Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources.
Betacoronavirus
COVID-19
Canada
Caregivers
Continuity of Patient Care
/ organization & administration
Coronavirus Infections
/ epidemiology
Critical Care
/ ethics
Critical Illness
France
/ epidemiology
Health Personnel
Health Priorities
/ ethics
Health Resources
/ supply & distribution
Health Services Accessibility
/ ethics
Humans
Intensive Care Units
/ organization & administration
Pandemics
Patient Transfer
Pneumonia, Viral
/ epidemiology
Practice Guidelines as Topic
Refusal to Treat
/ ethics
Resource Allocation
/ ethics
SARS-CoV-2
Social Justice
Switzerland
Triage
/ ethics
COVID-19
Critical care
Ethics
Pandemic
Prioritisation
Triage
Journal
Anaesthesia, critical care & pain medicine
ISSN: 2352-5568
Titre abrégé: Anaesth Crit Care Pain Med
Pays: France
ID NLM: 101652401
Informations de publication
Date de publication:
06 2020
06 2020
Historique:
pubmed:
20
5
2020
medline:
28
7
2020
entrez:
20
5
2020
Statut:
ppublish
Résumé
Relying on capacity increases and patient transfers to deal with the huge and continuous inflow of COVID-19 critically ill patients is a strategy limited by finite human and logistical resources. Prioritising both critical care initiation and continuation is paramount to save the greatest number of lives. It enables to allocate scarce resources in priority to those with the highest probability of benefiting from them. It is fully ethical provided it relies on objective and widely shared criteria, thus preventing arbitrary decisions and guaranteeing equity. Prioritisation seeks to fairly allocate treatments, maximise saved lives, gain indirect life benefits from prioritising exposed healthcare and similar workers, give priority to those most penalised as a last resort, and apply similar prioritisation schemes to all patients. Prioritisation schemes and their criteria are adjusted to the level of resource scarcity: strain (level A) or saturation (level B). Prioritisation yields a four level priority for initiation or continuation of critical care: P1-high priority, P2-intermediate priority, P3-not needed, P4-not appropriate. Prioritisation schemes take into account the patient's wishes, clinical frailty, pre-existing chronic condition, along with severity and evolution of acute condition. Initial priority level must be reassessed, at least after 48h once missing decision elements are available, at the typical turning point in the disease's natural history (ICU days 7 to 10 for COVID-19), and each time resource scarcity levels change. For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount. Prioritisation strategy is bound to evolve with new knowledge and with changes within the epidemiological situation.
Sections du résumé
BACKGROUND
Relying on capacity increases and patient transfers to deal with the huge and continuous inflow of COVID-19 critically ill patients is a strategy limited by finite human and logistical resources.
RATIONALE
Prioritising both critical care initiation and continuation is paramount to save the greatest number of lives. It enables to allocate scarce resources in priority to those with the highest probability of benefiting from them. It is fully ethical provided it relies on objective and widely shared criteria, thus preventing arbitrary decisions and guaranteeing equity. Prioritisation seeks to fairly allocate treatments, maximise saved lives, gain indirect life benefits from prioritising exposed healthcare and similar workers, give priority to those most penalised as a last resort, and apply similar prioritisation schemes to all patients.
PRIORITISATION STRATEGY
Prioritisation schemes and their criteria are adjusted to the level of resource scarcity: strain (level A) or saturation (level B). Prioritisation yields a four level priority for initiation or continuation of critical care: P1-high priority, P2-intermediate priority, P3-not needed, P4-not appropriate. Prioritisation schemes take into account the patient's wishes, clinical frailty, pre-existing chronic condition, along with severity and evolution of acute condition. Initial priority level must be reassessed, at least after 48h once missing decision elements are available, at the typical turning point in the disease's natural history (ICU days 7 to 10 for COVID-19), and each time resource scarcity levels change. For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount.
PERSPECTIVE
Prioritisation strategy is bound to evolve with new knowledge and with changes within the epidemiological situation.
Identifiants
pubmed: 32426441
doi: 10.1016/j.accpm.2020.05.008
pii: S2352-5568(20)30091-6
pmc: PMC7230138
pii:
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
333-339Informations de copyright
Copyright © 2020 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
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