From the Journals

Get triage plans in place before COVID-19 surge hits, critical care experts say



While triage of critical care resources should be a rare event during the COVID-19 crisis, failing to prepare for the worst-case scenario could have serious consequences, according to authors of recent reports that offer advice on how to prepare for surges in demand.

This transmission electron microscope image shows SARS-CoV-2—also known as 2019-nCoV, the virus that causes COVID-19. isolated from a patient in the U.S., emerging from the surface of cells cultured in the lab. Courtesy NIAID-RML

Even modest numbers of critically ill COVID-19 patients have already rapidly overwhelmed existing hospital capacity in hard-hit areas including Italy, Spain, and New York City, said authors of an expert panel report released in CHEST.

“The ethical burden this places on hospitals, health systems, and society is enormous,” said Ryan C. Maves, MD, FCCP, of the Naval Medical Center in San Diego, lead author of the expert panel report from the Task Force for Mass Critical Care and the American College of Chest Physicians (CHEST).

Ryan C. Maves, MD, of the Naval Medical Center, San Diego Andrew Bowser/MDedge News

Dr. Ryan C. Maves

“Our hope is that a triage system can help us identify those patients with the greatest likelihood of benefiting from scarce critical care resources, including but not limited to mechanical ventilation, while still remembering our obligations to care for all patients as best we can under difficult circumstances,” Dr. Maves said in an interview.

Triage decisions could be especially daunting for resource-intensive therapies such as extracorporeal membrane oxygenation (ECMO), as physicians may be forced to decide when and if to offer such support after demand outstrips a hospital’s ability to provide it.

“ECMO requires a lot of specialized capability to initiate on a patient, and then, it requires a lot of specialized capability to maintain and do safely,” said Steven P. Keller, MD, of the division of emergency critical care medicine in the department of emergency medicine at Brigham and Women’s Hospital and Harvard Medical School in Boston.

Those resource requirements can present a challenge to health care systems already overtaxed by COVID-19, according to Dr. Keller, coauthor of a guidance document in Annals of the American Thoracic Society. The guidance suggests a pandemic approach to ECMO response that’s tiered depending on the intensity of the surge over usual hospital volumes.

Dr. Steven P. Keller, Brigham and Women's Hospital, Boston

Dr. Steven P. Keller

Mild surges call for a focus on increasing ECMO capacity, while a moderate surge may indicate a need to focus on allocating scarce resources, and a major surge may signal the need to limit or defer use of scarce resources, according to the guidance.

“If your health care system is stretched from a resource standpoint, at what point do you say, ‘we don’t even have the capability to even safely do ECMO, and so, perhaps we should not even be offering the support’?” Dr. Keller said in an interview. “That’s what we tried to get at in the paper – helping institutions think about how to prepare for that pandemic, and then when to make decisions on when it should and should not be offered.”


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