How have triage decisions been managed in Spain? The example of the Autonomous Community of Madrid (CAM)

The CAM (in Spanish) has been the region with the highest number of COVID-19 cases (over 47 000 at the beginning of April 2020, accounting for close to 28% of all Spanish cases).4 It has also been the unfortunate first region where hospitals, and specifically their intensive care units (ICUs), were saturated. On 10 March 2020, the Department of Clinical Bioethics of the University Hospital Infanta Elena, Valdemoro (Madrid) already identified the magnitude of the problem and the need to establish common criteria for triage. They prepared a document entitled ‘Ethical considerations regarding the management of patients who may require care in intensive care units’. The document stated that local and national administrations should provide resources based on distributive justice criteria and specifically called for a collaboration between public and private health institutions at a national level.5

This call for action went unanswered. Most hospitals and primary care systems have had to organise triage independently. It was not until the third week of March when scientific societies began to publish their general recommendations,6 the Spanish National Bioethics Committee (Comité de Bioética de España) did so at the end of that month7 and the official position paper from the Ministry of Health had to wait until the beginning of April.8 By then, all of Madrid’s ICUs had surrendered to the surge of COVID-19, and each centre had managed its triage protocols as best as it could. Indeed, lacking any suprainstitutional guidance, many centres were triaging ‘on the go’, without any structured protocol at all. If this delay were not enough, many of the aforementioned guidelines were eminently theoretical, lacking usefulness for clinicians who had to make clear, rapid decisions in their clinical practice. Triaging systems were carried out—and still are—according to local idiosyncrasies.

The COVID-19 crisis has exposed the fragile fragmentation of the Spanish healthcare system into its 17 Autonomous Communities or regions. In fact, every international guidelines insists that, before triage protocols are applied, an attempt should be made to increase the availability of ALS resources. This might be achieved by increasing the number of beds at the ICUs, according to each institution's possibilities and, much more importantly, by ensuring interinstitutional and regional patient mobility. Unfortunately, we have seen neither patient transfers between communities nor transfer of ALS resources from the least affected to the most affected regions. Each region has independently managed their ICU beds and triage protocols. With the notable exception of the transfer of patients in the Madrid region to the large, improvised field hospital established in IFEMA Convention Center,9 interinstitutional transfers have been exceptional. Moreover, though the guiding triage principles were commonly shared, specific criteria and triage protocols could differ among institutions. The application of diverging criteria might have led individual patients to be admitted to the ICU at a particular hospital, while at another nearby institution their admission to the ICU could have been denied. This is a serious attack on equity by the Spanish health system. Fractionation has undoubtedly been detrimental to many patients.

Principles and criteria for triage

As participants in the task force for the elaboration of general guidelines for hospital triage in the Madrid region, we have had the opportunity to review many national protocols and proposals on triage. Lacking explicit recommendations from national or regional public institutions, healthcare professionals themselves have drafted most of these protocols, which are surprisingly homogeneous and based mainly on the same ethical principles and clinical criteria10–12 (table 1).

Which criteria should be considered appropriate?

In order to guarantee that the ethical principles of equity and greatest good for the greatest number of patients are upheld, triage criteria should be as objective as possible.13 As in transplantation protocol, the only way to achieve this goal is to use essentially, if not only, criteria based on clinical parameters that allow for an homogeneous evaluation of potential candidates for ALS.

Hence, if triage criteria should be clinical, the fundamental question is which criteria to consider and how to evaluate them. The first step in most protocols, both national and international,14 is to rule out which patients should not be ICU candidates, regardless of the contingency of the current epidemic. The goal is to identify which patients are poor candidates for ICU admission given their clinical characteristics (see clinical criteria below). This first step should also consider those individuals who, after being properly informed in a shared decision-making process, voluntarily refuse admission to an ICU, either expressly or through advance directives. For patients not meeting these exclusion criteria, the next decision is to assess who is better suited to be eligible to receive ALS. Clinical criteria try to establish which patients combine a more favourable prognosis (greater chances of survival and benefit derived from treatment) and an a priori shorter length of expected ICU admission (box 1).

The next step is possibly the most daunting: deciding, based on daily available ALS resources, which ALS candidates will be admitted to intensive care and which will not. Once all candidates have been evaluated, a priority order should be established, placing the patient who would clinically benefit the most from ALS first. Following White et al’s15 recommendations, some institutions use a colour code to clarify this priority. This should be considered a temporary decision. A patient who is not admitted to the ICU at a certain time point could be reassessed and admitted later if resources become available.

To facilitate triage decision making, some protocols incorporate the establishment of decision committees (triage committees) whose goals are to carry out this comprehensive assessment of patients and also to help relieve primary care teams of the moral and emotional burden of these decisions.16 In a similar vein to transplant committees, it might be advisable that each centre establish a triage committee compounded of specialists in intensive care medicine, other healthcare professionals with experience in treating patients with COVID-19 and members of the institutional Healthcare Ethics Committee. All of the members should have a good understanding of the principles that guide triage and the clinical criteria on which the decision-making process is based.

What we mean by bad criteria for triage decisions

The aforementioned criteria attempt to balance the duty to care for each individual patient with the moral obligation to respect the interests of society as a whole, promoting fairness among patients and equity in the distribution of health resources. However, some institutional recommendations in Spain have incorporated other less objective, ethically problematic criteria.15 Some examples are the use of a specific age cut-off point for access to ALS, proposing ‘social value’ criteria, prioritising healthcare professionals’ access to ALS and suggesting triage based on a ‘first come, first served’ basis.