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Critical Care During a Pandemic: Final report of the Ontario Health Plan for an Influenza Pandemic (OHPIP) Working Group on Adult Critical Care Admission, Discharge and Triage Criteria

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April 2006
Critical Care During a Pandemic
Final report of the Ontario Health Plan for an Influenza Pandemic (OHPIP)
Working Group on Adult Critical Care Admission, Discharge and Triage Criteria
Critical Care During a Pandemic Page 2 of 25
April 2006
Acknowledgements:
This report reflects the work of many skilled and dedicated individuals who worked tirelessly over the past
two years while dealing with a subject that can be both intellectually and emotionally challenging. We would
like to thank the panel of experts (appendix 1) who participated in the retreat to finalize the draft protocol.
The group also thanks the OHPIP steering committee, the Emergency Management Unit and the Critical
Care Transformation team for their support and encouragement. Finally, we wish to recognize the
leadership and foresight of the Hon. George Smitherman, Minister of Health and Long-Term Care in
recognizing the importance of working to prepare Ontario to respond to an influenza pandemic, and for
encouraging planners to tackle difficult issues in order to produce a plan that will serve as an example
internationally.
Members of the OHPIP Adult Critical Care Admission, Discharge, Triage Working Group:
Project Lead: Dr Michael Christian, Fellow Infectious Diseases & Critical Care McMaster University
Dr. Randy Wax, Intensivist Mount Sinai Hospital
Dr. Neil Lazar, Ethicist & Intensivist, University Health Network
Dr. Laura Hawryluck, Ian Anderson Continuing Education Program in End-of-Life Care at the
University of Toronto & Intensivist University Health Network
Dr. Margaret Herridge, Respirologist/Intensivist University Health Network
Wendy Fortier, Clinical Director of Critical Care, Emergency and Trauma, Ottawa Civic Hospital
Dr. Mathew Muller, Infectious Disease/Microbiology St Michael’s Hospital
Lt. Col (Ret’d) Dr. Tim Cook, Internist Mount Sinai Hospital
Dr. Frederick Burkle Jr, Director Asian Pacific Branch Center for International Emergency,
Disaster & Refugee Studies, Bloomberg School of Public Health, Johns Hopkins University
Doug Gowans, MOHLTC (Project Manager A/D/T Working Group)
Sandy Nuttall, MOHLTC
Vahe Kehyayan, MOHLTC
Penny Palmer, MOHLTC
This report has been prepared by Michael D. Christian, MD FRCPC with support and contributions from the
working group at large.
Please address correspondence to:
Michael D. Christian, MD, FRCPC
McMaster University Medical Centre
Room 2U
1200 Main Street West
Hamilton, ON
L8N 3Z5
phone: 905-521-2100, ext. 75180
fax: 905-523-1224
email: michael.christian@utoronto.ca
Critical Care During a Pandemic Page 3 of 25
April 2006
Introduction
At the outset it is essential to state three key
principles which underpin the foundations of this
report, and triage in particular. First, a triage
protocol for critical care is not aimed at deciding
who will or will not receive care. All patients will
be cared for. Every human life is valued and
every human being deserves respect, caring and
compassion. However, this does not mean that all
patients will or should receive critical care. Those
who do not receive critical care will not be
abandoned; rather they will continue to be cared
for with alternative levels of care. The second
important principle is that triage does not
challenge or contravene ethical doctrine. In fact,
triage is the application of ethics in a very practical
manner. Effective triage will ensure that fairness
and justice prevail during a time when
circumstances would leave people vulnerable to
inequitable treatment. A thoughtful and carefully
implemented triage protocol is based on clear and
transparent criteria and can protect individuals
from any inequities. Finally, in a resource-rich
country such as Canada, the type of triage
described below is only ethically, legally and
morally justifiable in an overwhelming crisis, such
as an influenza pandemic, when all available
resources are in danger of becoming exhausted.
This protocol should not be viewed as a first step
toward any type of resource rationing under
ordinary circumstances. It is to be used only in
genuinely extraordinary situations.
This report will begin by providing a brief
perspective on the need for triage during a
pandemic. A discussion pertaining to the general
critical care response will follow in order to provide
context for the role of triage. Next, background
regarding triage will be discussed before outlining
the draft protocol proposed by the working group.
A detailed explanation of the rationale used to
support the protocol will also be provided. Finally,
the working group will offer recommendations to
the Ontario Health Plan for an Influenza Pandemic
[OHPIP] steering committee and Ministry of Health
and Long-Term Care [MOHLTC] regarding next
steps to finalize and operationalize this protocol.
The Pandemic Perspective
As outlined in the OHPIP1, the Canadian
Pandemic Influenza Plan2 [CPIP] and the medical
literature(1;2), health care resources will be
overwhelmed during an influenza pandemic.
Estimates vary widely as to what the true impact
may be. For the purpose of pandemic triage
surge capacity planning the ‘Flu Surge’ model3
was used assuming a 35% attack rate over 6
weeks. This results in a higher peak patient
volume then with an 8 week model used when
planning for a sustained response. Using the
current statistics for the Ontario population,
hospital capacity and intensive care unit [ICU]
resources, a 6 week model predicts that hospital
admissions in Ontario for patients with influenza
will peak at 1 823 per day. This translates to 72%
of the total hospital capacity being utilized by
influenza patients. Similarly, the demand for ICU
resources will peak at 171% of current existing
ICU bed capacity and 118% of the current
ventilator capacity solely for patients with
influenza. When considering these statistics, as
overwhelming as they are, one does not have a
true appreciation of the gravity of the situation
without also considering the current day-to-day
ICU utilization rates which is over 90%4.
It is also important to note that ‘Flu Surge’ does
not take into account reductions in hospital
capacity due to illnesses among health care
workers. Although there is a limited ability to
increase the amount of ICU resources available
during a pandemic, they will be insufficient to meet
these increase demands on the system. These
dramatic but plausible predictions highlight the
need to have strategies that will optimize Ontario’s
Critical Care system to meet the needs of the
public during an influenza pandemic.
1 Ontario Health Pandemic Influenza Plan, May 2004,
pg 6 & 10.
2 Canadian Pandemic Influenza Plan, February 2004,
pg 18.
3
http://www.health.gov.on.ca/english/providers/program/
emu/pan_flu/flusurge.html
4 Final Report of The Ontario Critical Care Steering
Committee, March 2005.
Critical Care During a Pandemic Page 4 of 25
April 2006
The CPIP does not provided guidelines for
admission to critical care units. The CPIP simply
states:
“Management of patients in the ICU
will be similar to interpandemic
influenza care. The clinical
presentation of the disease and the
availability of resources will
determine which changes may be
desirable throughout the
pandemic..”5
Further, the CPIP does not provide specific
guidance with regard to the allocation of scarce
resources:
“Prioritization of health resources at
times of critical shortages will also
need to be considered. Local
community-based centers and
hospitals need to take a multi-
disciplinary approach and include
ethical and legal considerations
when developing any prioritization
processes. If supplies, equipment,
and access to intensive care must
be rationed, a fair and equitable
prioritization process will need to be
established.”6
Pandemic plans developed for other
jurisdictions7, 8,9 have also identified the need for
developing methods of rationing critical care
resources during periods of scare supply.
However, even these plans specifically developed
for critical care during an influenza pandemic10 do
not provide guidance with respect to triage.
In December 2004, the OHPIP Operations
Subcommittee convened a meeting to discuss the
allocation of scare critical care resources,
5 Canadian Pandemic Influenza Plan, February 2004,
pg 297.
6 Canadian Pandemic Influenza Plan, February 2004,
pg 354.
7 A Model Plan for Influenza Pandemic Preparedness
Version 3.1, September 2001, Ireland.
8 Australian Action Plan for Pandemic Influenza,
October 2003.
9 UK Health Departments’ Influenza pandemic
contingency plan, March 2005.
10 Australian and New Zealand Intensive Care Society
Influenza Pandemic Planning for ICU, August 2001.
especially ventilators, during an influenza
pandemic. A decision was made to strike a
working group of clinicians from the critical care
field to explore this issue. Dr Michael Christian
was assigned as project lead for the “Adult Critical
Care A/D/T Working Group”, comprised of
members as listed above. The working group
assessed a broad range of issues related to
critical care during a pandemic, made
recommendations to the OHPIP Steering
Committee, and identified future activities for the
working group in their interim report (dated April
19, 2005).
Critical Care During a Pandemic Page 5 of 25
April 2006
Recommendations of the Working Group:
¾ The OHPIP steering committee adopt the ethical framework by Sunnybrook &
Women’s College Health Sciences Centre Clinical Ethics Centre The Joint Centre
for Bioethics “Ethics in a Pandemic Influenza Crisis: Framework for Decision-
Making” and use this to guide the development of protocols pertaining to triage and
resource allocation during a pandemic.
