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Variation in Ventilator Allocation Guidelines by US State During the Coronavirus Disease 2019 PandemicA Systematic Review

Educational Objective
To understand the variation in ventilator allocation guidelines by US State during COVID-19
1 Credit CME
Key Points

Question  How many US states have ventilator allocation guidelines and how do these guidelines compare with one another?

Findings  In this systematic review of publicly available US state guidelines about ventilator allocation, only 26 states provided guidance on how this allocation should occur, and their guidelines varied significantly.

Meaning  These findings suggest significant variation in US state ventilator guidelines, which could cause inequity in allocation of mechanical ventilatory support during a public health emergency, such as the coronavirus disease 2019 pandemic.

Abstract

Importance  During the coronavirus disease 2019 pandemic, there may be too few ventilators to meet medical demands. It is unknown how many US states have ventilator allocation guidelines and how these state guidelines compare with one another.

Objective  To evaluate the number of publicly available US state guidelines for ventilator allocation and the variation in state recommendations for how ventilator allocation decisions should occur and to assess whether unique criteria exist for pediatric patients.

Evidence Review  This systematic review evaluated publicly available guidelines about ventilator allocation for all states in the US and in the District of Columbia using department of health websites for each state and internet searches. Documents with any discussion of a process to triage mechanical ventilatory support during a public health emergency were screened for inclusion. Articles were excluded if they did not include specific ventilator allocation recommendations, were in draft status, did not include their state department of health, or were not the most up-to-date guideline. All documents were individually assessed and reassessed by 2 independent reviewers from March 30 to April 2 and May 8 to 10, 2020.

Findings  As of May 10, 2020, 26 states had publicly available ventilator guidelines, and 14 states had pediatric guidelines. Use of the Sequential Organ Failure Assessment score in the initial rank of adult patients was recommended in 15 state guidelines (58%), and assessment of limited life expectancy from underlying conditions or comorbidities was included in 6 state guidelines (23%). Priority was recommended for specific groups in the initial evaluation of patients in 6 states (23%) (ie, Illinois, Maryland, Massachusetts, Michigan, Pennsylvania, and Utah). Many states recommended exclusion criteria in adult (11 of 26 states [42%]) and pediatric (10 of 14 states [71%]) ventilator allocation. Withdrawal of mechanical ventilation from a patient to give to another if a shortage occurs was discussed in 22 of 26 adult guidelines (85%) and 9 of 14 pediatric guidelines (64%).

Conclusions and Relevance  These findings suggest that although allocation guidelines for mechanical ventilatory support are essential in a public health emergency, only 26 US states provided public guidance on how this allocation should occur. Guidelines among states, including adjacent states, varied significantly and could cause inequity in the allocation of mechanical ventilatory support during a public health emergency, such as the coronavirus disease 2019 pandemic.

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Article Information

Accepted for Publication: May 17, 2020.

Published: June 19, 2020. doi:10.1001/jamanetworkopen.2020.12606

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Piscitello GM et al. JAMA Network Open.

Corresponding Author: Gina M. Piscitello, MD, Department of Medicine, Rush University, 1620 W Harrison St, Chicago, IL 60612 (gina_piscitello@rush.edu).

Author Contributions: Dr Piscitello had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Piscitello, Rojas, Siegler, Parker.

Acquisition, analysis, or interpretation of data: Piscitello, Kapania, Miller, Parker.

Drafting of the manuscript: Piscitello, Miller, Rojas.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Piscitello.

Administrative, technical, or material support: Kapania, Parker.

Supervision: Rojas, Siegler, Parker.

Conflict of Interest Disclosures: Dr Parker reported receiving grants from the National Heart, Lung, and Blood Institute outside the submitted work. No other disclosures were reported.

Funding/Support: Dr Miller is supported by grant No. T32 HL 07605 from the National Institutes of Health.

