The goal of triage is to ensure the best outcome for the largest number of patients. COVID-19 has overwhelmed Intensive Care Units in regions around the world so that there are simply not enough resources to provide the highest standard of care to every patient who might possibly survive.
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In those cases, triage should select patients who have the best chance of pulling through over those with low odds of survival.
The great difficulty in COVID-19 cases is that not enough is known about the disease for strong evidence-based approaches. Using what is known and being discovered, ICUs should form triage committees to evaluate patients and handle the critical decisions over which patients should receive care and which should be offered only palliative measures when the unit becomes overwhelmed.
Those interprofessional teams should:
- Ensure standards are developed to account for care equity
- Develop and impose ICU admission criteria
- Assess currently admitted patients regularly
- Handle removal of critical care when warranted
- Handle family communication
- Document triage decisions
COVID-19 Is Requiring Old Skills To Be Relearned in Some ICUs
Although prioritizing patients in triage is something every nurse has studied, it has become extraordinarily rare in modern medical practice. Even as American hospital bed capacity has declined over the past decades, well-developed regional healthcare cooperation has all but assured critically injured patients from even large incidents can be distributed to appropriate definitive care. While triage is still used to develop priority of care plans, a stark choice over who will live and who will die is not typically required. Almost all patients are treated to the limits of current medical science, rather than the limits of available resources.
COVID-19 is a disease that is spreading so quickly, infecting such high numbers of patients, and requires such lengthy and intensive care for enough of them that even regional surge capacities are being tested. Nurses and physicians may need to turn patients away from intensive care at some point, in some areas.
If it happens in your facility, it will be among the hardest things you will ever have to do in your nursing career.
Act Early to Lay The Groundwork for Effective Triage Efforts
If anything is harder than triage itself, it’s having to perform it without adequate guidelines and a well-established decision-making process. Healthcare facilities should act early to lay out their standards and decision points to avoid confusion in the heat of the moment
Form a Triage Committee or Appoint Officers
Triage is emotionally taxing and is a grave responsibility. To reduce the impact on care teams, it is best performed by providers who are not directly related or otherwise involved with the patient being assessed. An interprofessional triage team offers the best combination of experience and expertise for triage throughout the crisis.
Staffing shortages can make it difficult to put multiple providers on triage, but sharing the burden offers multiple benefits:
- Less individual emotional strain on decision-makers
- Higher quality decisions emerge by consensus
- Greater availability during high-pressure periods
In smaller or more heavily-taxed facilities, a single or handful of dedicated triage officers may take on the role instead. They should be appointed from staff who have:
- Extra training or experience in advanced medical ethics
- Clinical expertise to evaluate patient prognosis
- Communication skills for dealing directly with patient families and care teams
Review The Principles of Triage
The essential principle of triage is straightforward: patients with the best short-term prognosis with the available treatments should be admitted in preference to those who face a poor prognosis even with intensive intervention.
Triage guidelines should also incorporate aspects such as:
- Equity of care – Ensuring that patients are treated on a strictly medical basis, without preferential treatment for the wealthy, well-connected, or based on racial or cultural judgements.
- Preservation of as many lives as possible – Although triage is based in part on the conditions of an individual patient, the overriding goal should take in the overall community to ensure the maximum benefit is available to the largest number.
- Protection of medical staff – There may be circumstances where further treatment not only endangers the community, but also healthcare workers. Preserving the capacity to treat other and future patients takes precedence over individual treatment. This means triage considerations also have to incorporate factors such as current staffing, PPE availability, and staff qualifications.
Develop Allocation Standards
Predetermining as many decision points as possible will help reduce decision fatigue and allow triage committees to make more objective judgements even during periods of high stress.
Each facility will need to determine its own specific criteria for allocating resources based on both availability, local standards of care, and patient status. Those criteria should broadly cover the following elements:
ICU Admission – Strict standards for initial admission should be adopted early on to reduce crowding. Data out of Italy shows that the median time a patient will be in ICU after admission is 15 days for survivors, and 10 days for fatalities. Either way, once they are admitted, they’ll be taking up a bed for a while. Tight criteria should be developed around critical procedures that are only possible in an ICU environment, including:
- Mechanical ventilation
- Advanced hemodynamic care
ICU Exclusions – Beyond determining criteria for initial ICU admission, standards should be determined for specific categories of patient to be excluded from consideration for advanced care, even when current clinical presentation might argue otherwise. These will usually involve comorbid conditions or other factors that make a long-term recovery unlikely, including:
- Do not resuscitate orders
- Trauma or recurrent cardiac events
- Life expectancy less than 12 months, or otherwise in end-stages of fatal diseases like:
- COPD
- Heart or severe circulatory failure
- Cirrhosis of the liver
Although age should not be a primary factor keeping patients out of the ICU, it may be considered, particularly in cases where the individual also has significant comorbidities. In some cases, you can rely on existing, independently developed standards, such as the New York State Task Force Ventilator Allocation Guidelines, which were laid out in 2015.
