Chest
Contemporary Reviews in Critical Care MedicineToo Many Patients…A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters
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.