¾ The operations subcommittee appoint members and alternatives to a triage
advisory committee who will form the central triage advisory committee during a
pandemic and assist with the development of triage guidelines prior to a pandemic.
This committee will have to be appropriately resourced to allow necessary training
and preparation.
¾ The MOHLTC along with the OHPIP steering committee ensure that the
infrastructure requirements for effective triage exist or are developed including
processes for data collection and analysis of clinical information about the infection,
monitoring of resource availability, and communications.
¾ The MOHLTC embark on an effort to recruit and train physicians in all communities
who may serve as triage officers during mass casualty events or a pandemic.
These activities may be partnered with other emergency preparedness resources
such as the Emergency Medical Assistance Team [EMAT] or the initiative to
improve chemical, biological, radiation and nuclear [CBRN] preparedness.
¾ A review of legislation and the legal issues related to triage in a civilian health care
system be completed and reported back to the OHPIP steering committee.
¾ The communications subcommittee develop a communications strategy to inform
the public about issues related to the management of scarce resources during a
pandemic.
¾ Ensure that a working group is struck to develop management guidelines for
palliative care.
¾ Once critical care triage protocols have been finalized, they should be tested in a
pandemic exercise following pilot testing with focus groups of critical care
physicians from both the community and academic ICUs
¾ The potential role of Criticall in the centralized triage system should be explored.
¾ A retreat should be sponsored to facilitate the development of the critical care triage
tool.
Critical Care During a Pandemic Page 6 of 25
April 2006
Future Actions of the A/D/T Working Groups:
¾ Assist with the development of a tool for
triaging critical care resources during a
pandemic, including the development of
inclusion, exclusion, and Minimum
Qualifications for Survival [MQS] criteria.
¾ Assist the OHPIP Operations Sub-
committee in further developing a proposed
system for centralized triage during a
pandemic including identifying the required
infrastructure necessary to operationalize
the system.
¾ Assist the operations subcommittee in
identifying the requirements for training
triage officers and identify potential
resources for conducting such training.
Many of the recommendations of the working
group were incorporated into the 2005 iteration of
the OHPIP. The discussion below describes the
working groups activities related to triage.
Critical Care Response During A Pandemic In
Context
During a pandemic, as with any large emergency,
a series of strategies such as code orange
protocols and mass critical care will be employed
in an attempt to build surge capacity (figure 1).
However unlike virtually any other emergency that
has struck North America in the past century,
these strategies alone will quickly fall far short of
the ability to deal with the numbers of patients
who will seek care during a pandemic.
Consequently, difficult decisions will have to be
made about how best to prioritize scarce
resources to maximize the benefit of these
resources for the community as a whole. This
process is called ‘triage’, and will be explored in
detail in the next section of this report. First,
however, it is important to understand other
strategies that must be employed to maximize
system capacity.
The first response to any anticipated demand on a
hospital that will exceed its ability to provide care
for patients through routine operations should be
to implement an external disaster or “code
orange” protocol. Most code orange protocols
include a series of strategies (figure 1) that work in
concert to provide short-term surge capacity and
operate on an incident management system
[IMS](3). Some but not all of these strategies will
be applicable during a pandemic because dealing
with an influenza pandemic is not a matter of
short-term surge capacity, but rather long-term
sustainability. For example, in other types of
emergencies one of the fastest ways to increase
human resources is to hold back a shift from going
home, thereby immediately doubling staff
complement. In a pandemic that will last several
months, this type of strategy will not be feasible.
However, other human resources strategies will
be useful in a pandemic many of which are
described in the OHPIP. Examples include calling
back retired staff, or identifying and redeploying to
the ICU staff who previously worked in critical
care, but who have subsequently moved to other
departments.
During a pandemic, mutual aid agreements in
their traditional sense, where one organization will
lend staff or resources to another during an
emergency, are also of limited utility as all
hospitals in the province will be facing the same
challenges. Regardless, it will be critically
important for hospitals to work together to respond
to the pandemic. In many emergencies, all
elective and non-emergent services and surgeries
are cancelled in order to enable hospital
resources to be channeled towards responding to
the emerging crisis. Again, this type of strategy
cannot be applied to any great extent during a
pandemic because, as we learned from SARS(4),
failure to maintain other essential services during
a prolonged emergency impacts on the broader
health care system, and beyond. Therefore
during a pandemic, elective and non-emergent
services will have to be scaled back to increase
capacity in a systematic fashion. This will require
a coordinated approach between hospitals and
community-health sectors, to provide for a full
spectrum of services with reduced capacity, but
sufficient to address the urgent needs of the
population.
Scaling back elective services and surgeries frees
up areas in hospitals such as surgical intensive
care units, endoscopic units, step-down units and
0
25
50
75
100
125
150
175
200
time
ICU Capacity
Response Thresholds
120-130%
Normal
Ops
~150%
“Code
Orange”
Mutual aid
agreements
Call back staff
Cancel elective
ORs
Open alter native
care areas
Care team
model
IMS
etc
~170%
Mass
Critical
Care
•Modified
standard &
delivery of care
•Focus on key
interventions
•Expanded
roles
•etc
>170%
Mass Critical
Care & “True
Triage”
•Targeting
Resource s
based on the
Ultimate Ends of
maximizing
survival wit hin
the population
•“do the greatest
good for the
greatest
number”
•Dynamic
balance between
resources and
needs
Figure 1
Critical Care During a Pandemic Page 7 of 25
April 2006
post anaesthetic care units [PACU] that are well
equipped to provide critical care for critically ill
influenza and non-influenza patients. How much
critical care capacity can be increased will depend
largely on the availability of ventilators, and
personnel skilled in managing critically ill patients.
Additional personnel can be realized through
scale-back of elective and non-urgent services –
skills these HCWs poses may not have previously
been applied to critical care but may be readily
transferable to critical care. This later group has
significant potential for increasing critical care
capacity when a care team model is applied
(figure 2). In this model, health care workers
[HCWs] who have useful skills but lack experience
in a specific area can work in teams supervised by
those with the relevant experience. Instead of
individual HCWs caring for one or two patients, a
team of HCWs, who amongst them possess a
complete skill set and relevant experience,
collectively care for a group of patients. As an
example, in this model, a team composed of 2
ICU nurses supervising 3 step-down nurses
working in conjunction with a respiratory therapist
and a physician could care for 8 to 10 patients
This versus the traditional staff compliment of 1:1
or 1:2 ratio of critical care nurses, for example 4
ICU nurses caring for 5 ventilated patients.. The
use of care teams has proven to be effective in
past emergencies(5;6).
If after all efforts to expand capacity, demands still
exceed available capacity, the type of care being
provided must be altered to focus on key
interventions (table 1). This model of care is
referred to as mass critical care(7;8). Mass critical
care is aimed at ensuring resources are targeted
to optimize both the effectiveness and efficiency of
resource utilization including both supplies and
manpower. Only after all of the above strategies
have been employed to maximize system capacity
is it reasonable to implement the triage strategies
outlined in the next section.
Triage Overview
During a disaster, including a pandemic, surge
capacity may be maximized and despite the
implementation of mass critical care, resource
scarcities will still occur. In such situations it is
necessary, and in fact mandated by international
law(9-11), to utilize methods for allocating
resources that are both equitable and maximize
the benefit to the population at large(6). Such
methods are referred to as ‘triage’, not to be
confused with the prioritization “triage”
systems(12) used in emergency departments on a
routine basis(13). To differentiate between the
two, the term ‘TRUE Triage’ or ‘Targeting
Resources to achieve Ultimate Ends’ has been
suggested (work In Press, M. Christian). The
original concept of ‘triage’ was developed during
wartime(11) where scarce resources were used to
provide the maximum benefit to the population at
large, even if it meant that individual victims who
might have been saved under other
circumstances could not be treated
optimally(13;14). Triage must be based upon
established medical criteria, not factors such as
socioeconomic status or political affiliation, and
represents a dynamic balance between resource
availability versus demand(13).
Further, human rights, humanitarian laws(10) and
strict adherence to ethical practices, such as
transparency and accountability must be observed
when triage protocols are being developed(8).
Health care providers practicing in an emergency
have to balance the needs of individuals with the
responsibility they also have to all others in the
community as guardians of important resources.
Key critical care interventions:
Basic modes of ventilation
Hemodynamic support
Antibiotics
Disease specific countermeasures
ie/ thrombolysis
Prophylaxis
ie/ DVT
Figure 2
Table 1
Critical Care During a Pandemic Page 8 of 25
April 2006
In short, the primary goal of triage is to be able to
“do the greatest good, for the greatest
number”(13). A full exploration of the ethical
issues related to triage can be found in the
literature(9;11) as well as the framework included
in the Ontario Health Pandemic Influenza Plan
[OHPIP](15) and the report produced by the Joint
Centre for Bioethics11. Further discussion of the
ethical implications of a triage protocol for use
during a pandemic will be discussed below.
