1
|
Thomson WR, Puthucheary ZA, Wan YI. Critical care and pandemic preparedness and response. Br J Anaesth 2023; 131:847-860. [PMID: 37689541 PMCID: PMC10636520 DOI: 10.1016/j.bja.2023.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/21/2023] [Accepted: 07/23/2023] [Indexed: 09/11/2023] Open
Abstract
Critical care was established partially in response to a polio epidemic in the 1950s. In the intervening 70 yr, several epidemics and pandemics have placed critical care and allied services under extreme pressure. Pandemics cause wholesale changes to accepted standards of practice, require reallocation and retargeting of resources and goals of care. In addition to clinical acumen, mounting an effective critical care response to a pandemic requires local, national, and international coordination in a diverse array of fields from research collaboration and governance to organisation of critical care networks and applied biomedical ethics in the eventuality of triage situations. This review provides an introduction to an array of topics that pertain to different states of pandemic acuity: interpandemic preparedness, alert, surge activity, recovery and relapse through the literature and experience of recent pandemics including COVID-19, H1N1, Ebola, and SARS.
Collapse
Affiliation(s)
- William R Thomson
- Adult Critical Care Unit, Royal London Hospital, Whitechapel, London, UK; William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK.
| | - Zudin A Puthucheary
- Adult Critical Care Unit, Royal London Hospital, Whitechapel, London, UK; William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| | - Yize I Wan
- Adult Critical Care Unit, Royal London Hospital, Whitechapel, London, UK; William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
2
|
Jeyanathan J, Bootland D, Al-Rais A, Leung J, Wijesuriya J, Banks L, Breen T, DeCoverly R, Curtis L, McHenry A, Wright D, Griggs JE, Lyon RM. Lessons learned from the first 50 COVID-19 critical care transfer missions conducted by a civilian UK Helicopter Emergency Medical Service team. Scand J Trauma Resusc Emerg Med 2022; 30:6. [PMID: 35033171 PMCID: PMC8760584 DOI: 10.1186/s13049-022-00994-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/04/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic has placed exceptional demand on Intensive Care Units, necessitating the critical care transfer of patients on a regional and national scale. Performing these transfers required specialist expertise and involved moving patients over significant distances. Air Ambulance Kent Surrey Sussex created a designated critical care transfer team and was one of the first civilian air ambulances in the United Kingdom to move ventilated COVID-19 patients by air. We describe the practical set up of such a service and the key lessons learned from the first 50 transfers. METHODS Retrospective review of air critical care transfer service set up and case review of first 50 transfers. RESULTS We describe key elements of the critical care transfer service, including coordination and activation; case interrogation; workforce; training; equipment; aircraft modifications; human factors and clinical governance. A total of 50 missions are described between 18 December 2020 and 1 February 2021. 94% of the transfer missions were conducted by road. The mean age of these patients was 58 years (29-83). 30 (60%) were male and 20 (40%) were female. The mean total mission cycle (time of referral until the time team declared free at receiving hospital) was 264 min (range 149-440 min). The mean time spent at the referring hospital prior to leaving for the receiving unit was 72 min (31-158). The mean transfer transit time between referring and receiving units was 72 min (9-182). CONCLUSION Critically ill COVID-19 patients have highly complex medical needs during transport. Critical care transfer of COVID-19-positive patients by civilian HEMS services, including air transfer, can be achieved safely with specific planning, protocols and precautions. Regional planning of COVID-19 critical care transfers is required to optimise the time available of critical care transfer teams.
Collapse
Affiliation(s)
- J Jeyanathan
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - D Bootland
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - A Al-Rais
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - J Leung
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - J Wijesuriya
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - L Banks
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - T Breen
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - R DeCoverly
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - L Curtis
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - A McHenry
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - D Wright
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
| | - J E Griggs
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK
- University of Surrey, Guildford, UK
| | - R M Lyon
- Air Ambulance Kent Surrey Sussex, Redhill Aerodrome, Redhill, Surrey, RH1 5YP, UK.