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

References
1.
Slutsky  AS .  History of mechanical ventilation: from Vesalius to ventilator-induced lung injury.   Am J Respir Crit Care Med. 2015;191(10):1106-1115. doi:10.1164/rccm.201503-0421PPPubMedGoogle ScholarCrossref
2.
Calabresi  G .  Tragic Choices. W. W. Norton & Co; 1978.
3.
White  DB , Lo  B .  A framework for rationing ventilators and critical care beds during the COVID-19 pandemic.   JAMA. 2020;323(18):1773–1774. doi:10.1001/jama.2020.5046PubMedGoogle Scholar
4.
Christian  MD , Hawryluck  L , Wax  RS ,  et al.  Development of a triage protocol for critical care during an influenza pandemic.   CMAJ. 2006;175(11):1377-1381. doi:10.1503/cmaj.060911PubMedGoogle ScholarCrossref
5.
Christian  MD , Devereaux  AV , Dichter  JR , Rubinson  L , Kissoon  N ; Task Force for Mass Critical Care; Task Force for Mass Critical Care.  Introduction and executive summary: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.   Chest. 2014;146(4)(suppl):8S-34S. doi:10.1378/chest.14-0732PubMedGoogle ScholarCrossref
6.
Polzin-Rosenberg  N .  One ventilator too few?   Hastings Cent Rep. 2018;48(2). doi:10.1002/hast.830Google Scholar
7.
Daugherty Biddison  EL , Faden  R , Gwon  HS ,  et al.  Too many patients: a framework to guide statewide allocation of scarce mechanical ventilation during disasters.   Chest. 2019;155(4):848-854. doi:10.1016/j.chest.2018.09.025PubMedGoogle ScholarCrossref
8.
White  DB , Katz  MH , Luce  JM , Lo  B .  Who should receive life support during a public health emergency: using ethical principles to improve allocation decisions.   Ann Intern Med. 2009;150(2):132-138. doi:10.7326/0003-4819-150-2-200901200-00011PubMedGoogle ScholarCrossref
9.
Kanter  RK .  Would triage predictors perform better than first-come, first-served in pandemic ventilator allocation?   Chest. 2015;147(1):102-108. doi:10.1378/chest.14-0564PubMedGoogle ScholarCrossref
10.
Berlinger  N , Wynia  M , Powell  T ,  et al. Ethical framework for health care institutions and guidelines for institutional ethics services responding to the coronavirus pandemic. Hastings Center. March 16, 2020. Accessed April 1, 2020. https://www.thehastingscenter.org/ethicalframeworkcovid19/
11.
Truog  RD , Mitchell  C , Daley  GQ .  The toughest triage—allocating ventilators in a pandemic.   N Engl J Med. 2020;382(21):1973-1975. doi:10.1056/NEJMp2005689PubMedGoogle ScholarCrossref
12.
Cohen  IG , Crespo  AM , White  DB .  Potential legal liability for withdrawing or withholding ventilators during COVID-19: assessing the risks and identifying needed reforms.   JAMA. 2020;323(19):1901–1902. doi:10.1001/jama.2020.5442PubMedGoogle ScholarCrossref
13.
Ventilator Document Workgroup, Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. Ethical considerations for decision making regarding allocation of mechanical ventilators during a severe influenza pandemic or other public health emergency. Published July 2011. Accessed April 1, 2020. https://www.cdc.gov/about/advisory/pdf/VentDocument_Release.pdf
14.
New York State Task Force on Life and the Law; New York State Department of Health. Ventilator allocation guidelines. Published November 2015. Accessed March 29, 2020. https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf
15.
Indiana State Department of Health Crisis Standards of Care Community Advisory Group. Crisis standards of patient care guidance with an emphasis on pandemic influenza: triage and ventilator allocation guidelines. Published April 2014. Accessed March 29, 2020. https://docisolation.prod.fire.glass/?guid=aedb900d-d079-4a4d-e839-7a251cfecdab
16.
