Department of Anesthesiology, Critical Care Medicine and Pain, Hadassah Medical Center, Hebrew University of Jerusalem, Faculty of Medicine, Jerusalem, Israel.
Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China.
Crit Care Med. 2020 Aug;48(8):1196-1202. doi: 10.1097/CCM.0000000000004410.
Coronavirus disease 2019 patients are currently overwhelming the world's healthcare systems. This article provides practical guidance to front-line physicians forced to make critical rationing decisions.
PubMed and Medline search for scientific literature, reviews, and guidance documents related to epidemic ICU triage including from professional bodies.
Clinical studies, reviews, and guidelines were selected and reviewed by all authors and discussed by internet conference and email.
References and data were based on relevance and author consensus.
We review key challenges of resource-driven triage and data from affected ICUs. We recommend that once available resources are maximally extended, triage is justified utilizing a strategy that provides the greatest good for the greatest number of patients. A triage algorithm based on clinical estimations of the incremental survival benefit (saving the most life-years) provided by ICU care is proposed. "First come, first served" is used to choose between individuals with equal priorities and benefits. The algorithm provides practical guidance, is easy to follow, rapidly implementable and flexible. It has four prioritization categories: performance score, ASA score, number of organ failures, and predicted survival. Individual units can readily adapt the algorithm to meet local requirements for the evolving pandemic. Although the algorithm improves consistency and provides practical and psychologic support to those performing triage, the final decision remains a clinical one. Depending on country and operational circumstances, triage decisions may be made by a triage team or individual doctors. However, an experienced critical care specialist physician should be ultimately responsible for the triage decision. Cautious discharge criteria are proposed acknowledging the difficulties to facilitate the admission of queuing patients.
Individual institutions may use this guidance to develop prospective protocols that assist the implementation of triage decisions to ensure fairness, enhance consistency, and decrease provider moral distress.
2019 年冠状病毒病患者目前使全球的医疗系统不堪重负。本文为一线医生提供了实用的指导，以帮助他们做出关键的配给决策。
PubMed 和 Medline 搜索与流行期间 ICU 分诊相关的科学文献、综述和指南文件，包括专业机构的文件。
所有作者选择和审查了临床研究、综述和指南，并通过互联网会议和电子邮件进行了讨论。
参考文献和数据基于相关性和作者共识。
我们回顾了资源驱动分诊的关键挑战和受影响 ICU 的数据。我们建议，一旦最大限度地扩展了现有资源，就可以利用为最多数患者提供最大利益的策略来证明分诊是合理的。提出了一种基于 ICU 治疗提供的增量生存获益（挽救最多的生命年）的临床估计的分诊算法。“先来先服务”用于选择具有同等优先级和获益的个体。该算法提供了实用的指导，易于遵循，可迅速实施且具有灵活性。它有四个优先级类别：绩效评分、ASA 评分、器官衰竭数量和预测生存。各个单位可以根据当地要求对算法进行调整，以适应不断变化的大流行。虽然该算法提高了一致性，并为进行分诊的人员提供了实用和心理支持，但最终决策仍然是临床决策。根据国家和操作情况，分诊决策可以由分诊小组或个别医生做出。然而，一名经验丰富的重症监护专家医师应该最终对分诊决策负责。提出了谨慎的出院标准，以承认在为排队患者提供便利方面的困难。
个别机构可以使用本指南制定前瞻性方案，以协助实施分诊决策，确保公平性、增强一致性，并减少提供者的道德困境。