Unfortunately, no triage systems have been
developed for use in critical care or medical
illnesses. Illness severity scoring systems(16-18)
currently used in critical care research have
reasonable abilities to predict ICU outcome, but
they are cumbersome to use and therefore
particularly impractical for use during a disaster
when human resources are scarce. Further,
although validated for predicting outcome, they
have not been validated for guiding, or more
specifically restricting, treatment. Military triage
systems(19-21) are good only as a model for
critical care triage since they were devised
specifically for trauma and not medical conditions
or biological events. The ‘SEIRV’ triage system
was developed for use in bioterrorism attacks and
is used to categorize patients as susceptible,
exposed, infectious, removed and vaccinated [
SEIRV] (22). Although a very robust system which
provides many lessons that can and should be
applied to the overall response to bioevents, it
dose not address issues dealing with resource
allocation and has limited applicability during a
pandemic where the virus is ubiquitous in the
community. The SERVI system uses inclusion,
exclusion and minimum qualifications for survival
[MQS] to guide triage decisions. These should
also be used in all critical care triage systems.
Accurate triage is critical to maximize survival.
Triaging patients inappropriately to critical care is
called “over-triage”(13). Over-triage results in
inappropriate resource expenditures. Frykberg
showed that over-triage of patients involved in
11 Stand On Guard For Thee: Ethical considerations in
preparedness planning for pandemic influenza.
University of Toronto Joint Centre for Bioethics
Pandemic Influenza Working Group. November 2005.
http://www.utoronto.ca/jcb/home/documents/pandemic.
pdf
terrorist bombings is directly related to overall
increased mortality rates. Real-time data about
patient outcomes during a disaster is required to
allow modification of the triage criteria in order to
prevent under or over triage. Another possible
mechanism to fine tune triage criteria is to use
computer modeling based on databases of
patients with similar illnesses (ie/ influenza) from
non-bioevent occurrences. The utility of such
modeling was demonstrate by Dr Garner and his
colleagues during their work on trauma triage
guidelines(23).
Developing A Triage Protocol For a Pandemic
The Critical Care A/D/T working group reviewed
the medical literature to identify potential triage
systems that could be modified for use during an
influenza pandemic. Unfortunately, no triage
systems have been developed for use in critical
care or medical illnesses. However, the
Sequential Organ Failure Assessment score
[SOFA](24) was identified by the working group as
potentially having utility for inclusion as a
component of a triage tool. The SOFA score has
not been used for the rationing of critical care
resources but it was designed with this in
mind(24). Additional benefits of the SOFA score
is that it is not disease specific but rather uses
general physiologic parameters applicable to a
wide variety of conditions. Further, the scale has
been validated on a wide range of patients with
various reasons for being in critical care. Thus is
has better applicability during a pandemic when it
will be applied to all critical care patients as
opposed to disease specific scoring systems.
Preliminary drafts of this proposed tool were
developed and included in 2nd Iteration of the
OHPIP.
In addition to reviewing the scoring systems
currently employed in critical care units, the
working group also reviewed triage systems used
by the Canadian Military, US Military and in the
pre-hospital field(19-21). For the reasons
discussed above, these were felt to be good
models upon which to design a critical care triage
system. The working group developed an early
prototype triage protocol which was discussed in
the 2005 OHPIP. In January of 2006 a retreat
was held with experts from across the province to
provide comment on the prototype which was
incorporated by the working group to yield the
draft presented below.
Critical Care During a Pandemic Page 9 of 25
April 2006
Draft Triage Protocol and Rationale
The draft protocol being recommended to the
OHPIP steering committee for broader
consultation is detailed in Appendix I. It is not
possible to develop a perfect triage protocol in
advance of the pandemic as many factors are
unknown and unpredictable at this point. The
current protocol is not able to take into account
the natural history of a yet unknown pandemic
strain of influenza, nor can it predict which groups
are more or less likely to have poor outcomes.
Further, given that triage is a dynamic process
dependant on both the demands and availability of
resources, the protocol will have to evolve over
time. The primary goal of the current protocol is to
provide a starting point. This protocol is intended
to provide guidance for making triage decisions
during the first days to weeks of a pandemic,
following which a cycle of evaluating the
supply/demand balance and triage outcomes –
then modifying the protocols – will be required.
Although this is referred to as a triage protocol for
use during a pandemic, it must be noted that the
triage protocols apply to all patients who are being
considered for admission to critical care, since
there is only a single pool of critical care
resources that must be shared by both those with
and without influenza. Patients should be triaged
when the physician or HCW attending to them
believes that they meet the inclusion criteria for
ICU. If the patient is not at a centre with critical
care services, they should be triaged remotely
prior to transfer to a critical care centre to
minimize unnecessary transfers if the patient does
not meet the criteria for admission to the ICU, or
meets the exclusion criteria.
The triage protocol has three main components.
The first component is the inclusion criteria.
Broadly speaking these criteria identify patients
who may potentially benefit from admission to
critical care. The inclusion criteria primarily focus
on respiratory failure given that the ability to
provide ventilatory support is fundamentally what
differentiates the ICU from other acute care areas
such as step-down units, etc. With expanded care
models developed as part of the surge capacity
response it is anticipated that hemodynamic
support and other advanced care modalities will
be provided in areas that have appropriate
monitoring but don’t typically provide that level of
care. However, should hemodynamic support not
be available elsewhere, it will qualify as an
inclusion criteria.
The second component is the exclusion criteria
which can be broken down into 3 categories: 1)
people who currently have a very poor
prognosis/chance of survival even when treated
aggressively in an ICU, 2) people who will need a
level of resource that simply cannot be met during
a Pandemic situation and 3) those with underlying
significant and advanced medical illnesses whose
underlying illness has a poor prognosis with high
short-term mortality even without their current
concomitant critical illness. The first category
identifies patients who have a low probability of
recovery or overall poor prognosis irrespective of
the amount of resources dedicated to their care.
Essentially these are the ‘hard’ boundaries that
many intensivists recognize from their day-to-day
care of patients. For example, severe burns with
two or more high risk factors have a significant
mortality risk(25). Cardiac arrest patients who
have unwitnessed or recurrent arrests and those
who do not respond to prompt electrical
interventions such as defibrillation or cardiac
pacing, require significant resources but rarely
survive to discharge(26). Finally, those patients
with a SOFA score of > 11 have a mortality rate in
excess of 90% even with full critical care during a
normal period. It must be remembered that during
a pandemic mass critical care will be performed
focusing only on key interventions likely resulting
in at least equivalent if not higher mortality rates
then seen in studies validating the SOFA score.
Some people may benefit from ICU care during a
normal period, yet these benefits are achieved
with an intense use of resources and often
prolonged care. During a pandemic, with a triage
goal of doing the most for the most, such intense
consumption of resources will need to be limited.
Patients requiring large volume blood transfusions
have, at this time, been listed as an exclusion
criteria, as many conditions requiring large
transfusion are often associated with high
mortality rates. Further, the availability of blood
products may be limited if we cannot identify
“clean” or uninfected potential donors and
therefore turn donors away out of fears of infecting
others through blood transfusions. Hence, the
availability of blood during a pandemic remains
uncertain at this point.
Critical Care During a Pandemic Page 10 of 25
April 2006
The third cluster of exclusion criteria include
patients such as those with advanced cancer or
immunosuppression who have very high resource
requirements and are likely to suffer significant
complications from influenza among other
infections. Others in this cluster of exclusion
criteria are those patients who have end stage
organ failure involving their heart, liver or lungs.
The cut offs selected here are adopted from the
transplant literature(27;28)12. These cut offs
typically represent a mortality of >50% within the
next one to two years as the baseline natural
history of their organ failure. Given that
transplantation is unlikely during a pandemic,
combined with the cumulative mortality risk from
their acute illness requiring critical care, these
patients again fall into a category when
considerable resources would have to be
expended with an overall low probability of
survival.
The final aspect of the triage protocol deals with
the “minimum qualifications for survival” [MQS].
This term is also borrowed from military triage
protocols and represents a ceiling on the amount
of resources that can be expended on any one
individual. Again this is a concept very foreign to
western medical systems but has been required in
war zones and refugee camps. An illustrative
example can be drawn from these fields to better
explain the concept. In a drought situation in a
refugee camp, physicians are often faced with
many patients who have dehydration, but at the
same time have a very limited supply of saline
solution to treat patients. When faced with a
severely dehydrated patient on the verge of
cardiovascular collapse and volume resuscitation
is being provided, such a patient often require
liters and liters (possibly 10 or more liters) of fluid
to attempt to reverse the hypovolemic shock,
which often in the end is not possible to do.