Pennsylvania Department of Health. Interim Pennsylvania standards of care for pandemic guidelines: version 2. Published April 2020. Accessed May 8, 2020. https://www.health.pa.gov/topics/Documents/Diseases%20and%20Conditions/COVID-19%20Interim%20Crisis%20Standards%20of%20Care.pdf
17.
Subject Matter Experts Advisor Panel for the Governors Expert Emergency Epidemic Response Committee. Crisis standards of care guidelines for hospitals for the COVID-19 Pandemic. Revised April 2020. Accessed May 8, 2020. https://drive.google.com/file/d/1OgZXJNMr9AA9X-S1QJNBCCRif6kbdxI5/view
18.
Tennessee Altered Standards of Care Workgroup. Guidance for the ethical allocation of scarce resources during a community-wide public health emergency as declared by the Governor of Tennessee: version 1.6. Published July 2016. Accessed March 29, 2020. http://www.midsouthepc.org/wp-content/uploads/2018/05/2016_Guidance_for_the_Ethical_Allocation_of_Scarce_Resources.pdf
19.
Kansas Department of Health and Environment. Toolkit for COVID-19. Published February 2020. Accessed April 2, 2020. https://int.nyt.com/data/documenthelper/6847-kansas-triage-guidelines/02cb4c58460e57ea9f05/optimized/full.pdf#page=1
20.
Disability Rights Education and Defense Fund. Preventing discrimination in the treatment of COVID-19 patients: the illegality of medical rationing on the basis of disability. Published March 2020. Accessed April 1, 2020. https://dredf.org/the-illegality-of-medical-rationing-on-the-basis-of-disability/
21.
Department of Health and Human Services Office for Civil Rights in Action. Bulletin: civil rights, HIPAA, and the coronavirus disease 2019 (COVID-19). Published March 2020. Accessed May 8, 2020. https://www.hhs.gov/sites/default/files/ocr-bulletin-3-28-20.pdf
22.
DeMartino  ES , Dudzinski  DM , Doyle  CK ,  et al.  Who decides when a patient can’t? statutes on alternate decision makers.   N Engl J Med. 2017;376(15):1478-1482. doi:10.1056/NEJMms1611497PubMedGoogle ScholarCrossref
23.
Daugherty-Biddison  L , Gwon  H , Regenberg  A , Schoch-Spana  M , Toner  E . Maryland framework for the allocation of scarce life-sustaining medical resources in a catastrophic public health emergency. Published August 2017. Accessed March 31, 2020. https://www.law.umaryland.edu/media/SOL/pdfs/Programs/Health-Law/MHECN/ASR%20Framework_Final.pdf
24.
Michigan Department of Health and Human Services. Planning for children in disasters: a hospital toolkit. Accessed March 30, 2020. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EMSTRAUMASYSTEMS/EMSFORCHILDREN/Documents/MichiganHospitalPlanningForChildrenInDisasters.pdf
25.
Utah Department of Health and Utah Hospital Association. Utah crisis standards of care guidelines: version 2. Published June 2018. Accessed April 2, 2020. https://int.nyt.com/data/documenthelper/6852-utah-triage-guidelines/02cb4c58460e57ea9f05/optimized/full.pdf
26.
Illinois Department of Public Health. Guidelines on emergency preparedness for hospitals during COVID-19. Accessed May 8, 2020. https://www.dph.illinois.gov/sites/default/files/Guidelines%20on%20Emergency%20Preparedness.pdf
27.
Dorothy  E . Vawter  J , Garrett  E ,  et al. For the good of us all: ethically rationing health resources in Minnesota in a severe influenza pandemic. Accessed March 29, 2020. https://www.health.state.mn.us/communities/ep/surge/crisis/ethics.pdf
28.
Department of Health and Human Services Office for Civil Rights in Action. OCR resolves civil rights complaint against Pennsylvania after it revises its pandemic health care triaging policies to protect against disability discrimination. Published April 2020. Accessed May 9, 2020. https://www.hhs.gov/about/news/2020/04/16/ocr-resolves-civil-rights-complaint-against-pennsylvania-after-it-revises-its-pandemic-health-care.html
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