Resource Allocation Discussion

Good afternoon. My thoughts and prayers go out to those who are in the midst of our nation crisis and faced with immensely difficult decisions.

This tread is to ask for insight in regards to ventilator (and other life saving resource) allocation, specifically in pediatric children hospitals that have attached adult wards/ICUs. As we know, the current COVID-19 pandemic carries a much higher risk and mortality rate in adults. Given the current rate of spread, there may be (in some locations already so) many adult ICUs who are overrun with critically ill patients in need of mechanical ventilation which could impinge on resources even from children’s hospitals. For those of us that work in pediatric ICUs and potentially share ventilators with adult ICUs, how are the resources being allocated? I understand that this is a difficult question to answer but I am looking for ideas (and in the background, hoping that this never needs to be implimented). Is there a percentage of ventilators that are being allocated specifically to the children’s hosptial? Who is making the ‘micro’ decision to allocate a ventilator to a critically ill child, say with RSV or trauma vs an adult with COVID19? Have any institutions made a resource allocation team to make these decisions? The default seems to be that the individual providers will have to make the decision but I feel that this is inherantly problematic and ethically questionable at best. Hence, the inquiry. Does anyone have resources or experience with this?

Thank you,
JM

In recent public health emergency like COVID 19 pandemic, the demand for healthcare resources and services will dramatically increase. Out of necessity, scarce resources and patient care will have to be allocated so as to generally “do the greatest good for the greatest number”.
There are guidelines, frameworks and theories developed to answer. But at the end if we keep ourselves in patients’s or relatives place will it be acceptable to us if treating physician says, the probability of dying is high in your case so you will not be given further advanced care but will be give palliative care. Is this acceptable> ??? NO.
But considering greater good to all than one those tough decision needs to be taken.

Definition of survival changes: the short-term likelihood of survival of the acute medical episode and is not focused on whether a patient may survive a given illness or disease in the long-term (e.g., years after the pandemic). By adopting this approach, every patient is held to a consistent standard. Triage decision-makers should not be influenced by subjective determinations of long-term survival, which may include biased personal values or quality of life opinions.
At our system we have a Recourse Allocation triage team ( 10-12members), and all the decision making is solely made on clinical and only clinical criteria. no other techniques should be used like randomization, flipping a coin etc. . The attending physician will not take decision on allocating a resource eg. ventilator or ICU bed. NEW York state has created a robust guideline available on their health department website https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf

The most important is to identify the current existing alternative medical treatment, the treatment, and patient safety and comfort should continue irrespective of ventilator received or not. multiple assessment from patient admission till the decision making point need to be performed before making decision.
ALL patients are treated equally, and have equal chance to receive a scare recourse based on their clinical condition exclusion inclusion criteria and then severity scorings like SOFA that can be used for assessment and then categories patients on priorities.

1 Like

I am particularly concerned that the decisions for which we are trained to make will be removed from our hands at exactly the time when they are the most needed. While it is right that these critical care council evaluations and decisions will include non-intensivists and non-physicians, they should also include an ICU physician who is not at that moment the attending physician.

It is possible that these administrative bodies feel they are doing the best good by making rules for allocation of resources based on scoring mechanisms that override the expert opinion of an intensivist. As critical care physicians, we determine severity of illness scores and ventilator weaning scores among others but as we know from our training and experience, these numbers do not always offer the correct actionable direction.

These decisions frequently do not consider other unique therapeutic alternatives such as co-ventilation, or use of transport ventilators or anesthesia machine ventilators. Will administrative councils decide which recommendations (which often change daily in times of disaster) will inform their decision-making or will they consult an intensivist who has intimate knowledge of the interventions.

I believe that these disaster-appointed administrative bodies may not understand that we make solemn life and death decisions many times a day and that we are the best experts to make decisions about which patient profile should have a limited resource. I hope that the lack of scientific soundness of this particular type of administrative reasoning flies in the face of our commitment and training as critical care physicians. We must stop disaster plans that do not involve an intensivist in a critical decision-making role when confronted with patient profiles and resource allocation.

Dear Concerned Critical care expert, there is no where in any guidelines that are out there mentioned that ICU physician should not be involved, matter of fact is that all these triage decisions are taken by a team of experts that is chaired by a board certified critical care medicine Physician, other all members are from Physician groups, expect for 2 members , one a social worker and other member from a religious/philosophical group( only if the organization has any affiliations). All decision making is only done on based of medical criteria.
Your day to day practice is very valuable in any situations, but in a pandemic situation. the definition of survival is different then regular day practice. Please don’t create confusion for yourself, You as ICU physician are most important resource available and we as medical professionals and community cherish your hard work and selfless commitment to serve in these times. We all pray that these kind of guidelines should never be implemented in our life times, but in wake of uncontrolled pandemics, you have assurance that Critical care physicians and all the critical care staffs decision making will be and is included in these guidelines. these are guidelines, not written verdicts, each organization have to use it based on the common agreement of their group, which is headed by CCM physicians.

Thank you for your concern that I may be creating confusion for myself. I have not suggested that there may be a rule banning critical care physicians as members. Thank you also for providing assurance that critical care staff decision-making will be and is included in these guidelines (beyond providing SOFA scores and making objections through an appeals process, I imagine) and that they are headed by CCM physicians. Would you provide the central source for this assurance?