- University of Surrey, Guildford, UK.
| |
Collapse
|
3
|
Dittborn M, Cave E, Archard D. Clinical ethics support services during the COVID-19 pandemic in the UK: a cross-sectional survey. JOURNAL OF MEDICAL ETHICS 2021; 48:medethics-2021-107818. [PMID: 34753795 PMCID: PMC8593272 DOI: 10.1136/medethics-2021-107818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/19/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND The COVID-19 pandemic highlighted the need for clinical ethics support provision to ensure as far as possible fair decision making and to address healthcare workers' moral distress. PURPOSE To describe the availability, characteristics and role of clinical ethics support services (CESSs) in the UK during the COVID-19 pandemic. METHOD A descriptive cross-sectional online survey was developed by the research team. The survey included questions on CESSs characteristics (model, types of support, guidance development, membership, parent and patient involvement) and changes in response to the pandemic. Invitations to participate were widely circulated via National Health Service institutional emails and relevant clinical ethics groups known to the research team. RESULTS Between October 2020 and June 2021, a total of 53 responses were received. In response to the pandemic, new CESSs were established, and existing provision changed. Most took the form of clinical ethics committees, groups and advisory boards, which varied in size and membership and the body of clinicians and patient populations they served. Some services provided moral distress support and educational provision for clinical staff. During the pandemic, services became more responsive to clinicians' requests for ethics support and advice. More than half of respondents developed local guidance and around three quarters formed links with regional or other local services. Patient and/or family members' involvement in ethics discussions is infrequent. CONCLUSIONS The pandemic has resulted in an expansion in the number of CESSs. Though some may disband as the pandemic eases, the reliance on CESSs during the pandemic demonstrates the need for additional research to better understand the effectiveness of their various forms, connections, guidance, services and modes of working and for better support to enhance consistency, transparency, communication with patients and availability to clinical staff.
Collapse
Affiliation(s)
- Mariana Dittborn
- School of History, Anthropology, Philosophy and Politics, QUB, Belfast, UK
- Paediatric Bioethics Centre, Great Ormond Street Hospital, London, UK
| | - Emma Cave
- Durham Law School, Durham University, Durham, UK
| | - David Archard
- School of History, Anthropology, Philosophy and Politics, QUB, Belfast, UK
| |
Collapse
|
4
|
Wilkinson DJC. Frailty Triage: Is Rationing Intensive Medical Treatment on the Grounds of Frailty Ethical? THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2021; 21:48-63. [PMID: 33289443 PMCID: PMC8567739 DOI: 10.1080/15265161.2020.1851809] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
In early 2020, a number of countries developed and published intensive care triage guidelines for the pandemic. Several of those guidelines, especially in the UK, encouraged the explicit assessment of clinical frailty as part of triage. Frailty is relevant to resource allocation in at least three separate ways, through its impact on probability of survival, longevity and quality of life (though not a fourth-length of intensive care stay). I review and reject claims that frailty-based triage would represent unjust discrimination on the grounds of age or disability. I outline three important steps to improve the ethical incorporation of frailty into triage. Triage criteria (ie frailty) should be assessed consistently in all patients referred to the intensive care unit. Guidelines must make explicit the ethical basis for the triage decision. This can then be applied, using the concept of triage equivalence, to other (non-frail) patients referred to intensive care.