Continuing to treat such a patient means that 5 or
10 other patients with early hypovolemia who
could have been saved with 1 – 2 liters of iv fluid
will in turn also succumb to dehydration because
the iv fluids were all used in a failed attempt to
save a single individual. The alternative is to
place a ceiling on the amount of resources that
12 National Protocol For Assessment Of Cardiothoracic
Transplant Patients. March 2002. Prepared by the UKT
Cardiothoracic Advisory Group. A special health
authority of the national health service. UK Transplant,
Fox Den Road, Stoke Gifford, BRISTOL, BS34 8RR
will be allocated to anyone individual to ensure
that the maximum potential benefit of the available
resources can be realized and a larger number of
people overall can be saved.
This situation, unfortunately, is not all that different
from what we would likely face in critical care units
during a pandemic. Thus, the suggested triage
protocol includes MQS that dictate reassessment
at 48 and 120 hours as well as an ongoing ceiling
if a patient ever develops a SOFA score of 11 or
any other exclusion criteria. The key component
of the MQS is its attempt to identify early those
patients who are not improving and are likely to
have a poor outcome. Often in day-to-day
practice, this poor outcome isn’t realized until
several days or weeks of intensive care have
been invested in the patient. Clearly in a
pandemic, when resources are scarce, this is a
less-than-ideal situation, thus necessitating the
MQS.
The final component of the triage protocol is the
prioritization of patients for potential admission to
the ICU and ventilation. For ease of use, the
common blue/red/yellow/green colour scheme
was used.
Blue patients are those who fall in to the
expectant category and should not receive
critical care. Depending on their condition
and medical issues the patient may either
continue to have curative medical care on
a ward or palliative care.
Red patients are highest priority for ICU
admission and a ventilator if required. In
selecting the patients who will fit into this
category the aim was to find the balance
between those who are sick enough to
require the resource and will do poorly if
they don’t receive it, but are not so sick
that they are unlikely to recover even if
they do receive the care. Patients with a
single organ failure, particularly those with
respiratory failure due to influenza and
who otherwise have a very low SOFA
score are also included in the red category
assuming they have no exclusion criteria.
The goal is to optimize the effectiveness of
the triage protocol so that every patient
who receives resources will survive.
Clearly this an idealistic endpoint that is
not likely to be achieved with 100%
Critical Care During a Pandemic Page 11 of 25
April 2006
success, but it will be used as a target to
guide how the triage protocol will be
modified by monitoring patient outcomes
during the pandemic.
Yellow patients are those who at baseline
are very sick and may or may not benefit
from critical care. They should receive
care if the resources are available but not
at the expense of denying care to
someone in the red category who is more
likely to recover. At the re-assessment
points, patients who are improving are
given high priority (red) for continued care,
while those who are not showing signs of
improvement or worsening are prioritized
as yellow.
Green patients are essentially those who
should be considered for transfer out of the
ICU.
Ethics Considerations
The work of this group to produce this draft triage
protocol was guided by the ethics framework
included in the 2005 iteration of the OHPIP as well
as the more recent report “Stand On Guard For
Thee: Ethical considerations in preparedness
planning for pandemic influenza”13 from the Joint
Centre for Bioethics [JCB] in addition to the
members of the JCB who sat on the working
group. In their report “Stand on guard for thee”
the JCB outline 10 substantive and 5 procedural
values that should guide decision making
regarding for an influenza pandemic (see table 2).
This section of the report will discuss each of the
applicable values and detail how the protocol
embodies them. In each case the description from
the JCB report will be provided in italics followed
by commentary pertaining to the protocol.
13 Stand On Guard For Thee: Ethical considerations in
preparedness planning for pandemic influenza.
University of Toronto Joint Centre for Bioethics
Pandemic Influenza Working Group. November 2005.
http://www.utoronto.ca/jcb/home/documents/pandemic.
pdf
Individual Liberty:
“In a public health crisis, restrictions to individual
liberty may be necessary to protect the public from
serious harm. Restrictions to individual liberty
should: be proportional, necessary, and relevant;
employ the least restrictive means; and be applied
equitably.”
Clearly the triage protocol is a restriction of the
liberty currently enjoyed by individuals in our
society to access care. However, this restriction is
felt by the working group to be necessary in order
to serve the public as a whole and protect the
greater public from the potential harm of
unnecessary deaths due to inappropriate
utilization of resources. The protocol is
proportional in that it is flexible based on the
available resources (ie/ ‘yellow’ patients will have
access if the resources are available) and
mandating reassessments of triage status.
Similarly, it is to be used only when necessary,
and is equitable in that it applies to all patients
being considered for admission to ICU.
Equity:
“All patients have an equal claim to receive the
health care they need under normal conditions.
During a pandemic, difficult decisions will need to
be made about which health services to maintain
and which to defer. Depending on the severity of
the health crisis, this could curtail not only elective
surgeries, but could also limit the provision of
emergency or necessary services.”
This value speaks to the core necessity for
developing a triage protocol in the first place. A
triage protocol assists in fairly distributing
resources by preventing a few sick patients early
Values To Guide Ethical Decision-Making For A
Pandemic Influenza Outbreak
Substantive Procedural
Individual Liberty
Protection of the
public from harm
Proportionality
Privacy
Duty to provide care
Reciprocity
Equity
Trust
Solidarity
Stewardship
Reasonable
Open and
transparent
Inclusive
Responsive
Accountable
Table 2
Critical Care During a Pandemic Page 12 of 25
April 2006
in the pandemic from consuming all of the
resources, thus denying other equally needy
patients who follow. While it may be unfortunate
that some patients do not receive all that they
need, this does not by default make it unfair.
Trust:
“Trust is an essential component of the
relationships among clinicians and patients, staff
and their organizations, the public and health care
providers or organizations, and among
organizations within a health system. Decision
makers will be confronted with the challenge of
maintaining stakeholder trust while simultaneously
implementing various control measures during an
evolving health crisis. Trust is enhanced by
upholding such process values as transparency.”
The triage protocol helps to engender the trust of
the public in several ways. Firstly it is being
established by experts in the field well in advance
of a pandemic with time for thoughtful
contemplation and participation. The process is
based on relevant criteria derived from the
currently known best evidence available in the
medical literature. It has been developed in a
transparent manner openly acknowledging its
limitations and with plans for revision as
information becomes available regarding
prognostic factors/survival and resource
availability in an pandemic. An appeals/review of
decision-making process is also incorporated into
the triage plan as described below. The triage
plan’s details will in the end be informed by broad
consultation and will be made public.
Solidarity:
As the world learned from SARS, a pandemic
influenza outbreak, will require a new vision of
global solidarity and a vision of solidarity among
nations. A pandemic can challenge conventional
ideas of national sovereignty, security or
territoriality. It also requires solidarity within and
among health care institutions. It calls for
collaborative approaches that set aside traditional
values of self-interest or territoriality among health
care professionals, services, or institutions.”
The triage protocol will be implemented across all
hospitals and monitored via a central triage
agency. This will help to ensure a consistent
application of the protocol. The development of
the protocol has been collaborative with clinicians
from a variety of fields beyond critical care, as well
as various levels of care providers.
Stewardship:
“Those entrusted with governance roles should be
guided by the notion of stewardship. Inherent in
stewardship are the notions of trust, ethical
behaviour, and good decision-making. This implies
that decisions regarding resources are intended to
achieve the best patient health and public health
outcomes given the unique circumstances of the
influenza crisis.”
The committee has striven to uphold this
fundamental notion as it has developed the triage
plan. A comprehensive triage plan is essential to
achieve ethical stewardship in the midst of the
chaos of a pandemic. The motivation for
developing this triage protocol and the objectives
of it align very well with those described above.
Reasonable:
“Decisions should be based on reasons (i.e.,
evidence, principles, and values) that stakeholders
can agree are relevant to meeting health needs in
a pandemic influenza crisis. The decisions should
be made by people who are credible and
accountable.”
Every effort has been made to base the triage
protocol on sound science wherever any relevant
data exists. The criteria developed for inclusion
and exclusion have been reviewed by a wide
range of clinicians and have been found to have
face validity. That is, they are consistent with
current medical literature and the clinical
experience of those who have reviewed the
protocol. Finally, in terms of credible and
accountable decision making, it is recommended
that there be a central triage committee with
significant knowledge and experience in triage as
well as having trained triage officers applying the
protocol in the field. The triage officers would be
accountable back to the central triage committee.
Open and transparent:
“The process by which decisions are made must be
open to scrutiny, and the basis upon which
decisions are made should be publicly accessible”.
Critical Care During a Pandemic Page 13 of 25
April 2006
The triage protocol will be opened to public
comment and publicized both in the OHPIP as
well as in the peer reviewed medical literature. It
is recommended by the working group that the
Ministry not only include discussion of the protocol
during media interviews about the OHPIP, but that
they actively work to educate and inform the
public both about the need for triage and the types
of changes patients can expect in the delivery of
health care during a pandemic.
Inclusive:
“Decisions should be made explicitly with
stakeholder views in mind, and there should be
opportunities to engage stakeholders in the
decision-making process.”