Well, if you state and I quote, “these guidelines (beyond providing SOFA scores and making objections through an appeals process, I imagine) and that they are headed by CCM physicians.” then I would request you to please open any of the guidelines and read word to word. because you are fighting a battle that is based on misinformation and self made assumptions. Also I know American medical education system is one patient driven, patient driven treatment plans but the current situation is not for one patient. In Pandemic! there is no training on how to deal with patient surge! and not a patient surge when ther is road traffic accident, this is exponential surge with each patients with high severity of illness. so Get the grip of gravitas of the pandemic situation, and take time and read these guideline. I will attach a link too. so that there is no room for assumptions.

Lets take this in a compendium way.

  1. what kind of critical care delivery model is your health system/ hospital follow/adopted?
    I can answer for the one I work for: Closed ICU with Critical care director and day time bedside intensivist + 24/7 Tele-Intensivist Model.

So in functioning of the ICU( operational as well as clinical decision making - CCM plays a majot rolein every aspect of all hospital related decisions. And ICU is part of hospital) I don’t know what what kind of place do you work for that your concerned are that your opinions and ability of decision making will be overruled by some non physician people? and you would have to go to appeals. If that the situation where you are working then I don’t know what kind of assurance you want to me to provide you.

  1. Imagine a scenario where ICU bed capacity is 20. Patients in ICU admitted are 22, and you have a pool of patients( 100 patients) in step down that require ICU admissions. Suddenly one bed get vacant. and so from those hundred which patient will you give that one bed. Then which one patient would you give that bed. the one who will survive with that ICU bed if he ius in the ICU for 30 days or the one that will survive and get discharged in 1 day? or would you give that bed to a health care colleague who has acquire this infection, or a stroke case who is in golden period for treatment, or a pregnant women with complications. so if you have read the guidelines it mentions and coberes in depth decision flowcharts with only one criteria to judge and that is clinical criteria, no emotions.
    Here your clinical ability to save one individual patient is not important, when the pandemic has given you opportunity to do a greater good for the larger community of patients with limited hospital resources… There are modules that you can read, practice in such triage situations, You no longer work for patient driven diagnostic treatment plan, In Pandemics the driving force is how many people will survive in the limited recourse like ICU bed, ventilator and most important ICU intensivist. In a pandemic situation do you want to just treat one patient because your acumen, and ability proves that you will treat that patient for X amount of days.
    Identifying the vulnerable group is no ‘rocket science’ and therefore we must strive to utilize our efforts and direct our resources that would have a positive and beneficial outcome. It is no point on barking a tree where there is very little yield expected in return. We must therefore be well informed and well prepared to combat this deadly virus
    I will repeat that we all pray that this situation doesn’t escalate till triage for recourse allocation. but we still have to prepare.

Reading material: Triage for resource allocations:
Utley M, Pagel C, Peters MJ, et al. Does triage to critical care during a pandemic necessarily result in more survivors? Crit Care Med 2011;39:179–83. doi:10.1097/CCM.0b013e3181fa3c3b

Christian MD, Sprung CL, King MA, et al. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest 2014;146:e61S–74S. doi:10.1378/chest.14-0736

Vergano M, Bertolini G, Giannini A. . Clinical Ethics Recommendations for the Allocation of Intensive Care Treatments in exceptional, resource-limited circumstances - Version n. 1. Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI); 16th Mar 2020, 2020

Agency for Healthcare Research and Quality . AHRQ Publication No. 05-0043; Rockville, MD: 2005. Altered standards of care in mass casualty events. Prepared by Health Systems Research Inc. under Contract No. 290-04-0010.

AMA code of medical ethics: guidance in a pandemic. Available: https://www.ama-assn.org/delivering-care/public-health/ama-code-medical-ethics-guidance-pandemic

Emanuel EJ, Persad G, Upshur R, et al . Fair allocation of scarce medical resources in the time of Covid-19. N Engl J Med 2020. doi:doi:10.1056/NEJMsb2005114. [Epub ahead of print: 23 Mar 2020].pmid:http://www.ncbi.nlm.nih.gov/pubmed/32202722

Thank you to our supporters

              
Thank you to those that provided an unrestricted educational grant
Pfizer
The Society of Critical Care Medicine (SCCM) is the largest non-profit medical organization dedicated to promoting excellence and consistency in the practice of critical care. With members in more than 100 countries, SCCM is the only organization that represents all professional components of the critical care team. The Society offers a variety of activities that ensures excellence in patient care, education, research and advocacy. Read more
Headquarters
500 Midway Drive, Mount Prospect, IL 60056 USA

Phone: +1 847 827-6888
Fax: +1 847-439-7226
Email: support@sccm.org
© Society of Critical Care Medicine. All rights reserved.
The Society of Critical Care Medicine, SCCM and Critical Care Congress are registered trademarks of the Society of Critical Care Medicine.
Like SCCM on Facebook  @SCCM on Twitter  SCCM on LinkedIn  Subscribe to the SCCM YouTube Channel  Donate to SCCM