Collapse
|
5
|
Baksh RA, Pape SE, Smith J, Strydom A. Understanding inequalities in COVID-19 outcomes following hospital admission for people with intellectual disability compared to the general population: a matched cohort study in the UK. BMJ Open 2021; 11:e052482. [PMID: 34607870 PMCID: PMC8491000 DOI: 10.1136/bmjopen-2021-052482] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/11/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES This study explores the hospital journey of patients with intellectual disabilities (IDs) compared with the general population after admission for COVID-19 during the first wave of the pandemic (when demand on inpatient resources was high) to identify disparities in treatment and outcomes. DESIGN Matched cohort study; an ID cohort of 506 patients were matched based on age, sex and ethnicity with a control group using a 1:3 ratio to compare outcomes from the International Severe Acute Respiratory and emerging Infections Consortium WHO Clinical Characterisation Protocol UK. SETTING Admissions for COVID-19 from UK hospitals; data on symptoms, severity, access to interventions, complications, mortality and length of stay were extracted. INTERVENTIONS Non-invasive respiratory support, intubation, tracheostomy, ventilation and admission to intensive care units (ICU). RESULTS Subjective presenting symptoms such as loss of taste/smell were less frequently reported in ID patients, whereas indicators of more severe disease such as altered consciousness and seizures were more common. Controls had higher rates of cardiovascular risk factors, asthma, rheumatological disorder and smoking. ID patients were admitted with higher respiratory rates (median=22, range=10-48) and were more likely to require oxygen therapy (35.1% vs 28.9%). Despite this, ID patients were 37% (95% CI 13% to 57%) less likely to receive non-invasive respiratory support, 40% (95% CI 7% to 63%) less likely to receive intubation and 50% (95% CI 30% to 66%) less likely to be admitted to the ICU while in hospital. They had a 56% (95% CI 17% to 102%) increased risk of dying from COVID-19 after they were hospitalised and were dying 1.44 times faster (95% CI 1.13 to 1.84) compared with controls. CONCLUSIONS There have been significant disparities in healthcare between people with ID and the general population during the COVID-19 pandemic, which may have contributed to excess mortality in this group.
Collapse
Affiliation(s)
- R Asaad Baksh
- Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
- The LonDowns Consortium, London, UK
| | - Sarah E Pape
- Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
- The LonDowns Consortium, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| | - James Smith
- South London and Maudsley NHS Foundation Trust, London, UK
| | - André Strydom
- Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
- The LonDowns Consortium, London, UK
- South London and Maudsley NHS Foundation Trust, London, UK
| |
Collapse
|
6
|
Oakley B, Tillmann J, Ruigrok A, Baranger A, Takow C, Charman T, Jones E, Cusack J, Doherty M, Violland P, Wroczyńska A, Simonoff E, Buitelaar JK, Gallagher L, Murphy DGM. COVID-19 health and social care access for autistic people: European policy review. BMJ Open 2021; 11:e045341. [PMID: 34001500 PMCID: PMC8130751 DOI: 10.1136/bmjopen-2020-045341] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/28/2021] [Accepted: 02/17/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The global COVID-19 pandemic has had an unprecedented impact on European health and social care systems, with demands on testing, hospital and intensive care capacity exceeding available resources in many regions. This has led to concerns that some vulnerable groups, including autistic people, may be excluded from services. METHODS We reviewed policies from 15 European member states, published in March-July 2020, pertaining to (1) access to COVID-19 tests; (2) provisions for treatment, hospitalisation and intensive care units (ICUs); and (3) changes to standard health and social care. In parallel, we analysed survey data on the lived experiences of 1301 autistic people and caregivers. RESULTS Autistic people experienced significant barriers when accessing COVID-19 services. First, despite being at elevated risk of severe illness due to co-occurring health conditions, there was a lack of accessibility of COVID-19 testing. Second, many COVID-19 outpatient and inpatient treatment services were reported to be inaccessible, predominantly resulting from individual differences in communication needs. Third, ICU triage protocols in many European countries (directly or indirectly) resulted in discriminatory exclusion from lifesaving treatments. Finally, interruptions to standard health and social care left over 70% of autistic people without everyday support. CONCLUSIONS The COVID-19 pandemic has further exacerbated existing healthcare inequalities for autistic people, probably contributing to disproportionate increases in morbidity and mortality, mental health and behavioural difficulties, and reduced quality of life. An urgent need exists for policies and guidelines on accessibility of COVID-19 services to be updated to prevent the widespread exclusion of autistic people from services, which represents a violation of international human rights law.
