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Ventilator Allocation in Pandemic Times

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#1 mixingitup

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Posted 05 April 2008 - 02:21 PM

Florida1 over at Flutrackers posted this link last week and I followed up with a summary. The state of New York has adopted these guidelines (subject to change) for who will get a vent and who won't if there aren't enough for everyone if the next pandemic is severe. I suspect other states may adopt something similar. It's long and rather depressing but everyone should know these are in place. http://www.dmphp.org...abstract/2/1/20

Duty to care:
Physicians must not abandon, and patients should not fear abandonment
Patients who are not eligible to receive mechanical ventilation will receive forms of curative and palliative treatment.
More patients will want ventilators than can be accommodated

Duty to Steward Resources
Balancing an obligation to the community of patients against the primary duty to care for each patient generates ethical tension in devising a rationing system.
Clinicians need to save the greatest possible number of lives while continuing to care for each individual patient.

Duty to Plan
A failure to produce acceptable guidelines for a foreseeable crisis amounts to a failure of responsibility toward both patients and providers
Any guidelines devised will be imperfect, both ethically and medically.
Despite the difficulties inherent in planning, public health entities must accept this responsibility.

Distributive Justice
A fair allocation system must be applied broadly and consistently.
Cooperative agreements to pool scarce resources among local hospitals may help alleviate shortages.
The allocation of ventilators from state and federal stockpiles must take into account the ratio of local populations to available resources and supplement those resources accordingly.
Planners must designate appropriate resources for the most vulnerable, who are the most likely to experience the greatest impact in any disaster.

The state should publicize proposed guidelines, translate them into different languages as necessary, share them with health care leaders and the community, including historically underserved communities, and seek public comment.
Proposed revisions that will ensure a just allocation process should be incorporated.
These draft guidelines propose both withholding and withdrawing ventilators from patients with the highest probability of mortality to benefit patients with a high likelihood of survival.
The workgroup struggled with the notion of extubating patients, even those unlikely to survive, to offer ventilators to those more likely to survive.
Ethicists in the workgroup argued that guidelines for decision making under duress are more likely to be followed when they seek to reduce the number of times that one confronts the most difficult decision.
These guidelines permit patient extubation but aim to limit the times that clinicians face this most ethically and emotionally challenging aspect of the ventilator rationing system.

Pretriage Requirements
Hospitals should limit the noncritical use of ventilators
Elective procedures should be canceled and/or postponed
Facilities, working in collaboration with public health authorities, will need to document implementation of surge measures before they can access government ventilator stocks or institute rationing.
Triage may not be implemented by a facility without clear sanction from appropriate public health authorities.
Surge capacity must include securing adequate staff to operate ventilators and provide critical care.

Patient Categories
A just rationing system must be applied to all hospitalized patients who require critical care
The workgroup participants, although not unanimously, propose that patients be assessed on medical/clinical factors alone, regardless of their work role
The draft guidelines support access to ventilators based on clinical factors only.
Of note, the allocation of other scarce resources, such as vaccine or antiviral medications, may well favor health care providers based on differing ethical and clinical considerations

Acute Versus Chronic Care Facilities
Patients using ventilators in chronic care facilities would not be subjected to acute care triage guidelines.
If such patients required transfer to an acute care facility, they would be assessed by the same criteria as all of the other patients and may lose access to continued ventilator use.
An alternative approach would require assessing all of the intubated patients, whether in acute or chronic care facilities, by the same set of clinical criteria. Depending on the design of these criteria, the result may be the sudden and fatal extubation of stable, long-term ventilator-dependent patients in chronic care facilities.

Clinical Evaluation
A clinical evaluation system based on the Ontario Health Plan for an Influenza Pandemic (OHPIP) protocol and on the sequential organ failure assessment (SOFA) score is used in the draft guidelines
Incoming patients with clinical evidence of impending pulmonary failure meet the inclusion criteria and will be assessed for exclusion criteria, and then placed in categories based on a variation of the OHPIP system.
Patients on ventilators when triage begins will also be assessed to determine whether they meet criteria for continued use.
Candidates for extubation during a pandemic would include patients with the highest probability of mortality.

