corporate bioethics consultant, Novant Health, Winston-Salem, North Carolina; adjunct assistant professor, Department of Social Medicine, UNC-Chapel Hill School of Medicine, Chapel Hill, North Carolina.
senior vice president and chief clinical officer, Greater Winston-Salem Market, Novant Health, Winston-Salem, North Carolina.
N C Med J. 2021 Jan-Feb;82(1):21-28. doi: 10.18043/ncm.82.1.21.
An integrated nonprofit health care system with 13 North Carolina medical centers conducted a time-pressured quality improvement simulation of its plan to implement the "North Carolina Protocol for Allocating Scarce Inpatient Critical Care Resources in a Pandemic" attendant to pandemic scenario planning. Simulation objectives included assessing the plan in terms of a) efficiency and effectiveness; b) comorbidity scoring validity; c) impact by race/ethnicity, gender, age, and payer status; and d) simulation participant impressions of potential impact on clinicians. The simulation scenario involved scoring 14 patients with the constraint that only 10 could be afforded critical care resources. Also included were independent scoring validation by four clinicians, structured debriefs with simulation participants and observers, and tracking patient outcomes for 30 days. Triage scoring was identical among four triage teams. Lack of concordance in clinician comorbidity scoring did not alter patient prioritization for withdrawal of treatment in this small cohort. Protocol scoring was not correlated with resource utilization or near-term mortality. The simulation sample was small and selected when COVID-19 census was temporarily waning. No protocol for pediatric patients was tested. The simulation yielded resource allocation concordance using comorbidity scoring by attending physicians, which significantly accelerated triage team decision-making and did not result in notable disparities by race/ethnicity, gender, or advanced age. Qualitative findings surfaced tensions in balancing de-identified data with individualized assessment and in trusting the clinical judgments of other physicians. Additional research is needed to validate the protocol's predictive value related to patient outcomes.
一家拥有 13 家北卡罗来纳医疗中心的综合性非营利性医疗保健系统，针对其实施“北卡罗来纳州大流行期间分配稀缺住院重症监护资源协议”的计划，进行了一次紧迫的质量改进模拟。模拟目标包括评估该计划在以下方面的表现：a）效率和效果；b）合并症评分的有效性；c）按种族/族裔、性别、年龄和支付者身份划分的影响；d）模拟参与者对潜在对临床医生影响的印象。模拟场景涉及对 14 名患者进行评分，限制条件是只有 10 名患者可以获得重症监护资源。还包括由四名临床医生进行独立评分验证、与模拟参与者和观察员进行结构化的汇报、以及对患者进行 30 天的跟踪。四个分诊小组的分诊评分是一致的。在这个小队列中，临床医生合并症评分的不一致性并没有改变对停止治疗的患者的优先排序。协议评分与资源利用或近期死亡率无关。模拟样本较小，是在 COVID-19 患者人数暂时减少时选择的。未测试针对儿科患者的协议。该模拟使用主治医生的合并症评分产生了资源分配的一致性，这显著加速了分诊小组的决策过程，并且没有导致明显的种族/族裔、性别或高龄差异。定性研究结果表明，在平衡匿名数据与个体评估以及信任其他医生的临床判断方面存在紧张关系。需要进一步的研究来验证该协议与患者预后相关的预测价值。