Collapse
Affiliation(s)
- Bethany Oakley
- Department of Forensic and Neurodevelopmental Sciences, King's College London, London, UK
| | - Julian Tillmann
- Department of Psychology, King's College London, London, UK
- Department of Applied Psychology: Health, Development, Enhancement, and Intervention, University of Vienna, Vienna, Austria
| | - Amber Ruigrok
- Autism Research Centre, Department of Psychiatry, University of Cambridge, Cambridge, UK
| | | | | | - Tony Charman
- Department of Psychology, King's College London, London, UK
- South London and Maudsley NHS Foundation Trust, (SLaM), London, UK
| | - Emily Jones
- Centre for Brain and Cognitive Development, Birkbeck University of London, London, UK
| | | | - Mary Doherty
- Department of Anaesthesia, Our Lady's Hospital, Navan, Meath, Ireland
| | | | - Agnieszka Wroczyńska
- Department of Tropical and Parasitic Diseases, Medical University of Gdansk, Gdansk, Poland
| | - Emily Simonoff
- Department of Child & Adolescent Psychiatry, King's College London, London, UK
| | - Jan K Buitelaar
- Donders Institute for Brain, Cognition and Behavior, Department of Cognitive Neuroscience, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
- Karakter Child and Adolescent Psychiatry, University Center, Nijmegen, The Netherlands
| | - Louise Gallagher
- Discipline of Psychiatry, Trinity Translational Medicine Institute, Trinity College, Dublin, Ireland
| | - Declan G M Murphy
- Department of Forensic and Neurodevelopmental Sciences, King's College London, London, UK
- Sackler Institute for Translational Neurodevelopment, King's College London, London, UK
| |
Collapse
|
7
|
Lone NI, Suntharalingam G. Critical care in an ageing world: too much of a good thing, or a rising challenge? Anaesthesia 2021; 76:1291-1295. [PMID: 33887062 DOI: 10.1111/anae.15486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/28/2022]
Affiliation(s)
- N I Lone
- Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Critical Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - G Suntharalingam
- Critical Care, London North West University Healthcare NHS Trust, London, UK
| |
Collapse
|
8
|
Kuylen MNI, Kim SY, Ruck Keene A, Owen GS. Should age matter in COVID-19 triage? A deliberative study. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-107071. [PMID: 33687917 PMCID: PMC7944418 DOI: 10.1136/medethics-2020-107071] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 05/30/2023]
Abstract
The COVID-19 pandemic put a large burden on many healthcare systems, causing fears about resource scarcity and triage. Several COVID-19 guidelines included age as an explicit factor and practices of both triage and 'anticipatory triage' likely limited access to hospital care for elderly patients, especially those in care homes. To ensure the legitimacy of triage guidelines, which affect the public, it is important to engage the public's moral intuitions. Our study aimed to explore general public views in the UK on the role of age, and related factors like frailty and quality of life, in triage during the COVID-19 pandemic. We held online deliberative workshops with members of the general public (n=22). Participants were guided through a deliberative process to maximise eliciting informed and considered preferences. Participants generally accepted the need for triage but strongly rejected 'fair innings' and 'life projects' principles as justifications for age-based allocation. They were also wary of the 'maximise life-years' principle, preferring to maximise the number of lives rather than life years saved. Although they did not arrive at a unified recommendation of one principle, a concern for three core principles and values eventually emerged: equality, efficiency and vulnerability. While these remain difficult to fully respect at once, they captured a considered, multifaceted consensus: utilitarian considerations of efficiency should be tempered with a concern for equality and vulnerability. This 'triad' of ethical principles may be a useful structure to guide ethical deliberation as societies negotiate the conflicting ethical demands of triage.
