April 9, 2020

You may not have enough ventilators for the Covid-19 surge. Here are 4 ways to get ready.

Daily Briefing

    The ventilator shortage is forcing clinicians to have difficult conversations around which patients will receive support from a limited number of ventilators. The shortage has dominated the media cycle over the past week, but for hospital leaders the shortage goes beyond the headlines: it's a very real operational challenge impacting patients and the frontline clinicians caring for them.  

    How to protect your team's resilience in the coronavirus pandemic

    Whether your hospital is already facing a ventilator shortage, or is preparing for a potential shortage in the days and weeks ahead, it's essential to determine your ventilator allocation guidelines now to prevent downstream moral distress, legal issues, and inappropriate use of scarce supplies.

    Below, we outline four steps to help you develop and implement your organization's guidelines.

    4 steps to design and implement ventilator allocation guidelines

    1. Refresh state and hospital disaster triage guidelines for ventilator use to suit the demands of the Covid-19 pandemic. Public health officials are currently reviewing their state's respective pandemic plans and updating them to meet the needs of Covid-19. Look to local and state public health departments for the most up-to-date guidelines. If your hospital has yet to update its plan, ask your hospital's ethics committee to do a thorough review and update before your region faces an outbreak.

    2. Check for clauses in your state's resource allocation plan that grant immunity for civil liabilities to hospitals and clinicians that make allocation decisions during a national emergency or pandemic. Health care workers will make incredibly difficult decisions in managing Covid-19 patients, and it's important that they have legal protection while doing so. If your state does not have a resource allocation plan, look for a disaster or pandemic emergency act. Your state's governor may issue an executive order with legal immunity for health care workers during this time.

    3. Discuss your ventilator allocation guidelines with staff before allocation decisions have to be made. Rationing care or services can lead to moral distress and increased burnout among staff. Reassure staff as much as possible that your organization has sought provider input, consulted ethics advisors, and thoroughly vetted the guidelines before staff are forced to make those tough decisions.

    4. Establish a triage committee to serve as decision-makers for ventilator allocation. While frontline clinicians should provide input regarding specific patients, the triage committee should separately make decisions around ventilator allocation. Include representation from intensive care, palliative care, and clinical ethics as well as a mix of physicians, nurses, respiratory therapists and others with an understanding of the clinical course of Covid-19. The committee members should be free of bias as to gender, race, financial status, and other protected characteristics, and include someone with exceptional communication skills to have difficult conversations with patients and families impacted by the guidelines.

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    Draw on existing resource allocation frameworks to inform your organization's guidelines

    Below, we've highlighted prominent decision-making frameworks. While similar in nature, each of these frameworks differ slightly, illustrating the fact that there is not one clear way to allocate ventilators in times of scarcity. Regardless of the framework your hospital operates on, it is critical to consider patient choice about whether to be intubated.

    • Maryland CHEST framework: Over a two-year period, a Johns Hopkins-based team of researchers consulted the public and health care and disaster workers in each of Maryland's five emergency management regions about ventilator allocation guidelines. The resulting framework includes a scoring system that takes into account likelihood of short-term survival, based on the patient's Sequential Organ Failure Assessment (SOFA) or Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score, and likelihood of long-term survival based on their likelihood to live longer than 12 months if they receive ICU treatment. The framework includes considerations around age, pregnancy, and exclusion criteria.

    • Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) framework: On March 6, SIAARTI published resource allocation guidelines when hospitals experience extreme saturation. The 15 recommendations encourage hospital leaders to set an upper age limit for ICU admission during extreme resource-scarce situations. This framework argues that limited resources must be saved for those who have the greatest probability of survival and life expectancy for the largest number of people. ICU admission and resource allocation criteria also consider patient comorbidities in triage decisions.

    • Ezekiel Emmanuel et al. framework: Published in the NEJM on March 23, ten bioethicists, physicians, and other experts laid out six recommendations for rationing during the Covid-19 pandemic. Their recommendations—maximize benefits; prioritize health workers; do not allocate on a first-come-first-served basis; be responsive to evidence in decision-making; recognize and reward research participation; apply the same principles to all Covid-19 and non-Covid-19 patients—apply to all potentially rationed resources during the pandemic, but explicitly address ventilators and vaccines.

    • University of Pittsburgh framework: While reflecting the prioritization and scoring method of the CHEST framework, the University of Pittsburgh guidelines outline which comorbidities would be considered "major" and which would be "severely life limiting" when determining a patient's likelihood of long-term survival. This framework specifically removes categorical exclusion criteria to avoid triage decisions being interpreted to mean, "Some groups are 'not worth saving.'"
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