Heidinger Brandon A, Downar Ariane, Frolic Andrea, Downar James, Isenberg Sarina R
Bruyère Research Institute (Heidinger, A. Downar, J. Downar, Isenberg), Ottawa, Ont.; Department of Family Medicine (Frolic), McMaster University; Hamilton Health Sciences (Frolic), Hamilton, Ont.; Division of Palliative Care (J. Downar, Isenberg), Department of Medicine, University of Ottawa, Ottawa, Ont.
CMAJ Open. 2023 Sep 19;11(5):E838-E846. doi: 10.9778/cmajo.20220168. Print 2023 Sep-Oct.
As the COVID-19 pandemic created a surge in demand for critical care resources, the province of Ontario, Canada, released the Adult Critical Care Clinical Emergency Standard of Care for Major Surge (Emergency Standard of Care [ESoC]), a triage framework to guide the allocation of critical care resources in the expectation that intensive care units would be overwhelmed. Our aim was to understand physicians' and administrators' experiences and perceptions of planning to implement the ESoC, and to identify ways to improve critical care triage processes for future pandemics.
We conducted semistructured qualitative interviews with critical care, emergency and internal medicine physicians, and hospital administrators from various Ontario health regions who were involved in their hospital's or region's ESoC implementation planning. Interviews were conducted virtually between April and October 2021. We analyzed the data using thematic analysis.
We conducted interviews with 11 physicians and 10 hospital administrators representing 9 health regions. We identified 4 themes regarding participants' preparation to implement the ESoC: infrastructure to enable effective triage implementation; social, medical and political supports to enable effective triage implementation; moral dimensions of triage implementation; and communication of triage results. Participants outlined administrative and implementation-related improvements that could be provided at the provincial level, such as billing codes for ESoC. They also suggested improving ethical supports for the usability and quality of the ESoC (e.g., designating an ethicist in each region), and ways to improve the efficiency and usability of the tools for assessing short-term mortality risk (e.g., create information technology solutions such as a dashboard).
The implementation of a jurisdiction-level triage framework poses moral challenges for a health care system, but it also requires dedicated infrastructure, as well as institutional supports. Lessons learned from Ontario's process to prepare for ESoC implementation, as well as participants' suggestions, can be used for planning for current and future pandemics.
由于新冠疫情导致对重症监护资源的需求激增，加拿大安大略省发布了《成人重症监护重大激增临床应急护理标准》（应急护理标准[ESoC]），这是一个分诊框架，用于指导重症监护资源的分配，预计重症监护病房将不堪重负。我们的目的是了解医生和管理人员对计划实施ESoC的经验和看法，并确定改进未来大流行期间重症监护分诊流程的方法。
我们对安大略省各卫生区域参与其医院或地区ESoC实施规划的重症监护、急诊和内科医生以及医院管理人员进行了半结构化定性访谈。访谈于2021年4月至10月通过线上方式进行。我们使用主题分析法对数据进行了分析。
我们对代表9个卫生区域的11名医生和10名医院管理人员进行了访谈。我们确定了关于参与者实施ESoC准备工作的4个主题：支持有效分诊实施的基础设施；支持有效分诊实施的社会、医疗和政治支持；分诊实施的道德层面；以及分诊结果的沟通。参与者概述了省级层面可以提供的行政和实施相关改进措施，如ESoC的计费代码。他们还建议加强对ESoC可用性和质量的伦理支持（如在每个地区指定一名伦理学家），以及提高评估短期死亡风险工具的效率和可用性的方法（如创建信息技术解决方案，如仪表板）。
实施辖区级分诊框架给医疗系统带来了道德挑战，但也需要专门的基础设施以及机构支持。从安大略省ESoC实施准备过程中吸取的经验教训以及参与者的建议，可用于当前和未来大流行的规划。