As discussed above, the recommendation of the
working group is to take this draft protocol forward
to further consultation with the public and other
stakeholder consultations. As part of the current
process, broader critical care input is currently
being sought.
Responsive:
“There should be opportunities to revisit and revise
decisions as new information emerges throughout
the crisis. There should be mechanisms to address
disputes and complaints.”
The triage protocol incorporates a process to
review and revise based on new knowledge that
will arise during the pandemic and on resources
supply/demand. In addition, it importantly
incorporates an appeal process. The working
group recommends that the central triage
committee be formed to monitor the triage
process, revise the protocol throughout the
pandemic and address appeals for exceptions
from the field. Arrangements should also be made
prior to a pandemic to address disputes of triage
officers, clinicians or family members with the
triage protocol. One possible dispute resolution
process is to create an appeals panel consisting
of recently retired clinicians with critical care
experience and retired judges who can convene
using telecommuting technologies to arbitrate and
resolve conflicts in a timely manner. All efforts
should be made to minimize the need for such
appeals through public and health care education
regarding the triage protocols and thorough
training of the triage officers.
Accountable:
“There should be mechanisms in place to ensure
that decision makers are answerable for their
actions and inactions. Defense of actions and
inactions should be grounded in the 14 other
ethical values proposed above.”
The first step in ensuring accountability is to
ensure that the triage protocols are defensible in
ethics and law. Thus, the working group
recommends that a legal opinion be obtained from
the Attorney General’s office regarding the legal
standing of these triage protocols prior to a
pandemic. Subsequently, once the triage
protocols themselves have been found to meet
the standard of law, physicians who apply them
will be accountable to their College in the same
manner as any other circumstance. The standard
against which clinicians should be judged is that of
what any other reasonable physician would do in
the same circumstance. The difficulty in this,
however, is that since a pandemic is a very unique
circumstance, it may be difficult to determine the
standard of care.
Recommendations for Operationalization and
Next Steps
Effective triage depends on an established, skilled
and practiced infrastructure. Implementing a new
infrastructure in the middle of a major disaster is a
recipe for failure. Therefore, the working group
recommends that the infrastructure required for
critical care triage during a pandemic be
integrated with and be built upon the foundation
for surge capacity that is going to be developed by
the critical care transformation team lead by Dr
Tom Stewart. The working group feels that this
will create the optimum conditions for success and
strengthen both initiatives. This approach is also
the most cost effective approach. In the
remainder of this section, the specific
infrastructure that is required for critical care triage
during a pandemic will outlined as well as the next
steps in the development process recommended
by the working group.
Triage Officers:
The type of triage proposed in this report is
challenging both clinically and psychologically.
Therefore it is essential that proper training be
Critical Care During a Pandemic Page 14 of 25
April 2006
provided prior to a pandemic with ongoing support
provided throughout the pandemic. Prior
experience shows that the best triage decisions
are made by senior physicians who have training
in triage and significant clinical experience to draw
upon. During a pandemic when resources are
scarce it may not be possible to meet this ideal.
Although in most circumstances it will be
necessary to have a triage officer assess patients
in person, mechanisms should also be developed
to assist less senior or experienced physicians by
making available access to more
senior/experienced triage officers to provide
advice. Building upon existing infrastructure such
as the ‘NorthNetwork’ and ‘Telestroke’ should be
considered to facilitate this. Further, very clear
and well funded processes need to be in place to
support triage officers to deal with the significant
psychological stress we anticipate will be
associated with performing this function.
Central Triage Committee:
While the triage protocol has been designed for
ease of use in the field during a pandemic,
ongoing modifications will need to be made to the
protocol as the pandemic evolves. Such
modifications however are complex and require
the analysis of a large amount of data and
therefore are not amenable to individual triage
officers doing this in the field. Further, if individual
triage officers began modifying their protocols
independently, equity, trust, solidarity and
reasonableness are all at risk of being
compromised. Thus it is necessary to have a
central committee who are very familiar with triage
protocol development to oversee triage during the
pandemic. Through their triage officers in the
field, the triage committee must have absolute
command and control over the critical care
resources in order to ensure accountability.
Intelligence:
Good triage must be based on good information.
A wide variety of information including the
demands on the system, resource availability,
natural history of influenza and patient outcomes
in critical care are all important to enable
appropriate triage decisions to be made. Thus it
will be necessary to ensure that the central triage
committee has real time access to the necessary
system and epidemiologic data.
Communications Network:
In order to efficiently implement the triage
protocols there must be an efficient
communications network that allows two-way
communications between the “field” and the
command centre. This should allow for the flow of
data up to the central triage committee as well as
new directives and advice down to the field.
Given that such infrastructure does not currently
exist, the province needs to invest in technology
that would allow reliable communication with and
between triage officials given that delays in
communication may lead to under- or
over-triage.
Protocol Activation:
Knowing when to ‘pull the trigger’ or activate a
system is a challenge in any emergency. This
task becomes even more challenging when an
event is dynamic (evolving over time) rather then
static (a single point in time). A pandemic is the
extreme of a dynamic event as it may evolve over
months. Therefore knowing when to implement
the triage protocol will be a particular challenge.
However, the same is true of knowing when to
implement surge capacity strategies, mass critical
care or any of the other pandemic response
programmes. If the triage protocol is implemented
too late, many resources will utilized by a few
patients early in the pandemic. In addition, the
ICUs may quickly become ‘gridlocked’ with
patients. However, given the implications of being
declined for ICU admission, implementing the
protocol too early also carries with it significant
consequences for individual patients. The quality
of the decision will depend on the availability of
accurate information regarding resource
availability and the epidemiology of the pandemic.
Answering the question when to activate the triage
protocol, however, is only half the question. The
second consideration is how to implement the
protocol. Given that a pandemic is a dynamic
event that evolves over time, one approach would
be to implement the protocol in a gradual fashion,
particularly if only a gradual influx of cases initially.
This could be accomplished in two ways. First,
Critical Care During a Pandemic Page 15 of 25
April 2006
the breadth of the exclusion criteria could be
expanded in a graded manner. Secondly, the
protocol could be applied to new patients who are
being considered for admission as opposed to
applying the protocol to those already admitted to
the ICU at the time the pandemic begins.
However, should there be a rapid influx of patients
requiring critical care, it may be necessary to
apply the protocol ‘retroactively’ to patients
already admitted to the ICU. In either case, this is
one area of triage that still requires further
discussion prior to a pandemic.
Next steps:
The immediate next steps recommended by the
working group are:
1. Obtain a legal opinion regarding the triage
protocol from the Attorney General of
Ontario
2. Broader consultation within the health
community
3. Educate the public regarding the need for
triage during a pandemic, and seek public
input regarding the draft triage protocol
4. Design and document a concrete plan with
the Critical Care Transformation Team as
to how the required infrastructure will be
developed.
Conclusions
A tremendous amount of time, energy and
consideration has been invested in developing a
triage protocol to assist in critical care resource
allocation during the first days to weeks of a
pandemic. This is a starting point for the ongoing
work that will have to be done during a pandemic.
Every effort was made to ensure that this protocol
not only conforms with but embodies the ethical
framework endorsed by the OHPIP.
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(24) Ferreira FL, Bota DP, Bross A, Melot C,
Vincent JL. Serial evaluation of the SOFA
score to predict outcome in critically ill patients.
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Critical Care During a Pandemic Page 17 of 25
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- - Appendix I - -
Critical Care During a Pandemic Page 18 of 25
April 2006
Triage Retreat Participants
January 6, 2006
Dr. Margaret Herridge
Dr. Neil Lazar
Dr. Randy Wax
Dr. Laura Hawryluck
Dr. Tim Cook
Wendy Fortier
Dr. Sara Gray
Dr. Thomas Stewart
Dr. Bernard Lawless
Dr. Health Whittingham
Dr. William (Bill) Plaxton
Dr. R.J. Wojtyk
Dr. Michael Gardam
Dr. Donald Low
Kevin Taylor
Scott McIntaggart
Dr. Michael Christian
Critical Care During a Pandemic Page 19 of 25
April 2006
- - Appendix II - -
Critical Care During a Pandemic Page 20 of 25
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Critical Care Pandemic Triage Protocol
Any patient requested to be assessed for possible admission/transfer to critical care will undergo
the following steps in assessment:
Step 1: Assess to see if patient meets inclusion criteria
¾ If patient meets inclusion criteria proceed to Step 2
¾ If patient does NOT meet inclusion criteria reassess patient in future if there is a
deterioration in clinical status
Step 2: Assess for exclusion criteria
¾ If no exclusion criteria proceed to Step 3
¾ If exclusion criteria PRESENT ‘Blue tag’ patient, do not transfer to critical care.
Continue current level of care or palliate as indicated (see palliative care guidelines)
Step 3: Proceed to triage tool, ‘Initial Assessment”
Note: This triage protocol applies to ALL patients undergoing assessment for possible
admission/transfer to critical care.