Collapse
Affiliation(s)
- Margot N I Kuylen
- Department of Psychological Medicine, King's College London, London, UK
| | - Scott Y Kim
- Department of Bioethics, National Institutes of Health, Bethesda, Maryland, USA
- Center for Bioethics and Social Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - Alexander Ruck Keene
- 39 Essex Chambers, London, UK
- Dickson Poon School of Law, King's College London, London, UK
| | - Gareth S Owen
- Department of Psychological Medicine, King's College London, London, UK
| |
Collapse
|
9
|
Hamilton WL, Tonkin-Hill G, Smith ER, Aggarwal D, Houldcroft CJ, Warne B, Meredith LW, Hosmillo M, Jahun AS, Curran MD, Parmar S, Caller LG, Caddy SL, Khokhar FA, Yakovleva A, Hall G, Feltwell T, Pinckert ML, Georgana I, Chaudhry Y, Brown CS, Gonçalves S, Amato R, Harrison EM, Brown NM, Beale MA, Spencer Chapman M, Jackson DK, Johnston I, Alderton A, Sillitoe J, Langford C, Dougan G, Peacock SJ, Kwiatowski DP, Goodfellow IG, Torok ME. Genomic epidemiology of COVID-19 in care homes in the east of England. eLife 2021; 10:e64618. [PMID: 33650490 PMCID: PMC7997667 DOI: 10.7554/elife.64618] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/25/2021] [Indexed: 01/12/2023] Open
Abstract
COVID-19 poses a major challenge to care homes, as SARS-CoV-2 is readily transmitted and causes disproportionately severe disease in older people. Here, 1167 residents from 337 care homes were identified from a dataset of 6600 COVID-19 cases from the East of England. Older age and being a care home resident were associated with increased mortality. SARS-CoV-2 genomes were available for 700 residents from 292 care homes. By integrating genomic and temporal data, 409 viral clusters within the 292 homes were identified, indicating two different patterns - outbreaks among care home residents and independent introductions with limited onward transmission. Approximately 70% of residents in the genomic analysis were admitted to hospital during the study, providing extensive opportunities for transmission between care homes and hospitals. Limiting viral transmission within care homes should be a key target for infection control to reduce COVID-19 mortality in this population.
Collapse
Affiliation(s)
- William L Hamilton
- Cambridge University Hospitals NHS Foundation Trust, Departments of Infectious Diseases and MicrobiologyCambridgeUnited Kingdom
- University of Cambridge, Department of MedicineCambridgeUnited Kingdom
| | | | - Emily R Smith
- Cambridgeshire County CouncilCambridgeUnited Kingdom
| | - Dinesh Aggarwal
- University of Cambridge, Department of MedicineCambridgeUnited Kingdom
- Public Health EnglandColindaleUnited Kingdom
| | - Charlotte J Houldcroft
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
| | - Ben Warne
- Cambridge University Hospitals NHS Foundation Trust, Departments of Infectious Diseases and MicrobiologyCambridgeUnited Kingdom
- University of Cambridge, Department of MedicineCambridgeUnited Kingdom
| | - Luke W Meredith
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
| | - Myra Hosmillo
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
| | - Aminu S Jahun
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
| | - Martin D Curran
- Public Health England Clinical Microbiology and Public Health LaboratoryCambridgeUnited Kingdom
| | - Surendra Parmar
- Public Health England Clinical Microbiology and Public Health LaboratoryCambridgeUnited Kingdom
| | - Laura G Caller
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
- The Francis Crick InstituteLondonUnited Kingdom
| | - Sarah L Caddy
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
| | - Fahad A Khokhar
- University of Cambridge, Department of MedicineCambridgeUnited Kingdom
| | - Anna Yakovleva
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
| | - Grant Hall
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
| | - Theresa Feltwell
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
| | - Malte L Pinckert
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
| | - Iliana Georgana
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
| | - Yasmin Chaudhry
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
| | | | | | | | | | - Nicholas M Brown
- Cambridge University Hospitals NHS Foundation Trust, Departments of Infectious Diseases and MicrobiologyCambridgeUnited Kingdom
