Garber Sara, Brunner Jens O, Heller Axel R, Marckmann Georg, Bartenschlager Christina C
Lehrstuhl für Health Care Operations/Health Information Management, Wirtschaftswissenschaftliche und Medizinische Fakultät, Universität Augsburg, Universitätsstr. 16, 86159, Augsburg, Deutschland.
Professor of Decision Science in Healthcare, Department of Technology, Management, and Economics, Technical University of Denmark, Lyngby, Dänemark.
Anaesthesiologie. 2023 Aug;72(8):555-564. doi: 10.1007/s00101-023-01302-3. Epub 2023 Jun 26.
The significant increase in patients during the COVID-19 pandemic presented the healthcare system with a variety of challenges. The intensive care unit is one of the areas particularly affected in this context. Only through extensive infection control measures as well as an enormous logistical effort was it possible to treat all patients requiring intensive care in Germany even during peak phases of the pandemic, and to prevent triage even in regions with high patient pressure and simultaneously low capacities. Regarding pandemic preparedness, the German Parliament passed a law on triage that explicitly prohibits ex post (tertiary) triage. In ex post triage, patients who are already being treated are included in the triage decision and treatment capacities are allocated according to the individual likelihood of success. Legal, ethical, and social considerations for triage in pandemics can be found in the literature, but there is no quantitative assessment with respect to different patient groups in the intensive care unit. This study addressed this gap and applied a simulation-based evaluation of ex ante (primary) and ex post triage policies in consideration of survival probabilities, impairments, and pre-existing conditions. The results show that application of ex post triage based on survival probabilities leads to a reduction in mortality in the intensive care unit for all patient groups. In the scenario close to a real-world situation, considering different impaired and prediseased patient groups, a reduction in mortality of approximately 15% was already achieved by applying ex post triage on the first day. This mortality-reducing effect of ex post triage is further enhanced as the number of patients requiring intensive care increases.
在新冠疫情期间，患者数量大幅增加，给医疗系统带来了各种挑战。重症监护病房是在此背景下受影响尤为严重的领域之一。只有通过广泛的感染控制措施以及巨大的后勤保障努力，才得以在德国疫情高峰期治疗所有需要重症监护的患者，甚至在患者压力大且资源有限的地区也避免了进行分诊。关于大流行防范，德国议会通过了一项分诊法，明确禁止事后（三级）分诊。在事后分诊中，已在接受治疗的患者会被纳入分诊决策，治疗资源会根据个体成功可能性进行分配。关于大流行期间分诊的法律、伦理和社会考量在文献中有所记载，但对于重症监护病房中不同患者群体尚无定量评估。本研究填补了这一空白，应用基于模拟的方法对事前（一级）和事后分诊政策进行评估，同时考虑了生存概率、损伤情况和既往病史。结果表明，基于生存概率应用事后分诊可降低所有患者群体在重症监护病房的死亡率。在接近现实情况的场景中，考虑不同损伤程度和患有基础疾病的患者群体，在第一天应用事后分诊就已经实现了约15%的死亡率降低。随着需要重症监护的患者数量增加，事后分诊的这种降低死亡率的效果会进一步增强。
