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危重病资源稀缺时的分诊程序。

Triage Procedures for Critical Care Resource Allocation During Scarcity.

机构信息

Biomedical Ethics Research Program, Mayo Clinic, Rochester, Minnesota.

Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

出版信息

JAMA Netw Open. 2023 Aug 1;6(8):e2329688. doi: 10.1001/jamanetworkopen.2023.29688.

Abstract

IMPORTANCE

During the COVID-19 pandemic, many US states issued or revised pandemic preparedness plans guiding allocation of critical care resources during crises. State plans vary in the factors used to triage patients and have faced criticism from advocacy groups due to the potential for discrimination.

OBJECTIVE

To analyze the role of comorbidities and long-term prognosis in state triage procedures.

DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data gathered from parallel internet searches for state-endorsed pandemic preparedness plans for the 50 US states, District of Columbia, and Puerto Rico (hereafter referred to as states), which were conducted between November 25, 2021, and June 16, 2023. Plans available on June 16, 2023, that provided step-by-step instructions for triaging critically ill patients were categorized for use of comorbidities and prognostication.

MAIN OUTCOMES AND MEASURES

Prevalence and contents of lists of comorbidities and their stated function in triage and instructions to predict duration of postdischarge survival.

RESULTS

Overall, 32 state-promulgated pandemic preparedness plans included triage procedures specific enough to guide triage in clinical practice. Twenty of these (63%) included lists of comorbidities that excluded (11 of 20 [55%]) or deprioritized (8 of 20 [40%]) patients during triage; one state's list was formulated to resolve ties between patients with equal triage scores. Most states with triage procedures (21 of 32 [66%]) considered predicted survival beyond hospital discharge. These states proposed different prognostic time horizons; 15 of 21 (71%) were numeric (ranging from 6 months to 5 years after hospital discharge), with the remaining 6 (29%) using descriptive terms, such as long-term.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study of state-promulgated critical care triage policies, most plans restricted access to scarce critical care resources for patients with listed comorbidities and/or for patients with less-than-average expected postdischarge survival. This analysis raises concerns about access to care during a public health crisis for populations with high burdens of chronic illness, such as individuals with disabilities and minoritized racial and ethnic groups.

摘要

重要性

在 COVID-19 大流行期间,许多美国州发布或修订了大流行防范计划,指导危机期间关键护理资源的分配。各州的计划在用于对患者进行分类的因素方面存在差异,并且由于存在歧视的潜在风险,这些计划受到了倡导团体的批评。

目的

分析合并症和长期预后在州分类程序中的作用。

设计、设置和参与者:这项横断面研究使用了 2021 年 11 月 25 日至 2023 年 6 月 16 日期间平行进行的互联网搜索,收集了 50 个美国州、哥伦比亚特区和波多黎各(以下简称各州)制定的州认可的大流行防范计划的数据。对 6 月 16 日提供关键患者分诊逐步说明的计划进行了分类,以了解其对合并症的使用情况和预后预测。

主要结果和措施

列出的合并症的流行率和内容,以及它们在分诊中的功能以及预测出院后生存时间的说明。

结果

总体而言,32 个州颁布的大流行防范计划包括足够具体的分诊程序,以指导临床实践中的分诊。其中 20 个(63%)包含排除(20 个中的 11 个[55%])或优先顺序较低(20 个中的 8 个[40%])患者的合并症清单;一个州的清单是为了解决具有相同分诊分数的患者之间的关系而制定的。大多数具有分诊程序的州(32 个中的 21 个[66%])考虑了出院后超过预测的生存时间。这些州提出了不同的预后时间范围;21 个中的 15 个(71%)是数值的(从出院后 6 个月到 5 年),其余 6 个(29%)使用描述性术语,如长期。

结论和相关性

在这项对州颁布的关键护理分诊政策的横断面研究中,大多数计划限制了有清单合并症的患者和/或预计出院后生存时间短于平均水平的患者获得稀缺关键护理资源的机会。这项分析引起了人们对患有慢性疾病负担高的人群(如残疾人和少数族裔)在公共卫生危机期间获得护理的关注。

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