Removal of Life Support – Standards for removing patients from ICU supports should also be developed early on. There are a number of formulas that have been developed to predict mortality and illness severity for patients in various stages of ARDS; many are incorporated into a calculator page on MDCalc’s COVID-19 Resource Center. These can be used to roughly calculate and compare predicted odds of survival based on current clinical observations.
In addition to individual chances of survival, committees will have to figure out ways to weigh removal from life support against changing factors in the overall patient population. It becomes dramatically more difficult to remove support for previously admitted patients, even if demand has risen to the point where the patient might not have been admitted under current circumstances. This makes it critical to have well-established criteria for removal as well as solid documentation standards for those decisions.
Conducting ICU Triage During Peak Demand
The real test of triage will be keeping the ICU at peak operating capacity without overflowing. To some extent, this will be a regional challenge, as authorities attempt to balance the distribution of cases among hospitals. Many areas that have already hit an initial peak have designed certain hospitals for COVID-19 patients in order to reduce the spread of the infection. This can impact bed space available, but may free up other resources. Ad hoc capacity can be increased with additional staffing and equipment from other regional hospitals. In some regions, U.S. military units have brought in additional ICU capacity with mobile hospital units.
Triage During Admission – The initial triage assessment will be made on admission to the hospital. Very early stages can be conducted by phone or by front desk staff, although, almost by definition, patients capable of this level of assessment will not be ICU candidates. Other patients will be evaluated by the designated triage officers according to their current criteria, influenced by the factors outlined above, and current and estimated ICU population. The team should also address:
- Discussions with patient and family over their wishes for resuscitation and intubation. Experience has shown that patients can deteriorate quickly with COVID-19, so even in cases where the prognosis is relatively good, this should be addressed.
- Projected staffing levels, resource availability, and demand. This should be coordinated with regional authorities.
Evaluate Continued Commitment of Care – Patients should be re-assessed every 24 to 48 hours. Resource intensive interventions should only be performed in cases where the effectiveness has been proven. Depending on demand on the unit, care may be removed for patients where conditions have not been improving.
This decision is complicated by the need to judge continued resource commitment not only against other patients currently admitted, but also against the likelihood of new admissions.
Resuscitation attempts for coding patients should be brief or not conducted at all. This is particularly true when staff have limited access to PPE, since many procedures involve close contact and can generate infectious aerosols.
Documentation – All decisions should be carefully documented. The gravity of the situation is enormous, but apart from that, there is a real likelihood of subsequent malpractice and other legal claims being filed. During the chaos of an overwhelmed ICU, it can be difficult to justify the time that must be taken to handle paperwork, but this is an important part of triage team duties.
Triage Considerations Including Non-COVID-19 Patients
At least initially, if your facility or region haven’t restructured services to separate and isolate COVID-19 critical care from routine intensive care cases, you will also be faced with deciding between those cases for ICU beds.
This introduces additional uncertainty into decisions. Partly because COVID-19 case progression and fatality rates are not well understood, it is difficult to assess them against cases where outcomes may be more predictable. From what we know of novel coronavirus, it has a relatively low fatality rate among the general population. It’s also unclear what the efficacy of current treatments are… in New York, for instance, a study published in JAMA found that nearly 90 percent of COVID-19 patients who were put on ventilators passed away despite those heroic measures.
On the other hand, the death toll in areas where ICU support has been overwhelmed and unavailable for many victims offers concrete evidence that such treatment can make a real difference. The greatest obstacle currently is a lack of data to quantify it against typical ICU outcomes.
You also have to evaluate the additional risks you may create for non-COVID-19 patients by bringing them into an ICU that is filled with infectious patients. Where other critical care facilities are not available for transfer, some of those patients may be better off in other units as well.
Communication and Consequences
The triage committee or officer should take on the role of communicating end-of-life decision with families to help spare care teams from this difficult process.
Dedicated teams should also handle the physical process of terminating advanced support in cases where it must be removed. If possible, palliative care experts should remain with the patient during this process.