Inclusion Criteria
The patient must have 1 of criteria A or B
A) Requirement for invasive ventilatory support:
Refractory Hypoxemia (SpO2 < 90% on non-rebreather mask/ FiO2 > 0.85)
Respiratory Acidosis with pH < 7.2
Clinical evidence of impending respiratory failure
Inability to protect or maintain airway
B) Hypotension:
Hypotension (SBP < 90 or relative hypotension) with clinical evidence of shock (altered
level of consciousness, decreased urine output, or other end organ failure) refractory to
volume resuscitation requiring vasopressor/inotrope support that cannot be managed on
the ward.
Critical Care During a Pandemic Page 21 of 25
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Exclusion Criteria
The patient is excluded from admission/transfer to Critical Care if ANY of the following are present:
Severe trauma (needs to define further)
Severe burns
¾ A patient with any two of the following:
i. Age > 60 years old
ii. TBSA > 40%
iii. Inhalation injury
Cardiac Arrest
¾ Unwitnessed cardiac arrest
¾ Witness cardiac arrest not responsive to electrical therapy (defibrillation,
cardioversion, or pacing)
¾ Recurrent cardiac arrest
Severe cognitive impairment
Advanced untreatable neuromuscular disease
Metastatic Malignancy
Advanced & irreversible immunocompromise
Severe and irreversible neurologic event/condition
Endstage organ failure meeting following criteria
¾ Cardiac
i. NYHA class III or IV heart failure
¾ Lung
i. COPD with FEV1 < 25% predicted, baseline PaO2 < 55 mmHg, or
secondary pulmonary hypertension
ii. CF with postbrochodilator FEV1 < 30% or baseline PaO2 < 55 mmHg
iii. Pulmonary fibrosis with VC or TLC < 60% predicted, baseline PaO2 < 55,
or secondary pulmonary hypertension
iv. Primary pulmonary hypertension with NYHA class III – IV heart failure, or
right atrial pressure > 10 mmHg, or mean pulmonary arterial pressure of >
50 mmHg
¾ Liver
i. Child Pugh Score 7
Age > 85 years old
Requirement for transfusion of > 6 units PRBC within 24 hour period
Elective palliative surgery
Critical Care During a Pandemic Page 22 of 25
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SOFA Scale
Variable 0 1 2 3 4
PaO2/FiO2 mmHg >400 400 300 200 100
Platelets, x 103/μL
(x 106/L)
> 150
(> 150)
150
( 150)
100
( 100)
50
( 50)
20
( 20)
Bilirubin, mg/dL
(μmol/L)
<1.2
(< 20)
1.2-1.9
(20 – 32)
2.0-5.9
(33 – 100)
6.0-11.9
(101 – 203)
>12
(> 203)
Hypotension None
MABP < 70
mmHg Dop 5
Dop > 5,
Epi 0.1,
Norepi 0.1
Dop > 15,
Epi > 0.1
Norepi > 0.1
Glasgow Coma Score 15 13 – 14 10 – 12 6 – 9 < 6
Creatinine, mg/dL
(μmol/L)
<1.2
(< 106)
1.2-1.9
(106 – 168)
2.0-3.4
(169 – 300)
3.5-4.9
(301 – 433)
>5
(> 434)
Dopamine [Dop], epinephrine [Epi], norepinephrine [Norepi] doses in ug/kg/min
SI units in brackets
Adapted from:
Ferreira FL, Bota DP, Bross A, Melot C, Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically
ill patients. JAMA 2001; 286(14):1754-1758.
Critical Care During a Pandemic Page 23 of 25
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Critical Care Triage Tool
(Initial Assessment)
Colour
Code Criteria Priority/Action
Blue
Exclusion Criteria*
or
SOFA > 11*
Medical Mgmt
+/- Palliate &
d/c from CC
Red
SOFA 7
or
Single Organ Failure
Highest
Yellow SOFA 8 – 11 Intermediate
Green No significant organ
failure
Defer or d/c,
reassess as
needed
* If exclusion criteria or SOFA > 11 occurs at anytime from initial assessment to 48 hours
change triage code to Blue and palliate.
CC = critical care
d/c = discharge
Critical Care During a Pandemic Page 24 of 25
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Critical Care Triage Tool
(48 Hour Assessment)
Colour
Code Criteria Priority/Action
Blue
Exclusion Criteria
or
SOFA > 11
or
SOFA 8 – 11 no Δ
Palliate & d/c
from CC
Red SOFA score < 11 and
decreasing Highest
Yellow SOFA < 8 no Δ Intermediate
Green No longer ventilator
dependant d/c from CC
Δ = change
CC = critical care
d/c = discharge
Critical Care During a Pandemic Page 25 of 25
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Critical Care Triage Tool
(120 Hour Assessment)
Colour
Code Criteria Priority/Action
Blue
Exclusion Criteria*
or
SOFA > 11*
or
SOFA < 8 no Δ
Palliate & d/c
from CC
Red
SOFA score < 11 and
decreasing
progressively
Highest
Yellow
SOFA < 8 minimal
decrease
(< 3 point decrease in past 72h)
Intermediate
Green No longer ventilator
dependant d/c from CC
* If exclusion criteria or SOFA > 11 occurs at anytime from 48 – 120 hours change triage
code to Blue and palliate.
CC = critical care
d/c = discharge
Appeals/Exemptions
In rare and extenuating circumstances at the point of initial assessment where the triage officer
and/or the attending intensivist feels that a patient may be triaged as ‘Blue’ due to an anomaly of
the protocol and all likelihood has a significantly lower mortality the central triage committee should
be consulted. In some circumstances a 48 hour trial of care may be authorized at the end of which
the patient will be re-triaged according to protocol.
... A centrally placed triage decision-making function is critical in establishing lines of authority to eliminate competition for resources among providers and health facilities. 15,16 To optimize outcomes, the EOC, or its equivalent at regional, national, and international levels, must possess a timely and accurate evidence-based situational-awareness capacity to coordinate daily, if not hourly, triage-management decisions that are passed immediately to hospitals, ambulatory health care facilities, and other public and private agencies and organizations with health care responsibilities. 1 EOC outcome-data analyses will further determine the effect on the population base and redirect resources where needed. ...
... With sound best practices, triage-management decisions may yield no more than an additional 10%-15% of the population being saved. 1,16,30 The impact of this triage-management practice may not be fully known until the end of the epidemic. ...
... Hick and O'Laughlin provide a sample concept of operations for the development of triage criteria for restriction of mechanical ventilation in epidemic situations. 31 Christian et al. 16 provide an expanded critical-care pandemic triage protocol for assessment of admission to criticalcare units during an influenza pandemic. This triage protocol uses the Sequential Organ Failure Assessment score, which has utility for ''inclusion'' as a triage component 16,32 and specifically addresses the importance of a centrally placed or EOC-level triage committee to implement critical inclusion, exclusion, and MQS criteria as well as EOC ''absolute command and control over critical care resources to ensure accountability.'' ...
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Both the naturally occurring and deliberate release of a biological agent in a population can bring catastrophic consequences. Although these bioevents have similarities with other disasters, there also are major differences, especially in the approach to triage management of surge capacity resources. Conventional mass-casualty events use uniform methods for triage on the basis of severity of presentation and do not consider exposure, duration, or infectiousness, thereby impeding control of transmission and delaying recognition of victims requiring immediate care. Bioevent triage management must be population based, with the goal of preventing secondary transmission, beginning at the point of contact, to control the epidemic outbreak. Whatever triage system is used, it must first recognize the requirements of those Susceptible but not exposed, those Exposed but not yet infectious, those Infectious, those Removed by death or recovery, and those protected by Vaccination or prophylactic medication (SEIRV methodology). Everyone in the population falls into one of these five categories. This article addresses a population approach to SEIRV-based triage in which decision making falls under a two-phase system with specific measures of effectiveness to increase likelihood of medical success, epidemic control, and conservation of scarce resources.
... As for the specific ethical principles for scarce resources allocation decision, the analysis shows that the main value that drives allocative choices in emergency situations is to maximize the benefit of critical resources for the greatest number of people, the utilitarian goal of accomplishing "the greatest good for the greatest number" (36)(37)(38)(39). Indeed, regardless of the type of public health emergency, type of document, target population, and geographic area, allocation criteria are based on universally applied clinical criteria that evaluate a patient's likelihood of survival, typically on prognosis for short-term survival using triage tools such as the SOFA scores, the primary goal remaining to save the most lives, a principle that is mentioned in all the documents. ...
