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Critical Care Medicine

Comparison of 2 Triage Scoring Guidelines for Allocation of Mechanical Ventilators

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
JAMA Network Open
December 14, 2020
Original Investigation
Hannah Wunsch, MD, MSc1,2,3,4,5,6;
Andrea D. Hill, PhD1,2;
Nicholas Bosch, MD, MSc7;
Neill K. J. Adhikari, MDCM, MSc1,2,4,8;
Gordon Rubenfeld, MD, MS1,2,4,8;
Allan Walkey, MD, MSc7;
Bruno L. Ferreyro, MD4,9;
Bourke W. Tillmann, MD1,4;
Andre C. K. B. Amaral, MD1,2,4,8;
Damon C. Scales, MD, PhD1,2,3,4,8,10;
Eddy Fan, MD, PhD4,8,9;
Brian H. Cuthbertson, MB, ChB, MD1,2,4,5;
Robert A. Fowler, MDCM, MS1,2,3,4,8
Author Affiliations
  • 1Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
  • 2Sunnybrook Research Institute, Toronto, Ontario, Canada
  • 3ICES, Toronto, Ontario, Canada
  • 4Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
  • 5Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
  • 6Department of Anesthesiology, Columbia University, New York, New York
  • 7Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
  • 8Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  • 9University Health Network and Sinai Health System, Toronto, Ontario, Canada
  • 10Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
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Audio Editors' Summary (14:42)
JAMA Network Open and COVID-19
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Key Points

Question  What are the characteristics of intensive care unit (ICU) admissions identified by selected criteria of 2 proposed pandemic ventilator allocation triage guidelines using Sequential Organ Failure Assessment scores when applied retrospectively to critically ill US patients who received mechanical ventilation?

Findings  In this cohort study of 40 439 admissions to ICU that received mechanical ventilation, the criteria of the New York State ventilator allocation guideline identified 9% who would likely meet criteria for the lowest priority for ventilator allocation compared with 4% using a framework that considered saving lives and life-years. Only 655 admissions (1.6%) were in the lowest priority category for both guidelines, with 39% survival to hospital discharge for admissions identified as lowest priority using the New York State guideline compared with with 56% for admissions identified using the save lives/life-years criteria.

Meaning  A comparison of selected triage criteria for mechanical ventilation showed little agreement, suggesting that further clinical assessment of different potential criteria for triage decisions is important to ensure valid allocation of resources.

Abstract

Importance  In the current setting of the coronavirus disease 2019 pandemic, there is concern for the possible need for triage criteria for ventilator allocation; to our knowledge, the implications of using specific criteria have never been assessed.

Objective  To determine which and how many admissions to intensive care units are identified as having the lowest priority for ventilator allocation using 2 distinct sets of proposed triage criteria.

Design, Setting, and Participants  This retrospective cohort study conducted in spring 2020 used data collected from US hospitals and reported in the Philips eICU Collaborative Research Database. Adult admissions (N = 40 439) to 291 intensive care units from 2014 to 2015 who received mechanical ventilation and were not elective surgery patients were included.

Exposures  Two sets of triage criteria: New York State Ventilator Allocation triage criteria developed in 2015 and 2 selected criteria from a 4-component allocation framework developed in 2020 using principles of saving lives and saving life-years (referred to as save lives/life-years criteria). Two other equity-focused criteria of this framework, giving heightened priority to health care workers and other essential workers, and prioritizing younger over older patients, were not included.

Main Outcomes and Measures  Sequential Organ Failure Assessment (SOFA) scores were calculated for admissions. The proportion of patients who met initial criteria for the lowest level of priority for mechanical ventilation using each set of criteria and their characteristics and outcomes were assessed. Agreement was compared between the 2 sets of triage criteria, recognizing differences in stated criteria aims.

Results  Among 40 439 intensive care unit admissions of patients who received mechanical ventilation, the mean (SD) age was 62.6 (16.6) years, 54.9% were male, and the mean (SD) SOFA score was 4.5 (3.7). Using the New York State triage criteria, 8.9% (95% CI, 8.7%-9.2%) were in the lowest priority category; these lowest priority admissions had a mean (SD) age of 62.9 (16.6) years, used a median (interquartile range) of 57.3 (20.1-133.5) ventilator hours each, and had a hospital survival rate of 38.6% (95% CI, 37.0%-40.2%). Using the save lives/life-years triage criteria, 4.3% (95% CI, 4.1%-4.5%) were in the lowest priority category; these admissions had a mean (SD) age of 68.6 (13.2) years, used a median (interquartile range) of 61.7 (24.3-142.8) ventilator hours each, and had a hospital survival rate of 56.2% (95% CI, 53.8%-58.7%). Only 655 admissions (1.6%) were in the lowest priority category for both guidelines, with the κ statistic for agreement equal to 0.20 (95% CI, 0.18-0.21).

Conclusions and Relevance  Use of selected criteria from 2 proposed ventilator triage guidelines identified approximately 1 in every 10 to 25 admissions as having the lowest priority for ventilator allocation, with little agreement. Clinical assessment of different potential criteria for triage decisions in critically ill populations is important to ensure valid allocation of resources.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

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Critical Care Medicine Emergency Medicine Guidelines Ethics Respiratory Failure and Ventilation Coronavirus (COVID-19)
Article Information

Accepted for Publication: October 19, 2020.

Published: December 14, 2020. doi:10.1001/jamanetworkopen.2020.29250

Correction: This article was corrected on February 8, 2021, to clarify the triage scoring criteria.

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

Corresponding Author: Hannah Wunsch, MD, MSc, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Room D1.08, Toronto, ON M4N 3M5, Canada (hannah.wunsch@sunnybrook.ca).

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

Concept and design: Wunsch, Bosch, Adhikari, Rubenfeld, Ferreyro, Scales, Cuthbertson, Fowler.

Acquisition, analysis, or interpretation of data: Wunsch, Hill, Bosch, Adhikari, Walkey, Tillmann, Amaral, Scales, Fan, Cuthbertson, Fowler.

Drafting of the manuscript: Wunsch, Cuthbertson, Fowler.

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

Statistical analysis: Wunsch, Hill, Rubenfeld, Cuthbertson, Fowler.

Obtained funding: Cuthbertson.

Administrative, technical, or material support: Wunsch, Cuthbertson, Fowler.

Supervision: Bosch, Rubenfeld, Cuthbertson.

Conflict of Interest Disclosures: Dr Walkey reported receiving royalties from a patent with UpToDate. Dr Scales reported receiving grants from the Canadian Institutes for Health Research outside the submitted work. Dr Fan reported receiving personal fees from ALung Technologies Inc, MC3 Cardiopulmonary, Fresenius Medical Care, and Getinge outside the submitted work. No other disclosures were reported.

Funding/Support: Funding provided by St Michael’s Hospital Medical Services Association Alternative Funding Plan for COVID.

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.

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