- Public Health England Clinical Microbiology and Public Health LaboratoryCambridgeUnited Kingdom
| | | | - Michael Spencer Chapman
- Wellcome Sanger InstituteHinxtonUnited Kingdom
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS TrustLondonUnited Kingdom
| | | | | | | | | | | | - Gordon Dougan
- University of Cambridge, Department of MedicineCambridgeUnited Kingdom
| | - Sharon J Peacock
- University of Cambridge, Department of MedicineCambridgeUnited Kingdom
| | | | - Ian G Goodfellow
- University of Cambridge, Department of Pathology, Division of VirologyCambridgeUnited Kingdom
| | - M Estee Torok
- Cambridge University Hospitals NHS Foundation Trust, Departments of Infectious Diseases and MicrobiologyCambridgeUnited Kingdom
- University of Cambridge, Department of MedicineCambridgeUnited Kingdom
| | | |
Collapse
|
10
|
Fiest KM, Krewulak KD, Plotnikoff KM, Kemp LG, Parhar KKS, Niven DJ, Kortbeek JB, Stelfox HT, Parsons Leigh J. Allocation of intensive care resources during an infectious disease outbreak: a rapid review to inform practice. BMC Med 2020; 18:404. [PMID: 33334347 PMCID: PMC7746486 DOI: 10.1186/s12916-020-01871-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 11/25/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has placed sustained demand on health systems globally, and the capacity to provide critical care has been overwhelmed in some jurisdictions. It is unknown which triage criteria for allocation of resources perform best to inform health system decision-making. We sought to summarize and describe existing triage tools and ethical frameworks to aid healthcare decision-making during infectious disease outbreaks. METHODS We conducted a rapid review of triage criteria and ethical frameworks for the allocation of critical care resources during epidemics and pandemics. We searched Medline, EMBASE, and SCOPUS from inception to November 3, 2020. Full-text screening and data abstraction were conducted independently and in duplicate by three reviewers. Articles were included if they were primary research, an adult critical care setting, and the framework described was related to an infectious disease outbreak. We summarized each triage tool and ethical guidelines or framework including their elements and operating characteristics using descriptive statistics. We assessed the quality of each article with applicable checklists tailored to each study design. RESULTS From 11,539 unique citations, 697 full-text articles were reviewed and 83 articles were included. Fifty-nine described critical care triage protocols and 25 described ethical frameworks. Of these, four articles described both a protocol and ethical framework. Sixty articles described 52 unique triage criteria (29 algorithm-based, 23 point-based). Few algorithmic- or point-based triage protocols were good predictors of mortality with AUCs ranging from 0.51 (PMEWS) to 0.85 (admitting SOFA > 11). Most published triage protocols included the substantive values of duty to provide care, equity, stewardship and trust, and the procedural value of reason. CONCLUSIONS This review summarizes available triage protocols and ethical guidelines to provide decision-makers with data to help select and tailor triage tools. Given the uncertainty about how the COVID-19 pandemic will progress and any future pandemics, jurisdictions should prepare by selecting and adapting a triage tool that works best for their circumstances.
Collapse
Affiliation(s)
- Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Karla D Krewulak
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Kara M Plotnikoff
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Laryssa G Kemp
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Ken Kuljit S Parhar
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - John B Kortbeek
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
- Department of Anaesthesia, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary & Alberta Health Services, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, T2N4Z6, Canada
| | - Jeanna Parsons Leigh
- Faculty of Health, School of Health Administration, Dalhousie University, 5850 College Street, Halifax, Nova Scotia, B3H4R2, Canada.
- Department of Critical Care Medicine, Faculty of Medicine, Dalhousie University, 6299 South St, Halifax, Nova Scotia, B3H4R2, Canada.