Article
Aim: To investigate whether and how ten ethical principles are mentioned within documents on critical care resources allocation during public health emergencies. Materials and methods: We conducted a search of documents con-cerning critical resources allocation during public emergencies publicly available from Google and two specific international websites, up to November 2020. Each document was analyzed by two independent reviewers to assess whether a reference to any of the 10 key ethical principles indicated by the Northern Italy Ethical Committee could be found in the documents. Cohen's K statistic was used. Results: We obtained 34 documents, of which 19 were allocation frameworks, 15 crisis standards of care, 4 clinical triage protocol, 3 clinical guidelines and 2 public health emergency response plans. The principles most frequently mentioned as important for decision-making was "number of lives saved", followed by "transparency", "equity", "respect of person and their autonomy". The most cited tiebreakers were "younger first/life cycle" and "lottery". Conclusions: All documents aim to protect the life and health of the largest number of people and should be objective, ethical, transparent, applied equitably, and be publicly disclosed. It is plausible that short- and long-term prognostic tools can help allocate critical resources, but it remains strong that the decision-making process must be guided by a multi-principle ethical model that is not always easy to apply.
... The handbook provided a simple yet comprehensive guide to: (1) complement COVID-19 educational training [13], (2) review before deployment to COVID-19 ICUs, (3) provide just-in-time training , and (4) serve as a simple reference for experienced providers. No precedent existed at the time of handbook preparation; thus, initial topics were based on review of existing protocols from institutions in Italy and US, and from references from prior respiratory viral pandemics (including MERS, SARS, and influenza) [14]. Topics included staff safety, PPE use, patient transport, sample collection, pharmacologic treatment, airway management and resuscitation, protocol for extended PPE use, ARDS management, and daily workflow in COVID-19 ICUs. ...
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Background: The coronavirus disease 2019 (COVID-19) pandemic resulted in a surge of critically ill patients. This was especially true in New York City. We present a roadmap for hospitals and healthcare systems to prepare for a Pandemic. Methods: This was a retrospective review of how Mount Sinai Hospital (MSH) was able to rapidly prepare to handle the pandemic. MSH, the largest academic hospital within the Mount Sinai Health System, rapidly expanded the intensive care unit (ICU) bed capacity, including creating new ICU beds, expanded the workforce, and created guidelines. Results: MSH a 1,139-bed quaternary care academic referral hospital with 104 ICU beds expanded to 1,453 beds (27.5% increase) with 235 ICU beds (126% increase) during the pandemic peak in the first week of April 2020. From March to June 2020, with follow-up through October 2020, MSH admitted 2,591 COVID-19-positive patients, 614 to ICUs. Most admitted patients received noninvasive support including a non-rebreather mask, high flow nasal cannula, and noninvasive positive pressure ventilation. Among ICU patients, 68.4% (n=420) received mechanical ventilation; among the admitted ICU patients, 42.8% (n=263) died, and 47.8% (n=294) were discharged alive. Conclusions: Flexible bed management initiatives; teamwork across multiple disciplines; and development and implementation of guidelines were critical accommodating the surge of critically ill patients. Non-ICU services and staff were deployed to augment the critical care work force and open new critical care units. This approach to rapidly expand bed availability and staffing across the system helped provide the best care for the patients and saved lives.
... The first ICU triage protocol [74,131] for use following the SARS pandemic in 2003 proposed use of the SOFA score [132]. The SOFA score [133], originally a sepsis score, seemed attractive given its simplicity and limited laboratory data required to calculate it compared with other predictive scores. ...
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Given the rapidly changing nature of COVID-19, clinicians and policy makers require urgent review and summary of the literature, and synthesis of evidence-based guidelines to inform practice. The WHO advocates for rapid reviews in these circumstances. The purpose of this rapid guideline is to provide recommendations on the organizational management of intensive care units caring for patients with COVID-19 including: planning a crisis surge response; crisis surge response strategies; triage, supporting families, and staff.
... Issues of ethics, justice, and societal considerations are important in determining whether pediatric critical care beds should be made available for adults. It is widely accepted that there are finite critical care resources and the process to allocate these resources ethically must include considerations of equity of all patients in need (5)(6)(7). However, there is very limited practical guidance to assist providers facing the ethical challenges of considering both adults and pediatric patients together vying for a single pool of resources (8). ...
... Demand for ICU resources would peak at 171% of current ICU bed capacity, and ventilator use would peak at 118% capacity. These numbers would only add to the region's current day-to-day ICU utilization rates, which are approximately 90% capacity [27]. In Canada, this would definitely overwhelm current ICU resources. ...
Article
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Few viruses have shaped the course of human history more than influenza viruses. A century since the 1918–1919 Spanish influenza pandemic—the largest and deadliest influenza pandemic in recorded history—we have learned much about pandemic influenza and the origins of antigenic drift among influenza A viruses. Despite this knowledge, we remain largely underprepared for when the next major pandemic occurs. While emergency departments are likely to care for the first cases of pandemic influenza, intensive care units (ICUs) will certainly see the sickest and will likely have the most complex issues regarding resource allocation. Intensivists must therefore be prepared for the next pandemic influenza virus. Preparation requires multiple steps, including careful surveillance for new pandemics, a scalable response system to respond to surge capacity, vaccine production mechanisms, coordinated communication strategies, and stream-lined research plans for timely initiation during a pandemic. Conservative models of a large-scale influenza pandemic predict more than 170% utilization of ICU-level resources. When faced with pandemic influenza, ICUs must have a strategy for resource allocation as strain increases on the system. There are several current threats, including avian influenza A(H5N1) and A(H7N9) viruses. As humans continue to live in closer proximity to each other, travel more extensively, and interact with greater numbers of birds and livestock, the risk of emergence of the next pandemic influenza virus mounts. Now is the time to prepare and coordinate local, national, and global efforts.
... This will be the major barrier to the provision of critical care should an MCI occur. A two-tiered staffing model using care teams calls for non-critical care trained personnel to work collaboratively with specialized health care professionals (23). This model is also supported by the Society of Critical Care Medicine Hospital Disaster management course, which trains in core critical care knowledge and skills to non-critical care personnel. ...
... We have deliberately excluded the patient's medical history from the variables included in the analysis. Other proposed schemes have included such information (11,12). We believe that it will be logistically difficult to accurately assess these data during an overwhelming catastrophe. ...
Article
In the event of pandemic influenza, the number of critically ill victims will likely overwhelm critical care capacity. To date, no standardized method for allocating scarce resources when the number of patients in need far exceeds capacity exists. We sought to derive and validate such a triage scheme. : Retrospective analysis of prospectively collected data. Emergency departments of two urban tertiary care hospitals. Three separate cohorts of emergency department patients with suspected infection, comprising a total of 5,133 patients. None. A triage decision rule for use in an epidemic was developed using only those vital signs and patient characteristics that were readily available at initial presentation to the emergency department. The triage schema was derived from a cohort at center 1, validated on a second cohort from center 1, and then validated on a third cohort of patients from center 2. The primary outcome for the analysis was in-hospital mortality. Secondary outcomes were intensive care unit admission and use of mechanical ventilation. Multiple logistic regression demonstrated the following as independent predictors of death: a) age of >65 yrs, b) altered mental status, c) respiratory rate of >30 breaths/min, d) low oxygen saturation, and e) shock index of >1 (heart rate > blood pressure). This model had an area under the receiver operating characteristic curve of 0.80 in the derivation set and 0.74 and 0.76 in the validation sets. When converted to a simple rule assigning 1 point per covariate, the discrimination of the model remained essentially unchanged. The model was equally effective at predicting need for intensive care unit admission and mechanical ventilation. If, as expected, patient demand far exceeds the capability to provide critical care services in an epidemic, a fair and just system to allocate limited resources will be essential. The triage rule we have developed can serve as an initial guide for such a process.
Article
Introduction: The ability of an organization to accommodate a large influx of patients during a prolonged period is dependent on surge capacity. The aim of this article is to describe the surge experience with space, supplies, and staff training in response to COVID-19 and provide guidance to other organizations. Background: A hospital's response to a large-scale event is greatly impacted by the ability to surge and, depending on the type of threat, to maintain a sustained response. To identify surge capacity, an organization must first consider the type of event to appropriately plan resources. Preparation process: An epidemic surge drill, conducted in 2012, served as a guide in planning for the COVID-19 pandemic. The principles of crisis standards of care and a hospital incident command structure were used to clearly define roles, open lines of communication, and inform our surge plan. Preparation began by collaborating with multidisciplinary groups to acquire the most appropriate space, as well as adequate supplies, and identify and train staff. Implementation: Teams were formed to identify the necessary resources to expand the intensive care unit (ICU) environment quickly and efficiently. Educational training was developed for redeployed staff. Outcomes: Beth Israel Deaconess Medical Center experienced the largest surge of ICU patients within a hospital system in the state of Massachusetts. The ICU capacity was expanded by 93% from 77 to 149 beds, and the surge was maintained for approximately 9 weeks. Shadowing experiences before the actual surge were extremely valuable. Conclusions: Planning for the surge of critically ill patients required a thoughtful, collaborative approach. Ongoing staff support and communication from nursing leadership were necessary to ensure safe, effective care for critically ill patients in a new and dynamic environment.
