Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York.
Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Los Angeles David Geffen School of Medicine, Los Angeles.
JAMA Netw Open. 2023 Oct 2;6(10):e2336736. doi: 10.1001/jamanetworkopen.2023.36736.
The spring 2020 surge of COVID-19 unprecedentedly strained ventilator supply in New York City, with many hospitals nearly exhausting available ventilators and subsequently seriously considering enacting crisis standards of care and implementing New York State Ventilator Allocation Guidelines (NYVAG). However, there is little evidence as to how NYVAG would perform if implemented.
To evaluate the performance and potential improvement of NYVAG during a surge of patients with respect to the length of rationing, overall mortality, and worsening health disparities.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study included intubated patients in a single health system in New York City from March through July 2020. A total of 20 000 simulations were conducted of ventilator triage (10 000 following NYVAG and 10 000 following a proposed improved NYVAG) during a crisis period, defined as the point at which the prepandemic ventilator supply was 95% utilized.
The NYVAG protocol for triage ventilators.
Comparison of observed survival rates with simulations of scenarios requiring NYVAG ventilator rationing.
The total cohort included 1671 patients; of these, 674 intubated patients (mean [SD] age, 63.7 [13.8] years; 465 male [69.9%]) were included in the crisis period, with 571 (84.7%) testing positive for COVID-19. Simulated ventilator rationing occurred for 163.9 patients over 15.0 days, 44.4% (95% CI, 38.3%-50.0%) of whom would have survived if provided a ventilator while only 34.8% (95% CI, 28.5%-40.0%) of those newly intubated patients receiving a reallocated ventilator survived. While triage categorization at the time of intubation exhibited partial prognostic differentiation, 94.8% of all ventilator rationing occurred after a time trial. Within this subset, 43.1% were intubated for 7 or more days with a favorable SOFA score that had not improved. An estimated 60.6% of these patients would have survived if sustained on a ventilator. Revising triage subcategorization, proposed improved NYVAG, would have improved this alarming ventilator allocation inefficiency (25.3% [95% CI, 22.1%-28.4%] of those selected for ventilator rationing would have survived if provided a ventilator). NYVAG ventilator rationing did not exacerbate existing health disparities.
In this cohort study of intubated patients experiencing simulated ventilator rationing during the apex of the New York City COVID-19 2020 surge, NYVAG diverted ventilators from patients with a higher chance of survival to those with a lower chance of survival. Future efforts should be focused on triage subcategorization, which improved this triage inefficiency, and ventilator rationing after a time trial, when most ventilator rationing occurred.
2020 年春季，COVID-19 的爆发使纽约市的呼吸机供应空前紧张，许多医院几乎耗尽了可用的呼吸机，随后严重考虑实施危机护理标准，并实施纽约州呼吸机分配指南（NYVAG）。然而，关于如果实施 NYVAG 会如何表现，几乎没有证据。
评估在患者激增期间，NYVAG 在分配呼吸机的时间、总体死亡率和恶化的健康差距方面的表现和潜在改进。
设计、设置和参与者：本队列研究包括 2020 年 3 月至 7 月期间纽约市单一医疗系统中插管的患者。在危机期间共进行了 20000 次呼吸机分类模拟（10000 次遵循 NYVAG，10000 次遵循改进后的 NYVAG），危机定义为大流行前呼吸机供应使用率达到 95%。
NYVAG 呼吸机分类协议。
比较观察到的生存率与需要 NYVAG 呼吸机配给的模拟场景的生存率。
总队列包括 1671 名患者；其中，674 名插管患者（平均[SD]年龄，63.7[13.8]岁；465 名男性[69.9%]）被纳入危机期，571 名（84.7%）COVID-19 检测呈阳性。模拟呼吸机配给在 15.0 天内发生在 163.9 名患者身上，其中 44.4%（95%CI，38.3%-50.0%）如果提供呼吸机将存活，如果新插管患者重新分配呼吸机，只有 34.8%（95%CI，28.5%-40.0%）存活。虽然插管时的分类显示出部分预后差异，但 94.8%的呼吸机配给发生在时间试验之后。在这个亚组中，43.1%的患者插管 7 天或更长时间，SOFA 评分较好但没有改善。如果持续使用呼吸机，估计其中 60.6%的患者会存活。修订分类亚组，即改进后的 NYVAG，可以提高这种令人震惊的呼吸机分配效率低下（如果选择呼吸机配给的 25.3%（95%CI，22.1%-28.4%）的患者获得呼吸机，他们的存活率将会提高）。NYVAG 呼吸机配给并没有加剧现有的健康差距。
在这项针对经历模拟呼吸机配给的插管患者的队列研究中，NYVAG 将呼吸机从生存机会较高的患者转移到生存机会较低的患者。未来的努力应集中在分类亚组上，这可以提高这种分类效率，以及时间试验后的呼吸机配给，因为大多数呼吸机配给都发生在这个时候。
