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BREAKING BUSINESS NEWS | BREAKING BUSINESS NEWS AM | BREAKING BUSINESS NEWS PM

If COVID hospitalisations increase, it’s still not clear how patients will be
prioritised for ICU beds
The Conversation



26 Oct 2021



Around the world, the coronavirus pandemic has put unprecedented strain on
intensive care resources. In some places, including parts of Italy, the United
States, Canada, and the Asia-Pacific, ICUs have been overwhelmed. Reports from
Italy found doctors were “weeping in the hospital hallways because of the
choices they were going to have to make”.

In this respect, Australia has fared relatively well in the pandemic. Initial
modelling suggested Australian ICUs would be overwhelmed in April 2020, but
successful public health measures prevented this.

COVID vaccines now offer significant protection against hospitalisation. But as
Australia prepares to open its borders, experts have raised concerns that even
with 80% of the population vaccinated, hospitals may yet be strained and
possibly overwhelmed.

This raises the difficult question of how to undertake triage: who gets scarce
life-saving resources when hospitals are overwhelmed, and how are these
decisions made?

So far, Australian state and territory governments have not answered these
questions.

--------------------------------------------------------------------------------

Read more: In Victoria, whether you get an ICU bed could depend on the hospital

--------------------------------------------------------------------------------


RESOURCE ALLOCATION IN A CRISIS

Health systems can increase their capacity in a crisis. However, a recent study
found although Australia now has enough ICU beds and ventilators, we lack
sufficient trained staff to operate them. If we are overwhelmed by COVID, not
all patients who might benefit will be treated.

In some countries, governments have released their triage protocols for such
scenarios – documents that set out the process and rules that determine which
patients get treatment if hospitals are overwhelmed.

Most triage protocols aim to prioritise those who are most likely to benefit
from ICU admission.

For example, a province-wide protocol has been released in Alberta, Canada.
While not yet activated, the Alberta government is instructing clinicians on its
use as the province faces a devastating fourth wave.

The Alberta protocol involves a phased, multi-step process to decide which
patients to admit to critical care when demand for resources outstrips supply.

In phase 1 (major surge with critical care bed occupancy at 90% or greater),
those with certain conditions including severe dementia, advanced cancer, bad
burns, or at a high risk of stroke, are deprioritised.

In phase 2 (large scale surge with critical care bed occupancy at 95% or
greater), further categories of adult patients are deprioritised. Paediatric
triage is also activated, using similar criteria related to a child’s life
expectancy and likelihood of survival.


BENEFITS OF TRANSPARENT TRIAGE PROTOCOLS

When health system resources are overwhelmed, clinicians may be forced to deny
treatment to patients who would otherwise receive it.

This creates a risk clinicians might be subject to lawsuits for negligence,
disciplinary sanctions, or even criminal charges.

These legal risks may be reduced by triage protocols, which may provide
clinicians with a legal defence.

--------------------------------------------------------------------------------

Read more: We're two frontline COVID doctors. Here's what we see as case numbers
rise

--------------------------------------------------------------------------------

Another benefit of triage protocols is they can promote transparent and
consistent allocation decisions and minimise perceptions of bias.


A LACK OF TRANSPARENT PROTOCOLS

To maximise consistency and fairness, triage protocols should be issued by
governments, not individual hospitals.

However, in Australia, government coronavirus triage protocols either do not
exist, or have not been made public.

Our research found a lack of protocols on state and territory government
websites. Health department websites for the ACT, Northern Territory, South
Australia, Tasmania, Victoria, and Western Australia did not mention a
coronavirus triage protocol.

Queensland Health released a detailed ethical guidance framework, which was
later removed from its website in mid-2020, without an official statement or
explanation.

New South Wales Health has created a pandemic response framework, which mentions
allocation frameworks and tools, but these have not been made public.


PUBLIC SCRUTINY

There are good reasons to prepare and publicly release triage protocols before a
health crisis.

First, this allows debate on the ethical basis for decisions.

While there is broad agreement about some principles (for example, that
protocols should apply to all patients, not just those with COVID), considerable
debate remains on other issues.

Should younger people be prioritised? What about those who are vaccinated? If
two patients are eligible for a resource, what factors should act as a
“tiebreaker”? Should essential workers be prioritised?

Timely release of triage protocols allows for public scrutiny of these ethical
questions.

--------------------------------------------------------------------------------

Read more: Coronavirus and triage: a medical ethicist on how hospitals make
difficult decisions

--------------------------------------------------------------------------------

Second, releasing triage protocols before a health crisis allows exploration of
whether a protocol is lawful.

There are inherent risks here. A triage protocol could veer into unlawful
discrimination on the basis of age or disability, or violate guardianship laws
designed to protect the vulnerable.

Transparency, consultation, and litigation all play a role in testing the legal
boundaries. Guidelines in the United Kingdom, for example, were updated after a
legal action was initiated. The proposed challenge argued the guidelines
unlawfully discriminated against people with long-term disabilities by relying
too heavily on a frailty assessment tool. The revised guideline clarified that
the tool should not be used in certain groups.

Third, prior release enables preparation and education. Triage policy and
decision-making cannot be left until the ICU door.

Clinicians and the public must know what to expect and have a chance to
understand the necessity for triage and the basis of decisions being made.


WHAT NEEDS TO HAPPEN NOW?

State and territory governments should release triage protocols (if they have
them), and if not, they should develop them, with public consultation.

Governments can readily borrow from the experience of other jurisdictions. They
might also look to professional organisations for guidance.

While it’s possible Australian health services will not be overwhelmed, proposed
relaxations of border and quarantine controls clearly signal that pressure will
build in coming months.

Having unimplemented public triage protocols in place would be a small problem;
having no protocols when they are needed could be devastating.

--------------------------------------------------------------------------------

Read more: We're seeing more COVID patients in ICU as case numbers rise. That
affects the whole hospital

--------------------------------------------------------------------------------

Eliana Close contributed to the "ANZICS guiding principles for complex decision
making during the COVID-19 pandemic." She is currently appointed on an
Australian Research Council Future Fellowship (project number FT190100410:
Enhancing End-of-Life Decision-Making: Optimal Regulation of Voluntary Assisted
Dying) funded by the Australian Government.

Ben White receives funding from the Australian Research Council, the National
Health and Medical Research Council and Commonwealth and State Governments for
research and training about the law, policy and practice relating to end-of-life
care. Of relevance for this article, he contributed to the "ANZICS guiding
principles for complex decision making during the COVID-19 pandemic." He is a
current recipient of an Australian Research Council Future Fellowship (project
number FT190100410: Enhancing End-of-Life Decision-Making: Optimal Regulation of
Voluntary Assisted Dying) funded by the Australian Government.

Lindy Willmott receives funding from the Australian Research Council, the
National Health and Medical Research Council and the Commonwealth and State
governments for research and training about the law, policy and practice
relating to end-of-life care. Of relevance for this article, she contributed to
the "ANZICS guiding principles for complex decision making during the COVID-19
pandemic".

Simon Young, Tina Cockburn, and Will Cairns do not work for, consult, own shares
in or receive funding from any company or organisation that would benefit from
this article, and have disclosed no relevant affiliations beyond their academic
appointment.


Read the full article here.
This content was originally published by The Conversation. Original publishers
retain all rights. It appears here for a limited time before automated
archiving. By The Conversation

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COVID-19 – JOHNS HOPKINS UNIVERSITY



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