Article
Prior to the development of written policies and procedures for pandemic influenza, worker perceptions of ethical and workforce issues must be identified. To determine the relationship between healthcare worker (HCW) reporting willingness to work during a pandemic and perception of job importance, belief that one will be asked to work, and sense of professionalism and to assess HCW's opinions regarding specific policy issues as well as barriers and motivators to work during a pandemic. A survey was conducted in HCWs at The Children's Hospital in Denver, Colorado, from February to June 2007. Characteristics of workers reporting willingness to work during a pandemic were compared with those who were unwilling or unsure. Importance of barriers and motivators was compared by gender and willingness to work. Sixty percent of respondents reported willingness to work (overall response rate of 31%). Belief one will be asked to work (OR 4.6, P  <  0.0001) and having a high level of professionalism (OR 8.6, P  <  0.0001) were associated with reporting willingness to work. Hospital infrastructure support staffs were less likely to report willingness to work during a pandemic than clinical healthcare professionals (OR 0.39, P  <  0.001). Concern for personal safety, concern for safety of family, family's concern for safety, and childcare issues were all important barriers to coming to work. Educational programs should focus on professional responsibility and the importance of staying home when ill. Targeted programs toward hospital infrastructure support and patient and family support staff stressing the essential nature of these jobs may improve willingness to work.
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Over the past 20 years, there has been remarkable improvement in the chances of survival of patients treated in burn centers. A simple, accurate system for objectively estimating the probability of death would be useful in counseling patients and making medical decisions. We conducted a retrospective review of all 1665 patients with acute burn injuries admitted from 1990 to 1994 to Massachusetts General Hospital and the Shriners Burns Institute in Boston. Using logistic-regression analysis, we developed probability estimates for the prediction of mortality based on a minimal set of well-defined variables. The resulting mortality formula was used to determine whether changes in mortality have occurred since 1984, and it was tested prospectively on all 530 patients with acute burn injuries admitted in 1995 or 1996. Of the 1665 patients (mean [+/-SD] age, 21+/-20 years; mean burn size, 14+/-20 percent of body-surface area), 1598 (96 percent) lived to discharge. The mean length of stay was 21+/-29 days. Three risk factors for death were identified: age greater than 60 years, more than 40 percent of body-surface area burned, and inhalation injury. The mortality formula we developed predicts 0.3 percent, 3 percent, 33 percent, or approximately 90 percent mortality, depending on whether zero, one, two, or three risk factors are present. The results of the prospective test of the formula were similar. A large increase in the proportion of patients who chose not to be resuscitated complicated comparisons of mortality over time. The probability of mortality after burns is low and can be predicted soon after injury on the basis of simple, objective clinical criteria.
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Evaluation of trends in organ dysfunction in critically ill patients may help predict outcome. To determine the usefulness of repeated measurement the Sequential Organ Failure Assessment (SOFA) score for prediction of mortality in intensive care unit (ICU) patients. Prospective, observational cohort study conducted from April 1 to July 31, 1999. A 31-bed medicosurgical ICU at a university hospital in Belgium. Three hundred fifty-two consecutive patients (mean age, 59 years) admitted to the ICU for more than 24 hours for whom the SOFA score was calculated on admission and every 48 hours until discharge. Initial SOFA score (0-24), Delta-SOFA scores (differences between subsequent scores), and the highest and mean SOFA scores obtained during the ICU stay and their correlations with mortality. The initial, highest, and mean SOFA scores correlated well with mortality. Initial and highest scores of more than 11 or mean scores of more than 5 corresponded to mortality of more than 80%. The predictive value of the mean score was independent of the length of ICU stay. In univariate analysis, mean and highest SOFA scores had the strongest correlation with mortality, followed by Delta-SOFA and initial SOFA scores. The area under the receiver operating characteristic curve was largest for highest scores (0.90; SE, 0.02; P<.001 vs initial score). When analyzing trends in the SOFA score during the first 96 hours, regardless of the initial score, the mortality rate was at least 50% when the score increased, 27% to 35% when it remained unchanged, and less than 27% when it decreased. Differences in mortality were better predicted in the first 48 hours than in the subsequent 48 hours. There was no significant difference in the length of stay among these groups. Except for initial scores of more than 11 (mortality rate >90%), a decreasing score during the first 48 hours was associated with a mortality rate of less than 6%, while an unchanged or increasing score was associated with a mortality rate of 37% when the initial score was 2 to 7 and 60% when the initial score was 8 to 11. Sequential assessment of organ dysfunction during the first few days of ICU admission is a good indicator of prognosis. Both the mean and highest SOFA scores are particularly useful predictors of outcome. Independent of the initial score, an increase in SOFA score during the first 48 hours in the ICU predicts a mortality rate of at least 50%.
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This study was undertaken to provide up-to-date survival data for Canadian adult in-patients following attempted resuscitation from cardiac or respiratory arrest. We hope that objective data might encourage more meaningful dialogue between physicians, patients and their families regarding resuscitation wishes. We reviewed all records of adult cardiopulmonary arrest that occurred between Jan. 1, 1997, and Jan. 31, 1999, at the 3 main teaching hospitals in Edmonton. We then abstracted data from the full inpatient medical records to describe patient characteristics, type of arrest and survival details. The family physicians of survivors were contacted to confirm the outcomes. We included only adults admitted to hospital but not to a critical care bed. There were 247 arrests during the study period; 143 (57.9%) were witnessed, and 104 (42.1%) were unwitnessed). Of the patients whose arrests were witnessed, 48.3% (95% confidence interval [CI] 39.8%-56.8%) were able to be resuscitated, 22.4% (95% CI 1 5.8%-30.1%) survived to hospital discharge, and 18.9% (95% CI 12.8%-26.3%) were able to return home. Survival was highest after primary respiratory arrest and lowest after pulseless electrical activity or asystole. Of the patients with unwitnessed arrests, 21.2% (95% CI 13.8%-30.3%) were able to be resuscitated, but only 1 patient (1.0% [95% CI 0.0%-5.2%]) survived to hospital discharge and was able to return home. This patient survived an unwitnessed respiratory arrest. No patient who had an unwitnessed cardiac arrest survived to discharge. Most of the respiratory arrests were witnessed (93.1%), and most of the pulseless electrical activity or asystole arrests were unwitnessed (54.6%). We did not find age or sex to be independent predictors of survival. However, the risk of not returning home was higher among patients whose arrest occurred between 2301 and 0700 than among those whose arrest was between 0701 and 1500 (adjusted OR 3.2, 95% CI 1.0-10.1). Survival was significantly decreased after pulseless ventricular tachycardia or ventricular fibrillation arrest (adjusted OR 4.2, 95% CI 1.4-12.5) and even more so after pulseless electrical activity or asystole arrest (adjusted OR 21.0, 95% CI 6.2-71.7) than after respiratory arrest. Overall, survival following cardiopulmonary resuscitation in hospital does not appear to have changed markedly in 40 years. The type of arrest is highly predictive of survival, whereas age and sex are not.
Article
We sought to retrospectively measure the accuracy of multiple-casualty incident (MCI) triage algorithms and their component physiologic variables in predicting adult patients with critical injury. We performed a retrospective review of 1,144 consecutive adult patients transported by ambulance and admitted to 2 trauma centers. Association between first-recorded out-of-hospital physiologic variables and a resource-based definition of severe injury appropriate to the MCI context was determined. The association between severe injury and Triage Sieve, Simple Triage and Rapid Treatment, modified Simple Triage and Rapid Treatment, and CareFlight Triage was determined in the patient population. Of the physiologic variables, the Motor Component of the Glasgow Coma Scale had the strongest association with severe injury, followed by systolic blood pressure. The differences between CareFlight Triage, Simple Triage and Rapid Treatment, and modified Simple Triage and Rapid Treatment were not dramatic, with sensitivities of 82% (95% confidence interval [CI] 75% to 88%), 85% (95% CI 78% to 90%), and 84% (95% CI 76% to 89%), respectively, and specificities of 96% (95% CI 94% to 97%), 86% (95% CI 84% to 88%), and 91% (95% CI 89% to 93%), respectively. Both forms of Triage Sieve were significantly poorer predictors of severe injury. Of the physiologic variables used in the triage algorithms, the Motor Component of the Glasgow Coma Scale and systolic blood pressure had the strongest association with severe injury. CareFlight Triage, Simple Triage and Rapid Treatment, and modified Simple Triage and Rapid Treatment had similar sensitivities in predicting critical injury in designated trauma patients, but CareFlight Triage had better specificity. Because patients in a true mass casualty situation may not be completely comparable with designated trauma patients transported to emergency departments in routine circumstances, the best triage instrument in this study may not be the best in an actual MCI. These findings must be validated prospectively before their accuracy can be confirmed.