1. Inventory of potential ICU resources for a surge in demand
-
a.
Physical ventilators and beds (eg, OR, PACU)
-
b.
Human resources (staff with ICU training)
-
c.
Supplies and space to deliver care (eg, medications, disposable items, PPE, PACU)
|
Individual health-care facilities |
2. Establish identification triggers for and initiation of triage: as clinical demand reaches crisis stage and that crisis standards of care, including triage, should be initiated
-
a.
The decision to initiate triage should be made by an identified regional authority with situational awareness of regional health-care demands
-
b.
Triage must be consistently applied across the region, with documented rationale and oversight by the relevant regional authority
|
Regional government health authorities (county/state/province/national)
Regional or national emergency management authorities (eg, CDC or equivalent, state/province public health department) |
3. Preparation of a triage system
-
a.
Create central triage committee for the region, tasked with coordination and standardization. This should include representation of key stakeholders (medical, nursing, ethics, law, patient and community representatives)
-
b.
Identify members of institutional tertiary triage teams and support structures
-
c.
Prepare and distribute training materials to local officials for standardization of implementation
|
Public health department/ministry of health
Local hospitals with an ICU |
| 4. Agreement on a triage protocol to target resources to those with the greatest incremental benefit |
Regional health authorities and coalitions
Critical care professional societies and community, along with multistakeholder input |
| 5. Consideration of changes to allow limits to the delivery of life-sustaining measures in times of crisis care, and indemnity against litigation for decisions made in accordance with the triage policy
|
Regional health authority (ie, state health commissioner, provincial health minister)
Regional justice authority (ie, attorney general, governor) |
6. Standards of care
-
a.
Modify end-of-life care policies to indicate that the standard of care in a pandemic is to triage patients according to an accepted plan, and that consent is not required to implement treatment decisions taken according to that plan
-
b.
Ensure that patients unable to receive invasive life-sustaining therapies (eg, mechanical ventilation) are provided the best available care under the circumstances (eg, supplemental oxygen through another route, palliative care, family support)
-
c.
Clear clinical guidelines for medical management of people with respiratory failure, including palliative measures
-
d.
Standardized communication tools (eg, sensitive information sheets) to inform members of the public about triage decisions and the rationale behind them
|
State/provincial physician licensing board
Critical care/palliative care community |
7. Family and societal support
-
a.
Transparency with the public about triage processes
-
b.
Communication plans with the public (telephone hotlines, online resources) to ensure that information is readily available
-
c.
Work to preserve the integrity of family units, especially in cases of young children and during end-of-life
-
d.
Ensure support for grieving families
|
Institutional social work, mental health, and palliative care services
Consideration of COVID-19 hospice services |
8. Health-care worker support
-
a.
A systematic communication plan with the reasons for triage system activation, training on its use, and companion decision support tools to ensure consistent implementation is essential
-
b.
Triage decisions must be made collaboratively, using a team-based approach that includes the designated triage officer, providers directly assigned to care for individual patients, with support from hospital ethics and palliative care experts when necessary
-
c.
A systematic approach to support health-care workers, including incident debriefing, resiliency skills, and services to provide emotional support must be implemented in advance of triage system activation
|
Regional health authorities and attorney general, in collaboration with regional critical care leaders and ICU directors
Individual institutions |
9. Pediatric considerations
-
a.
Concentrate care for children at pediatric centers to preserve necessary pediatric systems, including accepting any pediatric transfers, even ones for whom they may not typically care
-
b.
Increasing pediatric age thresholds to 21, 25, or 30 years iteratively as surge requires (as long as no adult comorbidities exist that are not consistent with pediatric critical care practice)
-
a.
concentrate pediatric care in pediatri
|
Local health-care coalitions |
