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Perspectives of Triage Team Members Participating in Statewide Triage Simulations for Scarce Resource Allocation During the COVID-19 Pandemic in Washington State

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
JAMA Network Open
Published Online: April 18, 2022
Original Investigation
Catherine R. Butler, MD, MA1,2;
Laura B. Webster, DBe, RN, HEC-C3,4;
Douglas S. Diekema, MD, MPH5,6;
Megan M. Gray, MD5;
Vicki L. Sakata, MD5,7;
Mark R. Tonelli, MD, MA8;
Kelly C. Vranas, MD, MCR9,10
Author Affiliations
  • 1Division of Nephrology, Department of Medicine, University of Washington, Seattle
  • 2Veterans Affairs Health Services Research and Development Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington
  • 3Bioethics Program, Virginia Mason Medical Center, Seattle, Washington
  • 4Department of Bioethics and Humanities, University of Washington School of Medicine, Seattle
  • 5Department of Pediatrics, University of Washington School of Medicine, Seattle
  • 6Trueman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute, Seattle, Washington
  • 7Northwest Healthcare Response Network, Seattle, Washington
  • 8Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle
  • 9Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon
  • 10Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland
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Key Points

Question  What are the experiences of individuals participating in scarce resource triage teams during the COVID-19 pandemic, and how can clinicians prepare for this role?

Findings  In this qualitative study of 41 triage team members participating in multi-institutional triage simulations in Washington state, participants described how they grappled with clinical uncertainty and ethical challenges and how the triage task could conflict with professional values and required transformation of the usual clinical mindset.

Meaning  These findings highlight challenges that triage team members may face and suggest that clinical experience, education in ethical and operational foundations of triage, and experiential training may help prepare them for this difficult role.

Abstract

Importance  The COVID-19 pandemic prompted health care institutions worldwide to develop plans for allocation of scarce resources in crisis capacity settings. These plans frequently rely on rapid deployment of institutional triage teams that would be responsible for prioritizing patients to receive scarce resources; however, little is known about how these teams function or how to support team members participating in this unique task.

Objective  To identify themes illuminating triage team members’ perspectives and experiences pertaining to the triage process.

Design, Setting, and Participants  This qualitative study was conducted using inductive thematic analysis of observations of Washington state triage team simulations and semistructured interviews with participants during the COVID-19 pandemic from December 2020 to February 2021. Participants included clinician and ethicist triage team members. Data were analyzed from December 2020 through November 2021.

Main Outcomes and Measures  Emergent themes describing the triage process and experience of triage team members.

Results  Among 41 triage team members (mean [SD] age, 50.3 [11.4] years; 21 [51.2%] women) who participated in 12 simulations and 21 follow-up interviews, there were 5 Asian individuals (12.2%) and 35 White individuals (85.4%); most participants worked in urban hospital settings (32 individuals [78.0%]). Three interrelated themes emerged from qualitative analysis: (1) understanding the broader approach to resource allocation: participants strove to understand operational and ethical foundations of the triage process, which was necessary to appreciate their team’s specific role; (2) contending with uncertainty: team members could find it difficult or feel irresponsible making consequential decisions based on limited clinical and contextual patient information, and they grappled with ethically ambiguous features of individual cases and of the triage process as a whole; and (3) transforming mindset: participants struggled to disentangle narrow determinations about patients’ likelihood of survival to discharge from implicit biases and other ethically relevant factors, such as quality of life. They cited the team’s open deliberative process, as well as practice and personal experience with triage as important in helping to reshape their usual cognitive approach to align with this unique task.

Conclusions and Relevance  This study found that there were challenges in adapting clinical intuition and training to a distinctive role in the process of scarce resource allocation. These findings suggest that clinical experience, education in ethical and operational foundations of triage, and experiential training, such as triage simulations, may help prepare clinicians for this difficult role.

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Critical Care Medicine Emergency Medicine Ethics Public Health Coronavirus (COVID-19)
Article Information

Accepted for Publication: February 28, 2022.

Published: April 18, 2022. doi:10.1001/jamanetworkopen.2022.7639

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Butler CR et al. JAMA Network Open.

Corresponding Author: Catherine R. Butler, MD, MA, Division of Nephrology, Department of Medicine, University of Washington, 325 Ninth Ave, Seattle, WA 98104 (cathb@uw.edu).

Author Contributions: Dr Butler 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: Butler, Webster, Diekema, Gray, Sakata, Tonelli.

Acquisition, analysis, or interpretation of data: Butler, Webster, Diekema, Gray, Tonelli, Vranas.

Drafting of the manuscript: Butler, Vranas.

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

Statistical analysis: Butler.

Obtained funding: Butler.

Administrative, technical, or material support: Butler, Gray, Sakata, Tonelli.

Supervision: Butler, Diekema.

Conflict of Interest Disclosures: None reported.

Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the US government.

Additional Contributions: The authors would like to acknowledge Josh Edrich, MPH (Northwest Healthcare Response Network), for his contributions to study coordination. They also thank the study participants, whose efforts made this work possible. The contributor and participants were not compensated for this work.

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