| |
Collapse
|
11
|
Wilkinson D, Zohny H, Kappes A, Sinnott-Armstrong W, Savulescu J. Which factors should be included in triage? An online survey of the attitudes of the UK general public to pandemic triage dilemmas. BMJ Open 2020; 10:e045593. [PMID: 33293401 PMCID: PMC7725087 DOI: 10.1136/bmjopen-2020-045593] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/03/2020] [Accepted: 11/13/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE As cases of COVID-19 infections surge, concerns have renewed about intensive care units (ICUs) being overwhelmed and the need for specific triage protocols over winter. This study aimed to help inform triage guidance by exploring the views of lay people about factors to include in triage decisions. DESIGN, SETTING AND PARTICIPANTS Online survey between 29th of May and 22nd of June 2020 based on hypothetical triage dilemmas. Participants recruited from existing market research panels, representative of the UK general population. Scenarios were presented in which a single ventilator is available, and two patients require ICU admission and ventilation. Patients differed in one of: chance of survival, life expectancy, age, expected length of treatment, disability and degree of frailty. Respondents were given the option of choosing one patient to treat or tossing a coin to decide. RESULTS Seven hundred and sixty-three participated. A majority of respondents prioritised patients who would have a higher chance of survival (72%-93%), longer life expectancy (78%-83%), required shorter duration of treatment (88%-94%), were younger (71%-79%) or had a lesser degree of frailty (60%-69%, all p<0.001). Where there was a small difference between two patients, a larger proportion elected to toss a coin to decide which patient to treat. A majority (58%-86%) were prepared to withdraw treatment from a patient in intensive care who had a lower chance of survival than another patient currently presenting with COVID-19. Respondents also indicated a willingness to give higher priority to healthcare workers and to patients with young children. CONCLUSION Members of the UK general public potentially support a broadly utilitarian approach to ICU triage in the face of overwhelming need. Survey respondents endorsed the relevance of patient factors currently included in triage guidance, but also factors not currently included. They supported the permissibility of reallocating treatment in a pandemic.
Collapse
Affiliation(s)
- Dominic Wilkinson
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
- Newborn Care Unit, John Radcliffe Hospital, Oxford, Oxfordshire, UK
- Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Hazem Zohny
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
| | - Andreas Kappes
- Department of Psychology, School of Arts and Social Sciences, City University of London, London, UK
| | - Walter Sinnott-Armstrong
- Kenan Institute for Ethics, Department of Philosophy, Duke University, Durham, North Carolina, USA
| | - Julian Savulescu
- Oxford Uehiro Centre for Practical Ethics, Faculty of Philosophy, University of Oxford, Oxford, UK
- Wellcome Centre for Ethics and Humanities, University of Oxford, Oxford, UK
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Faculty of Law, University of Melbourne, Melbourne, Victoria, Australia
| |
Collapse
|
12
|
Griffiths F, Svantesson M, Bassford C, Dale J, Blake C, McCreedy A, Slowther AM. Decision-making around admission to intensive care in the UK pre-COVID-19: a multicentre ethnographic study. Anaesthesia 2020; 76:489-499. [PMID: 33141939 DOI: 10.1111/anae.15272] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2020] [Indexed: 12/24/2022]
Abstract
Predicting who will benefit from admission to an intensive care unit is not straightforward and admission processes vary. Our aim was to understand how decisions to admit or not are made. We observed 55 decision-making events in six NHS hospitals. We interviewed 30 referring and 43 intensive care doctors about these events. We describe the nature and context of the decision-making and analysed how doctors make intensive care admission decisions. Such decisions are complex with intrinsic uncertainty, often urgent and made with incomplete information. While doctors aspire to make patient-centred decisions, key challenges include: being overworked with lack of time; limited support from senior staff; and a lack of adequate staffing in other parts of the hospital that may be compromising patient safety. To reduce decision complexity, heuristic rules based on experience are often used to help think through the problem; for example, the patient's functional status or clinical gestalt. The intensive care doctors actively managed relationships with referring doctors; acted as the hospital generalist for acutely ill patients; and brought calm to crisis situations. However, they frequently failed to elicit values and preferences from patients or family members. They were rarely explicit in balancing burdens and benefits of intensive care for patients, so consistency and equity cannot be judged. The use of a framework for intensive care admission decisions that reminds doctors to seek patient or family views and encourages explicit balancing of burdens and benefits could improve decision-making. However, a supportive, adequately resourced context is also needed.
Collapse
Affiliation(s)
- F Griffiths
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - M Svantesson
- Faculty of Medicine and Health, University Health Care Research Center, Örebro University, Örebro, Sweden
| | - C Bassford
- Department of Intensive Care Medicine, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - J Dale
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - C Blake
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - A McCreedy
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - A-M Slowther
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|