care are therefore given a higher priority when resources are scarce. The Sequential Organ Failure Assessment (SOFA) score and the Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score are systems developed to predict mortality over the short term. The scoring quartiles for SOFA/PELOD-2

Assignment of Priority Score

For the purpose of allocating scarce ventilators during a disaster, each patient with demonstrated need for mechanical ventilator support would first be assessed for the previously outlined exclusion criteria. In the absence of any of these clearly defined criteria, each patient would then be assigned an initial priority score based on short- and long-term survival, as outlined in Table 1.

Once an initial priority score is assigned, credit of a single point should be deducted from the score of

Discussion of Operational Conditions and Assumptions

The operational conditions and assumptions surrounding the implementation of a framework such as this one are central to its ability to contribute both to continuity of operations and associated community stability.

Limitations

It is unlikely that those tasked with allocation will face a simple case of determining which of two patients should receive a single ventilator. By definition, the sorts of disasters that trigger the need an allocation framework will result in many patients, arriving in a continuing stream, with shortages of not only ventilators, but also related necessary equipment and trained personnel. The high likelihood of difficult, chaotic conditions further reinforces the need for preparing an

Conclusion

All would hope that this framework will never be needed, either because we are lucky enough never to experience such a severe disaster or because our preparedness and response efforts keep a disaster from becoming a catastrophe. If a catastrophic shortage of life-sustaining medical resources cannot be averted, however, we have provided an allocation scheme that is informed by the values of the people of Maryland and is consistent with the general consensus of experts. This must be a living

Acknowledgments

Author contributions: E. L. D. B. takes responsibility for the integrity of the data and the accuracy of the data analysis. E. L. D. B., H. S. G., M. S.-S., A. C. R., R. F., J. S., D. P. M., and E. S. T. substantially contributed to the writing of the manuscript.

Financial/nonfinancial disclosure: None declared.

Other contributions: The authors acknowledge Jacquie Toner, PhD, for her efforts as the lead facilitator for this project. We also thank Chrissie Juliano, MPP, for her assistance in

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FUNDING/SUPPORT: The work that informed this manuscript was funded by the US Department of Health and Human Services through the Hospital Preparedness Program. The funder had no role in the design or conduct of the study or the interpretation of the results.

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