Exclusion Criteria for Ventilator Access
Patients who meet exclusion criteria will not have access to ventilators and will not enter into the scoring system
Exclusion criteria should focus primarily on current organ function rather than on specific diseases.
Age is not an exclusion criterion
Much public comment argued that it is more appropriate to maximize life-years saved rather than lives, a system that enhances access for children at the expense of older adults.
Renal failure is an exclusion criterion
Exclusion criteria are subject to revision

Initial Assessment Using Sequential Organ Failure Assessment (SOFA)
The SOFA score adds points based on objective measures of function in 6 domains: lungs, liver, brain, kidneys, blood clotting, and blood pressure
A perfect SOFA score is 0. The worst possible score is 24, which indicates life-threatening abnormalities in all 6 systems.

Time Trials
Continued use of the ventilator will be reassessed at intervals of 48 and 120 hours.
Patients showing improvement would continue ventilator use until the next assessment, whereas those who no longer met the criteria would lose access to mechanical ventilation.

Triage Decision Makers
Clinicians providing direct care will relay data to a supervising clinician serving as a triage officer, who will calculate the SOFA score and make triage decisions but will not provide direct care.
Establishing triage officers provides role sequestration that will help sustain clinicians who serve during disasters.
Without such measures, the secondary effects of the disaster on clinicians, including burnout and stress, may prove more corrosive than the original trauma.

Palliative Care
Patients who are extubated against their wishes should be offered palliative care based on their clinical conditions and preferences.
Terminal weaning in response to patient preferences can include sedation so that the patient need not experience air hunger.
Facilities should prepare for a significant increase in demand for expertise in palliative care.
The guidelines do not support the use of manual ventilation devices for patients who do not meet criteria for ventilator access.

Review of Triage Decisions
Daily retrospective review would provide oversight and accountability for triage decisions
It would not permit intervention for individual decisions.

Communicating information appropriately is one of the most significant challenges raised by a public health disaster.
Physicians will need to discuss altered standards of care in a disaster
Political leaders and health officials must emphasize publicly that standards of care are and must be different in a public health disaster.
Clinicians will do all that they can with the available resources, and the community will need to adjust to scarcity.
Patients and families must be informed immediately that ventilator support represents a trial of therapy that may not improve the patient's condition sufficiently and that the ventilator will be removed if the patient does not meet specific criteria.
Staff training for disaster readiness must include guidance on how to discuss such time trials.
Communication must be clear upon hospital and intensive care unit admission, as well as upon initiation of ventilator treatment

Future Work
A series of focus groups across New York state are planned as a means of providing public education and soliciting comments from a range of community members, including parents, older adults, people with disabilities, and communities of color.

#2 soapaddict


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Posted 06 April 2008 - 10:20 AM

Hi Mixin:).

What do they mean by 'ventilation'? Is that an oxygen machine??

#3 mixingitup

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Posted 07 April 2008 - 12:52 PM

Yes, the ventilators are the machines that assist breathing. In my mind, I always associate them as life support but there may be other machines for that, too.

This would be a major issue for a pandemic where the flu was serious enough to attack the lungs; like the Avian Flu is currently doing. Most of the patients are brought to the hosiptal with *high hot and breathless* conditions that require a vent. Currently, about 62% of them die, even with the vent and Tamiflu.

I just read some of the Department of Transportation's recommendations for pandemic preparedness and they are basing those on 30% attack rate, waves lasting up as much as 3 months for a total period of 1.5 years (3 waves).

The figures our govt are projecting are very mild in comparison. For some strange reason, they are only recommending 2 weeks supply of food to be stockpiled.

I'm curious how you feel about who should get the vents when needed and who shouldn't. By the sound of these guidelines, there won't be any holding out for a miracle. If your loved one doesn't respond in the timeframe, they will take them off and give it to the next person.

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Posted 07 April 2008 - 10:35 PM

Ahhh... then you all ought to take up glass working. I had to buy a M15 for torching, which puts out 8 psi of pure oxygen all day long... that's probably enough to ventilate 10 people, so we're safe cuz we have our own oxygen tank ventilation system! hehehe.

So we're all set for breathing:)!

#5 mixingitup

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Posted 08 April 2008 - 04:53 AM

uhhh, I don't think an oxygen tank works the same as a ventilator. Nice try though :) :bjump:

#6 soapaddict


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Posted 08 April 2008 - 10:43 PM

It's not? Oh, darn.


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