Drs. John L. Hick and Daniel T. O'Laughlin of University of Minnesota propose a concept of operations and a set of suggested guidelines for triage of mechanical ventilators in a pandemic or bioterrorist attack. "When a large-scale pandemic does occur, we're simply going to run out of resources," comments Dr. Hick. "We need to be talking now about how we are going to allocate scarce resources to the patients most likely to benefit from them."
Drs. Hick and O'Laughlin developed their proposal after a recent drill showing that an epidemic affecting ten percent of the Minneapolis area would lead to a "rapid and critical shortfall" in the supply of mechanical ventilators. "Despite a surge capacity of between 2,500 and 3,500 beds in the area, there were 16 ventilators available in our regional system," says Dr. Hick.
The proposal calls for a set of general guidelines to be developed in advance by a team of public health officials and medical experts. The guidelines would be subject to review by a separate group, including elected officials and members of the public.
The guidelines would be arranged in tiers--as resources are exhausted, another, more stringent set of criteria would come into effect. At each level, the criteria would be based on clinical indicators of the patient's chances or survival and likely use of health care resources, with the objective of directing scarce resources to the patients most likely to benefit.
In a crisis, the guidelines would rapidly be tailored to the specific situation, then issued as part of an emergency order. "The goal would be to promote consistency between hospitals and regions," says Dr Hick. "Across the board, resource allocation would be as equal as possible. The concept is distributive justice--doing the greatest good for the greatest number of patients."
In Minnesota, the process is underway, according to Dr. Hick. "A set of general guidelines has been developed by a science team and vetted by a guidelines review group. Reception has generally been very positive, including discussions of the ethical issues involved with community groups."
Even more important than the specific plan that emerges, Dr. Hick believes, is the establishment of a decision-making process. "We need to start talking about this now and develop a fair process so that, in a crisis, a mechanism is in place to apply the best science we have to make the best use of the available resources. Although our plan is not definitive, we hope it will serve as the starting point for a discussion that needs to be had."
About the Society for Academic Emergency Medicine (SAEM)
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